AMBERWOOD POST ACUTE
For profit - Corporation
88 Beds
PACS GROUP
Data: November 2025
Trust Grade
43/100
#131 of 208 in CO
Photo by Amberwood Post Acute
Photo by Amberwood Post Acute
Photo by Amberwood Post Acute
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Amberwood Post Acute in Denver has a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #131 out of 208 facilities in Colorado, placing it in the bottom half, and #13 out of 21 in Denver County, meaning only a few local options are better. The facility's situation appears to be worsening, with the number of issues increasing from 13 in 2023 to 16 in 2024. Staffing is a weak point, earning only 2 out of 5 stars, with a concerning turnover rate of 49%, which is on par with the state average but suggests instability. Additionally, the facility has $9,636 in fines, which is average, but there is less RN coverage than 84% of Colorado facilities, indicating potential risks in resident care. Specific incidents of concern include that two residents were not adequately protected from fall risks despite known hazards, with one sustaining a head injury. The facility also failed to maintain proper hygiene practices, such as not ensuring staff washed hands appropriately or that resident rooms were cleaned effectively. Furthermore, proper food safety protocols were not followed, which could put residents at risk of illness. Overall, while there are some average aspects, the facility has significant weaknesses that families should carefully consider.
- Trust Score
- D
- In Colorado
- #131/208
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $9,636 in fines. Lower than most Colorado facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Colorado. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 36 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 38%
Needs review
13 → 16 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 16 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Colorado average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 49%
Near Colorado avg (46%)
Higher turnover may affect care consistency
Federal Fines: $9,636
Below median ($33,413)
Minor penalties assessed
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 36 deficiencies on record
1 actual harm
Oct 2024
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#76) of two residents out of 39 sample residents.
Specifically, the facility failed to provide Resident #76 with an appropriate discharge process.
Findings include:
I. Facility policy and procedure
The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.
Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice to pay for a stay at this facility; or the facility ceases to operate.
Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences.
If the facility does not permit a resident's return to the facility based on an inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights.
The facility will send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice will occur at the same time the notice of discharge is provided to the resident and resident representative.
If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility.
II. Resident #76
A. Resident status
Resident #76, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 7/11/24. According to the July 2024 computerized physician orders (CPO), the diagnoses included schizoaffective disorder, bipolar disorder.
The 7/8/24 minimum data set (MDS) assessment revealed the resident had short term memory impairment with severe impairment in making decisions regarding daily life. She required supervision or was independent with all activities of daily living (ADL).
The assessment documented the resident had hallucinations, delusions, physical behaviors directed toward others, verbal behaviors directed toward others and wandering during the assessment period.
The assessment indicated that the resident's return to the facility was not anticipated and active discharge planning had occurred.
B. Record review
The behavioral care plan, initiated on 7/5/24, documented Resident #76 was verbally aggressive with staff and peers. The resident had a history of calling emergency services if her expectations were not met, declining medication if they appeared different or a different brand from a previous facility, physically hitting another resident and making false accusations. Resident #76 was difficult to redirect when cycling. She yelled and expressed her delusions and hallucinations at herself in the mirror.
The interventions included administering medications as ordered, anticipating and meeting needs promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize feelings, establishing a rapport, maintaining a calm, slow and understandable approach, notifying the physician and responsible party of episodes of aggression and abusive behaviors, observing and documenting changes in behavior and potential triggers, observing for clinical factors influencing behavioral indicators, reducing stimuli, and staying calm and composed, avoiding direct eye contact and staring, using short and clear sentences and avoiding any chance for a power struggle.
The 6/27/24 behavior progress note documented Resident #76 began speaking over other speakers during a resident meeting with a resident advocate. The facility staff attempted to address the resident's behavior by asking her to hold her comments until the appropriate time, however Resident #76 continued to speak over others, refused to listen and continued to disrupt the meeting.
The 7/2/24 behavior progress note documented Resident #76 had provided a personal shopping list to the activity director (AD). Upon asking the resident some questions about the items, Resident #76 became verbally aggressive, repeatedly using profane language, despite the AD attempting de-escalation techniques.
The 7/3/24 behavior progress note documented Resident #76 called the police stating that someone had stolen her money.
The 7/5/24 interdisciplinary team (IDT) progress note documented Resident #76 continued to express delusions, disorganized thoughts and speech, chaotic behavior, anxiety, apathy and blank facial expressions.
The 7/5/24 IDT note further indicated Resident #76 had been accepted to the locked behavioral unit at a sister facility.
-However, there was no documentation to indicate the reason for the expected discharge to the sister facility or the anticipated date of the pending discharge.
The 7/5/24 nursing progress note documented Resident #76 had pushed another resident without cause. The charge nurse got in between the residents and separated them. Resident #76 continued to have behavioral outbursts.
Resident #76 said she did not hit anyone, continued to use profanity and shouted at other residents. The resident was able to be redirected to the lobby but kept on showing aggression toward staff and other residents.
The 7/11/24 change of condition note documented Resident #76 was sent to the hospital due to very hostile and aggressive behavior toward staff and was not able to be redirected. The physician ordered for the resident to be sent to the hospital for behavior management and then discharged to a sister facility.
-A review of Resident #76's EMR did not reveal documentation to indicate that the resident or the resident's representative had been notified of the resident's immediate discharge to the hospital.
C. Staff interviews
The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said Resident #76 had been a resident at the facility, but had since been discharged to a sister facility. She said Resident #76 had a diagnosis of schizoaffective disorder and would refuse to take her psychotropic medications. She said the resident would constantly yell throughout the day, call emergency services daily and was verbally and physically aggressive.
The SSD said the facility IDT had met with Resident #76's primary care physician (PCP) and determined, based on the resident's behaviors, the facility was not able to care for the resident and meet her needs. She said they planned to discharge the resident to a sister facility, however the paperwork was taking a long time. She said, in the meantime, the resident was sent to the hospital due to her behaviors and the hospital was instructed to discharge her to the accepting sister facility.
The SSD said she was not aware if Resident #76 was given a 30-day or immediate discharge notice. She said Resident #76 was her own responsible party. She said she never discussed Resident #76's right to appeal the discharge with her or her family.
The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:00 p.m. The DON said Resident #76 had severe mental health issues and would not take her medications, despite multiple attempts by multiple staff members. She said Resident #76 was disruptive to the community and verbally and physically aggressive.
The DON said the facility determined Resident #76's needs would be better met at a sister facility.
The RCC said the facility did not issue Resident #76 a 30-day or immediate discharge notice when the resident was discharged to the hospital. The RCC said the facility did not provide Resident #76 with the education of the right to appeal the discharge.
The RCC said a 30-day discharge notice should be given when the facility determined they could not meet a resident's needs. She said the discharge notice should include the resident's right to appeal the discharge. She said the discharge process should be documented in the resident's medical record and be included as part of the comprehensive care plan.
The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the facility did not provide Resident #76 with a discharge notice. She said a 30-day discharge notice should have been provided and education given to the resident regarding the appeal process. The NHA said the facility felt they could not care for Resident #76 due to her unpredictable behavior.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to permit a resident to return to the facility following a facility-in...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for one (#76) of two residents reviewed for discharge out of 39 sample residents.
Specifically, the facility failed to reassess Resident #76's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and directed the hospital to discharge the resident to a sister facility instead of allowing the resident to return to the facility.
Findings include:
I. Facility policy and procedure
The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.
Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility; the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; the resident has failed, after reasonable and appropriate notice to pay for a stay at this facility; or the facility ceases to operate.
Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences.
If the facility does not permit a resident's return to the facility based on an inability to meet the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights.
The facility will send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman. Notice will occur at the same time the notice of discharge is provided to the resident and resident representative.
If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the facility during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility.
II. Resident #76
A. Resident status
Resident #76, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 7/11/24. According to the July 2024 computerized physician orders (CPO), the diagnoses included schizoaffective disorder, bipolar disorder.
The 7/8/24 minimum data set (MDS) assessment revealed the resident had short term memory impairment with severe impairment in making decisions regarding daily life. She required supervision or was independent with all activities of daily living (ADL).
The assessment documented the resident had hallucinations, delusions, physical behaviors directed toward others, verbal behaviors directed toward others and wandering during the assessment period.
The assessment indicated that the resident's return to the facility was not anticipated and active discharge planning had occurred.
B. Record review
The behavioral care plan, initiated on 7/5/24, documented Resident #76 was verbally aggressive with staff and peers. The resident had a history of calling emergency services if her expectations were not met, declining medication if they appeared different or a different brand from a previous facility, physically hitting another resident and making false accusations. Resident #76 was difficult to redirect when cycling. She yelled and expressed her delusions and hallucinations at herself in the mirror.
The interventions included administering medications as ordered, anticipating and meeting needs promptly, documenting and recording behavioral episodes, encouraging the resident to verbalize feelings, establishing a rapport, maintaining a calm, slow and understandable approach, notifying the physician and responsible party of episodes of aggression and abusive behaviors, observing and documenting changes in behavior and potential triggers, observing for clinical factors influencing behavioral indicators, reducing stimuli, and staying calm and composed, avoiding direct eye contact and staring, using short and clear sentences and avoiding any chance for a power struggle.
-A review of the comprehensive care plan did not reveal a discharge care plan had been developed.
Cross reference F622: the facility failed to ensure a proper discharge process was provided to Resident #76.
The 6/27/24 behavior progress note documented Resident #76 began speaking over other speakers during a resident meeting with a resident advocate. The facility staff attempted to address the resident's behavior by asking her to hold her comments until the appropriate time, however Resident #76 continued to speak over others, refused to listen and continued to disrupt the meeting.
The 7/2/24 behavior progress note documented Resident #76 had provided a personal shopping list to the activity director (AD). Upon asking the resident some questions about the items, Resident #76 became verbally aggressive, repeatedly using profane language, despite the AD attempting de-escalation techniques.
The 7/3/24 behavior progress note documented Resident #76 called the police stating that someone had stolen her money.
The 7/5/24 interdisciplinary team (IDT) progress note documented Resident #76 continued to express delusions, disorganized thoughts and speech, chaotic behavior, anxiety, apathy and blank facial expressions.
The 7/5/24 IDT note further indicated Resident #76 had been accepted to the locked behavioral unit at a sister facility.
The 7/5/24 nursing progress note documented Resident #76 had pushed another resident without cause. The charge nurse got in between the residents and separated them. Resident #76 continued to have behavioral outbursts. Resident #76 said she did not hit anyone, continued to use profanity and shouted at other residents. The resident was able to be redirected to the lobby but kept on showing aggression toward staff and other residents.
The 7/6/24 nursing progress note, documented at 6:37 a.m., revealed Resident #76 had an episode of yelling and screaming at staff and refused to take her evening medication on 7/5/24. She did not sleep and was wandering the hallways.
The 7/6/24 nursing progress note further indicated that the resident was being sent to the hospital due to her behavior and that they had spoken with the hospital and informed them to transfer her to another facility at discharge.
Another 7/6/24 nursing progress note documented the resident returned to the facility at 6:33 p.m. and had refused all care at the hospital.
The 7/8/24 physician progress notes documented the resident had exhibited 27 reported behaviors since her admission to the facility, including dissatisfaction with meals, calling emergency services for non-emergencies, loud outbursts in the dining room, intrusive behaviors, delusions, hallucinations, disorganized thinking, persistent feelings of being watched or persecuted and strong beliefs that were not based in reality. The resident was scheduled to transfer to another facility from the hospital.
The 7/8/24 behavior progress note documented Resident #76 displayed almost harmful behavior by standing close to a male resident and looking like she was going to push him out of her way. The NHA intervened and redirected Resident #76 into alternate activities.
The 7/11/24 change of condition note documented Resident #76 was sent to the hospital due to very hostile and aggressive behavior toward staff and she was not able to be redirected. The physician ordered for the resident to be sent to the hospital for behavior management and then discharged to a sister facility.
-However, review of Resident #76's electronic medical record (EMR) revealed there was no documentation to indicate the facility had reassessed the resident after her transfer to the hospital to determine if the resident was able to return to the facility.
-There was no documentation in Resident #76's EMR to indicate what needs the facility could not meet after the resident's hospitalization.
III. Staff interviews
The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said Resident #76 had been a resident at the facility, but had since been discharged to a sister facility. She said Resident #76 had a diagnosis of schizoaffective disorder and would refuse to take her psychotropic medications. She said the resident would constantly yell throughout the day, call emergency services daily and was verbally and physically aggressive.
The SSD said the facility IDT had met with Resident #76's primary care physician (PCP) and determined, based on the resident's behaviors, the facility was not able to care for the resident and meet her needs (see 7/8/24 physician progress note above).
-However the facility did not have any documentation indicating a discharge plan was in progress and had been discussed with the resident.
The SSD said they planned to discharge the resident to a sister facility, however the paperwork was taking a long time. She said, in the meantime, the resident was sent to the hospital due to her behaviors and the facility instructed the hospital to discharge her to the accepting sister facility.
The SSD said Resident #76 was her own responsible party. She said she never discussed the discharge planning with Resident #76.
The SSD said she was responsible for discharge planning. She said a care plan focus for discharge planning should have been developed within Resident #76's comprehensive plan of care.
The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:00 p.m. The DON said Resident #76 had severe mental health issues and would not take her medications, despite multiple attempts by multiple staff members. She said Resident #76 was disruptive to the community and verbally and physically aggressive.
The DON said the facility determined Resident #76's needs would be better met at a sister facility.
The RCC said the discharge process should be included as part of the comprehensive care plan.
The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the SSD was responsible for documenting the active discharge plan and developing the discharge plan of care. The NHA confirmed the active discharge process and the discharge care plan was not documented for Resident #76.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission scree...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care planning and transition of care for two (#65 and #43) of three residents reviewed out of 39 sample residents.
Specifically, the facility failed to initiate therapy as recommended by the PASRR Level II in a timely manner for Resident #65 and Resident #43.
Findings include:
I. Facility policy and procedure
The Behavioral Health Services policy and procedure, revised February 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part,
The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.
Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.
Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.
Residents who do not display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment, substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot be attributed to a specific clinical condition that makes the pattern unavoidable.
Staff must promote dignity, autonomy, privacy, socialization and safety as appropriate for each resident and are trained in ways to support residents in distress.
II. Resident #65
A. Resident status
Resident #65, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizophrenia (a chronic illness that effects a persons thoughts, feelings and behaviors), history of suicidal behavior and third degree burns over more than 60% of his body.
The 9/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed set up assistance with eating, oral hygiene, toileting and personal hygiene.
B. Record review
Resident #65's care plan, revised 10/10/24, revealed the resident had a Level II PASRR focus of at risk for complications due to meeting the criteria for referral for evaluation and treatment. The goal was to avoid complications of the mental health diagnosis to the extent possible. Interventions included to allowing the resident to make choices within decision making abilities, allowing the resident time to adjust to changes in routine and schedule, providing a psychiatric/psychology evaluation as indicated/ordered, and referring the resident the resident was referred for psychiatric psychiatric case consultation, therapy and crisis intervention/safety plan.
Resident #65's PASRR Level II, dated 9/13/24, documented the recommended treatment was to provide psychiatry case consultation, case management, individual therapy and a crisis intervention/individual safety plan.
The 10/10/24 progress note documented a referral was sent per Resident #65's request for counseling.
A review of the October 2024 CPO revealed a physician's order for a counseling referral was placed on 10/10/24.
-However, the facility failed to process the referral until 10/10/24, three weeks after the Level II PASRR notice of determination was received.
III. Resident #43
A. Resident status
Resident #43, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included bipolar disorder (mental disorder that causes abnormal shifts in a person's mood and behavior), acute and chronic respiratory failure and muscle wasting.
The 9/3/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She had no behaviors and did not reject care. The resident was dependent on staff with transfers, toilet use, personal hygiene and bathing.
B. Record review
Resident #43's care plan, revised 8/12/24, documented the resident had a level II PASRR for self isolation and a medical diagnosis that required adjunctive behavioral care. The interventions included a focus of staff to work with the resident to enhance her quality of life by implementing the PASRR Level II recommendations to prevent and mitigate effects of the major mental illness. The interventions included providing a psychiatry consultation and providing individual therapy.
A behavioral health services referral was documented on 3/22/24 for Resident #43.
A therapy progress note was entered on 6/17/24.
A review of the residents October 2024 CPO did not reveal a physician's order for behavioral health services.
-A review of Resident #43's electronic medical record (EMR) did not reveal additional documentation that the resident was receiving behavioral services.
IV. Staff interviews
The social service director (SSD) was interviewed on 10/15/24 at 1:00 p.m. The SSD said it was her responsibility to facilitate referrals for behavioral health services. She said she had referred Resident #43 to behavioral health services, then referred the resident to another behavioral health services provider and when that provider vacated the position. The SSD said she did not have documentation indicating she initiated a new referral for Resident #43 upon the behavioral health services provider leaving their position at the facility. The SSD said she needed help and was not able to keep up with all of her responsibilities and did not have an assistant to help her.
The SSD said a referral for behavioral health services for Resident #65 was sent on 10/10/24 and the notice of determination was obtained on 9/19/24. She said a week was a reasonable amount of time to expect a referral to be sent.
-However, Resident #65's notice of determination was received on 9/19/24 and a referral to behavioral health services was not completed until 10/10/24 (during the survey).
The director of nursing (DON) was interviewed on 10/15/24 at 5:01 p.m. The DON said she was not aware that behavioral health services were not being provided for Resident #43 or Resident #65. She said the SSD needed help to ensure the residents receive the care they need.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure services provided to residents met profession...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure services provided to residents met professional standards of quality for one (#15) of one resident out of 39 sample residents.
Specifically, the facility failed to ensure Resident #15's as needed (PRN) pain medications had physician ordered parameters related to the strength of the medications and the severity of the resident's pain level (on a pain scale of 1-10).
Findings include:
I. Professional Reference
According to the Society for Post Acute and Long-term Care (AMDA), Pain Management clinical practice guideline (2021) , retrieved on 10/17/24 from: https://paltmed.org/sites/default/files/2024-02/PainManagement2021CPGFinal.pdf,
Levels of pain management identify pain levels by severity. Non-opioid analgesics for mild pain, low potency opioids for moderate pain, high potency opioids for severe pain, and adjunctions combined with any step.Giving PRN analgesics based on guesswork may limit the benefits and increase the risk of harm. Orders for PRN analgesics need to be clear and specific about the location and type of pain that they are intended to treat.
II. Facility policy and procedure
The Administering Medications policy and procedure, dated April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, If a resident uses PRN medications frequently, the attending physician and interdisciplinary care team,with support from the consultant pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.
III. Resident Status
Resident #15, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar disorder and diabetes mellitus.
The 7/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.
IV. Record Review
Review of Resident #15's October 2024 CPO revealed the following physician's orders:
Oxycodone oral tablet 5 milligrams (mg). Give 5 mg by mouth every six hours as needed for pain,ordered 9/29/24.
-There were no administration parameters for the level of pain the medication should be given for.
Tramadol oral tablet 50 mg. Give 50 mg by mouth every six hours as needed for pain, ordered 9/28/24.
-There were no administration parameters for the level of pain the medication should be given for.
Tylenol (acetaminophen) oral tablet 325 mg. Give two tablets by mouth every six hours as needed for fever/chills or mild pain.
-The order indicated the Tylenol should be given for mild pain, however, there was no indication as to what mild pain was on a scale of 1-10.
Resident #15's pain management care plan, initiated 1/5/24, revealed the resident was at risk for pain or discomfort due to general decline. The goal was for the resident's pain to be relieved to a tolerable level as indicated by the resident, using verbal or nonverbal communication to the extent possible.
Interventions included assessing the resident for non-verbal indicators of pain and assessing the resident's pain every shift as indicated.
V. Staff Interviews
Licensed practical nurse (LPN) # 1 was interviewed on 10/15/24 at 11:36 a.m. LPN #1 said PRN pain medications should have pain perimeters. LPN #1 said a resident was asked to verify their pain level on a pain scale of 1-10 and to describe where the pain was. LPN #1 said the physician's orders were reviewed for the pain perimeters for which strength of medication to give.
LPN #1 said if a resident was non-verbal she would use a non-verbal pain scale. LPN #1 said she assessed facial expressions and body tension to determine a pain scale level and then medicated the resident for pain based on the severity of pain and medication order.
LPN #3 was interviewed on 10/15/24 at 11:38 a.m. LPN #3 said some pain medications were scheduled and some were PRN. LPN #3 said the physician's orders should have pain scale parameters. LPN #3 said each medication should specify what level of pain, on a 1-10 pain scale, the medication should be given for. LPN # 3 said if a resident requested a specific medication she would verify if their reported pain level met the ordered pain level parameter.
LPN #3 reviewed the PRN pain medication orders for Resident #15. LPN #3 said she thought there should be pain scale parameters for each medication, but she said she would verify it with the director of nursing (DON). LPN #3 said the PRN pain medication orders for Resident #15 were ordered by an emergency department physician.
The DON and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said pain medications should have administration parameters to indicate what level of pain each medication should be given for.
The RCC said the facility had reviewed, updated and audited the PRN pain medication orders for Resident #15 (during the survey).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the resident representative with the proper discharge noti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the resident representative with the proper discharge notifications for one (#182) of two residents out of 39 sample residents.
Specifically, the facility failed to develop and implement a collaborate discharge plan with Resident #182
Findings include:
I. Facility policy and procedure
The Facility-Initiated Transfer or Discharge policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part,
A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility.
II. Resident #182
A. Resident status
Resident #182, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus, depression and history of traumatic brain injury.
The 9/26/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required setup assistance with dressing and eating and supervision with personal hygiene and toileting. The resident had hallucinations and physical and verbal behavioral symptoms directed towards others.
-The assessment indicated active discharge planning was not occurring for the resident.
-The assessment indicated no referral had been made to the local contact agency and the reason was referral not wanted.
B. Record review
A behavior note, documented on 10/3/24 at 7:52 p.m., revealed referrals were sent to many memory care facilities for placement and the facility would keep Resident #182 safe until he could be transferred to a more appropriate facility.
A behavior note, documented on 10/8/24 at 3:48 p.m., revealed the resident entered a female resident's room without permission the prior evening and kissed her. The facility was actively seeking placement at other facilities for appropriate placement of Resident #182 and the referral process was prioritized to maintain the safety and security of the community.
A behavior note, documented on 10/11/24 at 4:12 a.m., revealed the resident was exhibiting behaviors of fear, agitation, anger, anxious, restless, and combativeness. The resident was hallucinating and hit and kicked multiple staff members. The facility called 911 to assist staff and the resident was transported to the hospital for evaluation.
-There was no documentation in Resident #182's EMR to indicate the resident or resident representative had been involved in the development of a discharge plan for the resident.
C. Staff interviews
The social services director (SSD) was interviewed on 10/15/24 at 12:49 p.m. The SSD said Resident #182's discharge planning process was not documented in the resident's EMR or the resident's comprehensive care plan.
The regional clinical consultant (RCC) was interviewed on 10/15/24 at 5:00 p.m. The RCC said the discharge process should be documented in the resident's medical record and be included as part of the comprehensive care plan.
The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the SSD was responsible for documenting the active discharge plan and developing the discharge plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#24) of four residents reviewed for assistance with ADLs out of 39 sample residents.
Specifically, the facility failed to ensure Resident #24's fingernails were trimmed and clean.
Findings include:
I. Facility policy
The Activities of Daily Living (ADL), Supporting policy, revised March 2018, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:30 p.m. It read in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.
Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.
Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care).
A resident's ability to perform ADLs will be measured using clinical tools, including the MDS (minimum data set) assessment, functional decline or improvement will be evaluated in reference to the assessment reference date (ARD).
Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.
The resident's response to interventions will be monitored, evaluated and revised as appropriate.
II. Resident #24
A. Resident status
Resident #24, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease and chronic obstructive pulmonary disease (COPD).
The 8/30/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required setup or clean up assistance with eating and oral hygiene.
He required substantial/maximal assistance with toileting hygiene, showering/bathing himself and upper and lower body dressing.
B. Observations and resident interview
On 10/10/24 at 4:03 p.m. Resident #24's finger nails were long and dirty. His fingernails extended past the tip of his fingers and had brown matter underneath them.
Resident #24 said he wanted his fingernails cut. He said he did not know the last time his fingernails were trimmed.
C. Record review
The ADL care plan, revised on 3/10/23, documented Resident #24 had an ADL self-care performance deficit related to cellulitis, deep vein thrombosis (DVT), anaphylaxis episode and history of venous ulcers. The resident preferred a sponge bath as an alternative when he did not want a shower. Interventions included bathing/showering, checking nail length and trimming and cleaning on bath days and as necessary, reporting any changes to the nurse, offering a sponge bath two to three times a week and providing a sponge bath when a full bath or shower could not be tolerated.
D. Staff interviews
Licensed practical nurse (LPN) #6 was interviewed on 10/10/24 at 4:05 p.m. LPN #6 said Resident #24's fingernails were long and dirty. She said staff should be washing residents' hands all the time. She said residents' fingernails should be trimmed every couple of weeks. She said if the resident's nails were not trimmed, the residents could hurt themselves. She said staff should be keeping the residents' nails clean and trimmed.
The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said nail care should be done as needed and should be checked during bathing. She said CNAs should be cleaning residents' hands and checking their nails. She said the nurses would do the trimming of fingernails when necessary. The DON said staff should be cleaning residents' hands multiple times per day to keep their hands and nails clean.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were provided services that meet professional standards for one (#51) of one resident out of 39 sample residents.
Specifically, the facility failed to ensure Resident #51's leg wraps for lymphedema (a chronic condition that causes swelling due to a buildup of lymph fluid in the body) were ordered in a timely manner.
Findings include:
I. Resident status
Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included lymphedema, heart disease, and obesity.
The 9/24/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for dressing and personal hygiene.
II. Record review
A progress note documented by the nurse practitioner (NP), dated 9/17/24 at 11:15 a.m., revealed Resident #51 was referred to the lymphedema clinic and the NP requested the facility obtain lymphedema wraps for the resident.
-However, a physician's order for the lymphedema wraps was not entered into Resident #51's electronic medical record (EMR), which resulted in the resident not receiving the recommended treatment.
The care plan for risk of skin breakdown was revised on 8/28/23. An intervention was to administer treatments as ordered. There was not a care plan for edema (swelling) or use of the wraps.
III. Staff interviews
The director of nursing (DON) was interviewed on 10/14/24 at 1:00 p.m. The DON said they had problems finding someone to come to the facility to measure Resident #51's legs for the lymphedema wraps. She said measuring the legs was a specialized service and there were specific companies designated to do so.
The regional clinical consultant (RCC) sent an email on 10/14/24 at 1:48 p.m. which indicated the DON had entered a physician's order into Resident #51's EMR for the leg wraps and documented a progress note. The RCC said the facility was working with the director of rehabilitation to get the needed measurements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to mai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#18) of one resident out of 39 sample residents.
Specifically, the facility failed to arrange optometry services timely for Resident #18.
Findings include:
I. Resident #18
A. Resident status
Resident #18, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body).
The 9/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. He required partial/moderate assistance for upper body dressing and personal hygiene. He required supervision or touching assistance with oral hygiene.
The assessment indicated the resident had adequate vision and had corrective lenses.
B. Resident observation and interview
On 10/9/24 at 3:41 p.m. Resident #18 said he had asked to be seen by the eye doctor and had not been seen. He said he needed glasses to see.
During the interview, Resident #18 was not wearing eyeglasses.
C. Record review
A 9/19/24 admission summary note documented Resident #18 indicated that he would like a dental and vision referral.
The activities care plan, initiated on 9/23/24, documented Resident #18's activities of interest included driving, cooking barbeque, camping, hiking, watching preferred television choices, going outdoors, socializing with peers and listening to music such as R&B and oldies. Interventions included staff making sure the resident had his glasses on during group activities of interest due to a visual deficit.
The ancillary care plan, initiated 10/14/24, documented Resident #18 would have access to audiology, dental, podiatry and ophthalmology services quarterly per request and/or as needed. Interventions included ensuring eye health and visual acuity, performing regular eye exams to detect vision changes and eye conditions, as tolerated prescribing and managing eyeglasses or contact lenses, if needed treating common eye conditions (cataracts, glaucoma) and educating Resident #18 on eye care and safety measures.
-There was no documentation in Resident #18's electronic medical record (EMR) to indicate the resident had been referred to see the eye doctor.
-A consent for vision services was not obtained until 10/4/24.
D. Staff interviews
The social services director (SSD) was interviewed on 10/15/24 at 12:46 p.m. The SSD said when she started working at the facility in October of 2023, none of the residents had been reviewed or referred for ancillary services. She said most of the new admissions were caught up, however, she said recently she had struggled with referring residents for ancillary services, such as vision services timely. She said she was doing the best she could but it had been hard for her to keep up.
The SSD said ancillary services were offered every quarter and upon admission. She said she went over ancillary services during care conferences or in conversation. She said she would ask the residents if they needed vision, hearing or dental services.
The SSD said the eye doctor came to the facility quarterly. She said the eye doctor would be at the facility on 10/22/24 and she would make sure Resident #18 was seen.
The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said ancillary services, including vision services should be offered to all residents. She said she did not know how often residents were referred for ancillary services. She said residents needing to be seen by the eye doctor should be seen every six months.
The DON said social services was responsible for scheduling ancillary appointments, along with the interdisciplinary team (IDT) involvement. She said ancillary services should be arranged and scheduled timely. The DON said Resident #18 should have been seen by the eye doctor more timely.
The nursing home administrator (NHA) was interviewed on 10/15/24 at 6:00 p.m. The NHA said social services was responsible for scheduling ancillary services. She said she recognized the SSD needed help to be able to submit referrals and complete her job duties timely. She said ancillary services should be submitted timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#65) of two residents reviewed for accidents out of 39...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#65) of two residents reviewed for accidents out of 39 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards.
Specifically, the facility failed to implement a plan of care that adequately addressed the risks posed to Resident #65 and other residents in the facility due to Resident #65's smoking habit and history of self-inflicted injury from fire.
Findings include:
I. Facility policy and procedure
The Smoking policy, dated 6/17/24, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part, Smoking is a privilege. To be an independent smoker, residents must demonstrate that they are safe to smoke by staff assessment and must comply with all smoking rules.
II. Resident #65
A. Resident status
Resident #65, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included schizophrenia (a chronic illness that effects a persons thoughts, feelings and behaviors), history of suicidal behavior and third degree burns over more than 60% of his body.
The 9/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed set up assistance with eating, oral hygiene, toileting and personal hygiene.
B. Record review
The admission assessment was completed on 9/19/24 by licensed practical nurse (LPN) #7. It documented the resident did not smoke and did not use tobacco products.
A smoking assessment was completed on 9/25/24 at 5:08 p.m. by registered nurse (RN) #1. The assessment revealed Resident #65 smoked, smoked over ten times per day, was able to light his own cigarettes and was able to smoke without supervision.
The trauma care plan, initiated on 10/10/24, revealed Resident #65 was at risk for decreased psychosocial well being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to being in a self inflicted fire or explosion and triggered by conversations about this event when not prompted or initiated by self. The resident's goal was to demonstrate effective coping strategies. The interventions included monitoring Resident #65 for signs and symptoms of decreased psychosocial wellbeing, adjustment issues, emotional distress, ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing and reporting abnormal findings to the physician, and avoid triggering the resident by not engaging or initiating questions regarding the self inflicted fire that resulted in his burns.
The psychosocial care plan, initiated 10/10/24, identified the resident had a history of hallucinations, suicidal ideations and delusions which were controlled by medications. The goals were to have the residents' psychosocial needs met and minimize the risk for decline in mood and behavior. The interventions included allowing the resident to voice his feelings and frustrations as indicated and to observe for tearfulness, increased agitation and decreased participation in care.
-A review of Resident #65's comprehensive care plan did not reveal a care plan that addressed the resident's smoking.
-A review of Resident #65's electronic medical record (EMR) did not include documentation to indicate the facility's plan to monitor Resident #65 who had a history of self-inflicted burns, smoked independently and had possession of a lighter
III. Staff interviews
The social service director (SSD) was interviewed on 10/15/24 at 12:29 p.m. The SSD said Resident #65 obtained the burns on his body by dousing himself in gasoline at a gas station and then lighting himself on fire two years ago prior to his admission to the facility. She said he was hallucinating and hearing voices when that incident occurred and was subsequently diagnosed with schizophrenia and put on medication. She said the facility only had one supervised smoker (this was not Resident #65). She said she was not aware that Resident #65 was not supervised during smoking. The SSD said there should have been a safety plan in place and a care plan to address Resident #65's safety when smoking. She said Resident #65 should be supervised when smoking due to his history of self inflicted burns.
RN #2 was interviewed on 10/15/24 at 1:21 p.m. RN #2 said she was aware of how Resident #65 obtained the burns on his body and she was not aware he was smoked. She said RN #1 usually was responsible for completing the smoking assessments for residents. RN #2 said upon reflection she did remember seeing cigarettes and a lighter on the resident's dresser in his room recently.
The assistant director of nursing (ADON) was interviewed on 10/15/24 at 1:24 p.m. The ADON said she was aware of how Resident #65 obtained the burns on his body. She said he was not safe to smoke unsupervised.
The NHA and the director of nursing (DON) were interviewed together on 10/15/24 at 1:49 p.m. The DON said Resident #65 denied smoking upon admission. She said the resident did not exhibit concerns of fire safety upon admission. She said she was not aware the resident currently smoked.
The NHA said Resident #65 was able to smoke independently. She said he deserved the autonomy to be able to smoke until he showed otherwise.
IV. Facility follow-up
The NHA provided documentation on 10/15/24 at 6:00 p.m. that showed Resident #65 would be evaluated daily to continue to smoke independently for the next 90 days to ensure the safety of Resident #65 and the residents in the community.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure one (#3) of one resident out of 39 sample residents were fre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure one (#3) of one resident out of 39 sample residents were free of significant medication errors.
Specifically, the facility failed to ensure the insulin pen was primed prior to administration for Resident #3.
Findings include:
I. Professional reference
According to the Tresiba product information, dated July 2022, retrieved on 10/16/24 from https://www.mynovoinsulin.com/insulin-products/tresiba/support-and-resources/videos-and-resources.html, Priming the pen, turn the dose selector to 2 (two) units, hold the pen with the needle pointing up, tap the pen gently to allow any air bubbles to ride to the top, depress and hold the dose button with the needle pointing up.
II. Facility policy and procedure
The Administering Medications policy and procedure dated, April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part,
Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (quality assurance and performance improvement) committee to inform process changes and or the need for additional staff training.
Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies that the correct pen is used for that resident.
III. Resident #3
A. Resident status
Resident #3, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus.
The 8/30/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.
B. Observation
On 10/10/24 at 9:02 a.m. licensed practical nurse (LPN) #2 was preparing and administering medications for Resident #3.
LPN #2 entered the room of Resident #3 with the resident's Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml. LPN #2 turned the dial on the insulin pen to read 50 units, cleaned the injection site on the resident's abdomen and administered the insulin to the resident.
-LPN #2 did not prime the insulin pen prior to administering the insulin to the resident.
C. Record review
The October 2024 CPO documented the following physician's order:
-Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliter). Inject 50 units subcutaneously in the morning for diabetes mellitus, ordered 8/23/24.
IV. Staff interviews
LPN #2 was interviewed on 10/10/24 at 9:28 a.m. LPN #2 said when she administered insulin, she would turn the dial on the insulin pen to the ordered unit dose. LPN #2 said she would clean the skin with an alcohol prep pad then injects insulin being sure to rotate injection sites.
The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said an insulin pen should be primed prior to administration. She said the insulin pen should be dialed to two units and the insulin expelled from the pen prior to drawing up the prescribed dose of insulin The DON said it was important to prime the insulin pen to ensure the resident had received the full dose of insulin.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for four (#7, #17, #33 and #39) of four residents reviewed for personal f...
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Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for four (#7, #17, #33 and #39) of four residents reviewed for personal funds accounts out of 39 sample residents.
Specifically, the facility failed to notify Residents #7, #17, #33 and #39, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person.
Findings include:
I. Record review
A copy of residents' personal funds account balances, as of 10/15/24, was provided by the business office manager (BOM) on 10/15/24 at 5:06 p.m. It revealed in pertinent part,
-Resident #7 had an account balance of $2,671.23 which was $671.23 over the allotted $2000.00 eligibility limit for Medicaid funded residents.;
-Resident #17 had an account balance of $2,585.18 which was $585.18 over the allotted $2000.00 eligibility limit for Medicaid funded residents.;
-Resident #33 had an account balance of $3,575.87 which was $1,575.87 over the allotted $2000.00 eligibility limit for Medicaid funded residents.; and
-Resident #39 had an account balance of $2,681.23 which was $681.23 over the allotted $2000.00 eligibility limit for Medicaid funded residents
II. Staff interviews
The BOM was interviewed on 10/15/24 at 4:46 p.m. and again at 5:06 p.m. The BOM said she was responsible for managing the personal funds accounts for the residents at the facility. She said a personal funds account was offered to each resident upon admission and the facility provided account balance statements to residents every quarter.
The BOM said each resident and/or their responsible party was responsible to spend down their account to ensure they did not exceed the allotted Medicaid allowed amount of $2000.00. She said if a resident exceeded the allotted $2000.00, the resident could be at risk of losing their Medicaid status.
The BOM said she was aware there were four accounts that were significantly over the allotted $2000.00 Medicaid amount. She said she had just started working for the facility in August 2024. She said the facility had not yet notified the residents and/or their responsible parties about the spend down amounts for Resident #7, #17, #33 and #39. The BOM said she would provide the list to the nursing home administrator (NHA) and get started on the spend down for the residents.
The NHA was interviewed on 10/15/24 at 6:00 p.m. The NHA said the BOM was responsible for monitoring the residents' personal accounts to ensure they did not exceed the allotted Medicaid amount of $2000.00. She said if a resident's account exceeded the allotted amount, then the resident could be at risk of losing their Medicaid status.
The NHA said she was informed in August 2024 that one resident's account was over the allotted amount, however, she was not aware there were four other residents' accounts that had exceeded the $2000.00 limit. She said she would work with the BOM immediately to contact the residents and their family members to spend down the money.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Resident #66
A. Resident status
Resident #66, under the age [AGE], was admitted on [DATE]. According to the October 2024 CPO...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VI. Resident #66
A. Resident status
Resident #66, under the age [AGE], was admitted on [DATE]. According to the October 2024 CPO, diagnoses included anoxic brain damage (lack of oxygen to the brain) and persistent vegetative state.
The 11/13/23 MDS assessment revealed the resident had severe cognitive impairment and a BIMS assessment was unable to be conducted. He required total staff assistance with oral hygiene, toileting hygiene, showering/bathing himself, upper and lower body dressing, personal hygiene and rolling left and right.
B. Record review
The activities of daily living (ADL) self-care deficit care plan, revised on 11/3/23, documented Resident #66 had actual ADL/mobility decline and required assistance related to vegetative state. Interventions included providing the assistance of one to two people for ADLs.
The 9/19/24 rehabilitation screening form documented Resident #66 would benefit from occupational therapy (OT) to assess for a restorative nursing program (RNP) to follow through with upper extremity (UE) range of motion (ROM) and splinting.
-Review of Resident #66's EMR revealed there was no documentation regarding restorative services being provided for Resident #66.
C. Staff interviews
The MDS coordinator (MDSC) was interviewed on 10/15/24 at 3:58 p.m. MDSC said Resident #66 had been on a restorative program and then had been back and forth to the hospital several times. She said Resident #66 should have been restarted on restorative services for passive range of motion for his wrist and joints. The MDSC said it was important for Resident #66 to receive restorative services so he did not get contractures. She said therapy would be evaluating the resident tomorrow (10/16/24) and recommending a new restorative program for him.
The DON was interviewed on 10/15/24 at 5:00 p.m. The DON said she was not aware that she had to re-initiate the restorative program when Resident #66 returned from the hospital. She said she was not made aware that the resident was not receiving the passive range of motion services. She said Resident #66 would be evaluated again by therapy and put on a restorative program tomorrow (10/16/24).
The NHA was interviewed on 10/15/24 at 6 p.m. The NHA said she thought the restorative issues had been corrected. She said she would be meeting with the RNAs weekly to look at restorative documentation going forward.
Based on observations, record review and interviews, the facility failed to ensure three (#43, #51 and #66) 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 39 sample residents.
Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #43, Resident #51 and Resident #66 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, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It 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 #43
A. Resident status
Resident #43, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 computerized physicians orders (CPO), diagnoses included muscle weakness, chronic kidney disease, bipolar disorder, acute and chronic respiratory failure and muscle wasting.
The 9/3/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff with transfers, toilet use, personal hygiene and bathing.
The assessment indicated the resident had no behaviors and did not reject care.
According to the MDS assessment, the resident did not receive restorative nursing services and the last time the resident received physical therapy services was on 8/28/24 for a total of 31 minutes.
B. Record review
A review of a list of residents on restorative programs documented Resident #43 was on a restorative program.
A review of the restorative nurse aides (RNA) range of motion task charting from 9/11/24 to 10/11/24, a period of 30 days, revealed documentation that Resident #43 refused restorative services on 9/16/24.
-There was no other documentation of the resident having received restorative services.
-A review of Resident #43's October 2024 CPO did not reveal any physician's orders for restorative services.
-A review of the resident's comprehensive care plan did not reveal a care plan focus for restorative services.
III. Resident #51
A. Resident status
Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included lymphedema, heart disease and obesity.
The 9/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for dressing and personal hygiene.
B. Resident interview
Resident #51 was interviewed on 10/9/24 at 9:19 a.m. Resident #51 said her restorative program was not done as often as it was supposed to be. She said the facility had cut back on the restorative services program. Resident #51 said she was supposed to have restorative services two to three times per week but that had not happened. She said she needed restorative services because her knees were bone on bone and she needed to do what she could to maintain her abilities.
C. Record review
A review of a list of residents on restorative programs documented Resident #51 was on a restorative program.
A review of the RNA restorative range of motion task charting revealed Resident #51 had two restorative sessions from 9/11/24 to 10/11/24, a period of 30 days.
-A review of Resident #51's October 2024 CPO did not reveal any physician's orders for restorative services.
A review of the residents comprehensive care plan did not reveal a care plan focus for restorative services.
IV. Additional record review
A performance improvement plan (PIP) was provided by the director of nursing (DON) on 10/14/24 at 1:00 p.m. The PIP was dated 8/20/24 and read in pertinent part,
It was identified that the facility failed to ensure that the documentation by the MDS nurse, RNAs and the DON was not completed accurately and there are many residents that have incomplete assessments and chart notes. The DON did not complete the attestations and the MDS nurse or the DON did not consistently enter notes in the chart of residents receiving restorative services. The RNAs did chart but the charting lacks substance and is not concise.
A restorative team of the DON, the MDS nurse, RNA and the DOR (director of rehabilitation) was formed to evaluate the charting process and implemented a training meeting to ensure that the documentation is concise and completed promptly.
The RNAs will complete the comments section of the RNA weekly summary with a note about the resident's response to the restorative treatment they received.
The MDS nurse and the DON will complete restorative notes going forward and will discuss outstanding documentation weekly.
The DON will complete the attestations monthly.
The RNAs will complete 6 (six) days of restorative with 2 (two) programs consisting of 15 minutes each to capture on the MDS assessment.
Audit in 4 (four) weeks to evaluate the effectiveness of the new charting process - the expectation is that a 25% (percent) improvement in restorative charting will be achieved within the first month and charting will improve to reflect 100% compliance within the next 60 days.
-However, record review for Resident #43 and Resident #51 revealed there was no documentation to indicate the residents were receiving their restorative programs (see record review above).
V. Staff interviews
The DON was interviewed on 10/14/24 at 1:00 p.m. The DON said the facility had a PIP in place for the restorative program. She said the facility went some time without a restorative program and realized they needed to train staff. She said the restorative program was back in full effect.
-However, record review for Resident #43 and Resident #51 revealed there was no documentation to indicate the residents were receiving their restorative programs (see record review above).
-The NHA provided a clarification email on 10/14/24 at 1:25 p.m. The NHA's email said the facility had had daily coverage for the restorative program for the past year and a half and the only time restorative staff were pulled from the program was when a scheduled certified nurse aide (CNA) called out sick or went on break.
The restorative program supervisor (RNAS) was interviewed on 10/15/24 at 3:58 p.m. The RNAS said when a resident was placed on a restorative program, she was responsible for adding the task for charting so the RNA was reminded to chart the restorative service. She said the restorative programs needed work and that was why the PIP was started in September 2024. The RNAS said she began looking at the restorative program during other training and realized the facility needed to be more compliant with the restorative services. She said it was the responsibility of the therapy department to train restorative staff on how to perform the restorative programs.
The RNAS reviewed the electronic medical records (EMR) for Resident #43 and Resident #51 and said she was not able to find documentation that restorative services were provided to either resident. She said if restorative services were not provided to the residents they would be at risk of decline in their functional abilities.
The DON was interviewed a second time on 10/15/24 at 5:14 p.m. The DON said she began helping with the restorative program at the end of August 2024 when she found the restorative RNAs did not have access to the facility's electronic charting system in order to document the restorative services. She said a recent audit of resident restorative programs (during the survey) confirmed the RNAs were still not documenting appropriately.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater.
Specifically, the medication administration ob...
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Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater.
Specifically, the medication administration observation error rate was 14.63%, or six errors out of 41 opportunities for error.
Findings include:
I. Facility policy and procedure
The Administering Medications policy and procedure, dated April 2019, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part,
Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI (quality assurance and performance improvement) committee to inform process changes and or the need for additional staff training.
II. Medication administration observations
On 10/10/24 at 9:02 a.m. licensed practical nurse (LPN) #2 was preparing and administering medications for Resident #3. The resident had a physician's order for Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliter). Inject 50 units subcutaneously in the morning for diabetes mellitus, ordered 8/23/24.
-LPN #2 entered the room of Resident #3 with the resident's Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml. She turned the dial on the insulin pen to read 50 units, cleaned the resident's abdominal injection site with a personal hygiene wipe and administered the insulin injection to the resident without priming the insulin pen.
Cross reference F760 for failure to ensure residents were free from significant medication errors.
On 10/10/24 at 9:28 a.m. LPN #2 was preparing and administering medications for Resident #49. The resident had physician's orders for the following medications:
Amlodipine Besylate oral tablet 10 mg (milligram), give one tablet by mouth one time a day for hypertension (HTN), hold for a systolic blood pressure (maximum blood pressure in your arteries when your heart beats) less than 110 mm/Hg (millimeters of mercury), ordered 7/27/2024.
-LPN #2 did not check Resident #49's blood pressure prior to administration.
Senna-Docusate Sodium oral tablet 8.6-50 mg, give 8.6 mg orally one time a day for bowel management, ordered 7/27/2024.
-LPN #2 administered two tablets of senna-docusate, not one tablet as indicated in the physician order.
On 10/15/24 at 9:04 a.m. LPN #5 was preparing and administering medications for Resident #43. The resident had physician's orders for the following medications:
Psyllium oral packet (Metamucil) 25%, give one packet by mouth in the morning for constipation, ordered 8/28/2024.
-The bulk bottle packaging directions read one rounded tablespoon, three times daily, however LPN #5 measured out three rounded plastic spoonfuls into one seven oz (ounce) glass.
Aspirin oral capsule 81 mg, give one tablet by mouth one time a day, for cerebellar stroke syndrome, ordered 8/28/2024.
-LPN #5 administered an 81 mg chewable aspirin tablet.
Milk of Magnesia oral suspension, give 30 ml by mouth every 24 hours as needed for constipation, ordered 8/27/2024.
-Resident #43 was administered the previous dose on 10/14/24 at 9:22 p.m., twelve hours prior.
III. Staff interviews
LPN #5 was interviewed on 10/15/24 at 9:37 a.m. LPN #5 said she used three spoonfuls of Metamucil because the package read one rounded tablespoon three times.
The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said an insulin pen should be primed prior to administering the insulin. She said the pen should be dialed to two units and the insulin expelled from the pen prior to drawing up the prescribed dose of insulin. The DON said it was important to prime the insulin pen prior to administration to ensure the resident received the full dose of insulin.
The DON said it was important to follow the physician's order when administering medications. The DON said if a resident received a higher amount of a medication, such as with the Metamucil, it could cause harm.
The RCC said physician's orders for bulk medications, such as Metamucil, should match the directions on the bulk medication bottle. She said she would review and edit the physician's orders for Metamucil to make them more clear. She said the physician's order should match the format the facility was using, for example bulk versus a packet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with accepted professional standards for two of three treatment carts a...
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Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with accepted professional standards for two of three treatment carts and one of three medication carts.
Specifically, the facility failed to:
-Ensure treatment carts were locked when unattended; and,
-Ensure medication carts were locked when unattended.
Findings include:
I. Facility policy
-The medication storage policy was requested from the facility but was not provided by the end of the survey on 10/15/24.
II. Observations
On 10/9/24 at 8:17 a.m. the treatment cart on the south hall was unlocked and unattended. Several residents and staff were walking in the hallway past the treatment cart. There were linens piled on top of the treatment cart.
At 8:23 a.m. the treatment cart on the north hall was unlocked and unattended. There were several residents in the hall near the cart.
At 2:14 p.m. the treatment cart on the south hall was unlocked and unattended. Residents were walking in the hallway, staff walked past the cart and maintenance walked past the cart. The cart remained unlocked until 2:33 p.m. when the nurse was notified and locked the cart.
On 10/10/24 at 8:37 a.m. the treatment cart on the north hall was unlocked and unattended. A resident in a wheelchair went past the cart.
At 8:39 a.m. the treatment cart on the south hall was unlocked and unattended. There were several residents walking by the cart in the hall.
At 9:12 a.m. the treatment cart on the north hall was still unlocked and unattended. The nurse was notified and the cart was locked.
At 1:41 p.m. the medication cart on the south hall was unlocked and unattended. A resident in a wheelchair went past the cart. Several staff members, including the director of nursing (DON), a therapy assistant and a certified nurse aide (CNA) passed the cart and the DON walked past the cart a second time. None of the staff members observed that the medication cart was unlocked. The nurse returned to the cart from a resident's room over 15 feet away from the cart at 1:46 p.m. and locked the cart at 1:51 p.m.
III. Staff interviews
An unidentified agency nurse was interviewed on 10/9/24 at 8:24 a.m. The agency nurse said the treatment cart should be locked when it was unattended so residents did not get into it. She said she had just arrived at the facility and the night shift staff must have left it unlocked.
The DON was interviewed on 10/15/24 at 5:01 p.m. The DON said the treatment carts and medication carts should be locked when unattended. She said the carts had scissors and medications in them that would be dangerous to residents with mental health issues and wandering behaviors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assist residents in obtaining routine or emergency dental services as needed for three (#18, #32 and #51) of four residents reviewed for dental services out of 39 sample residents.
Specifically, the facility failed to ensure dental services were offered to Resident #18, Resident #32 and Resident #51.
Findings include:
I. Facility policy
The Emergency Dental Care policy, revised April 2007, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:30 p.m. It read in pertinent part, Emergency dental care is available to all residents of this facility.
Emergency dental care is available on a twenty-four (24) hour basis.
Should a resident need emergency dental care, the dental consultant shall be notified so that arrangements for the emergency care can be made.
Social services shall contact the consultant dentist to set up the appointment. Should social services be unavailable, the charge nurse shall contact the consultant dentist.
Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate, broken, or otherwise damaged teeth or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention.
II. Resident #18
A. Resident status
Resident #18, age [AGE], was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body).
The 9/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of nine out of 15. He required partial/moderate assistance for upper body dressing and personal hygiene. He required supervision or touching assistance with oral hygiene.
The MDS assessment indicated the resident had no dental issues and was edentulous (did not have teeth).
B. Resident interview and observation
Resident #18 was interviewed on 10/9/24 at 3:42 p.m. Resident #18 said he had asked to be seen by the dentist and had not seen the dentist since he was admitted to the facility. He said he would like to see the dentist and get dentures. He said he would like to eat hard food, such as steak.
An observation of Resident #18's mouth during the interview revealed the resident had no teeth.
C. Record review
The care plan for nutrition, revised 9/16/24, documented Resident #18 had potential risk for altered nutritional intake related to being edentulous, left hemiplegia (paralysis of one side of the body), denied chewing difficulty and fed himself after some set-up assistance. Interventions included evaluating the need for assistance with eating and drinking as needed providing meal set-up assistance if needed, providing food preferences per resident choice and observing for signs and symptoms of dysphagia (swallowing difficulties) as evidenced by pocketing food in the mouth, coughing, choking, drooling or holding foods in mouth.
The 9/19/24 admission summary note documented Resident #18,would like a dental and vision referral.
The ancillary care plan, initiated 10/14/24, documented Resident #18 would have access to audiology, dental, podiatry and ophthalmology services quarterly, per request, and/or as needed. Interventions included ensuring oral health and preventing dental issues, scheduling regular dental check-ups and cleanings, providing treatment for dental conditions (fillings, extractions) as needed, educating Resident #18 and staff on oral hygiene practices and monitoring denture care and adjustments, if needed.
-Review of Resident #18's electronic medical record (EMR) revealed there was no documentation indicating that a referral had been made for the resident to be seen by the dentist.
-A consent for dental services was signed on 10/4/24, however, there was no documentation that the resident was referred to be seen by the facility's dental provider since his admission
III. Resident #32
A. Resident status
Resident #32, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included anxiety disorder and depression.
The 8/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required setup or clean-up assistance with eating and oral hygiene.
The MDS assessment indicated the resident had no dental issues and was edentulous.
-However, the resident had upper and lower teeth which were chipped (see resident observation and interview below).
B. Resident interview and observation
Resident #32 was interviewed on 10/9/24 at 2:20 p.m. Resident #32 said he had been asking to see the dentist since he was admitted to the facility. He said he had never been seen by the dentist. He said his teeth were bothering him and had some pain in his mouth. He said he had let staff know that he needed to be seen by the dentist and had not heard when he would be seen.
An observation of Resident #32's mouth during the interview revealed the resident had upper and lower teeth that were chipped and needed to be repaired.
C. Record review
A 3/27/24 nurse practitioner note documented Resident #32 presented with a chief complaint of tooth pain, which had been managed with ibuprofen. The resident was seeking further relief from his symptoms and required a dental appointment.
On 4/26/24 the social services note documented Resident #32 informed the social services director (SSD) of cracked teeth and tooth pain. The note indicated the SSD would submit an emergency evaluation to the dentist for the resident to be evaluated and treated by a dentist.
On 6/6/24 the dental note documented Resident #32 was on the facility dentist's schedule for dental treatment, however, Resident #32 was in the hospital.
The ancillary care plan, revised 8/7/24, documented Resident #32 would have access to audiology, dental, and ophthalmology services quarterly, per the resident's request, and/or as needed. Interventions included ensuring oral health and preventing dental issues, scheduling regular dental check-ups and cleanings, providing treatment for dental conditions (fillings, extractions) as needed, educating Resident #32 and staff on oral hygiene practices and monitoring denture care and adjustments.
On 9/5/24 a progress note documented Resident #32 was not seen by the dentist and he was placed on the reserve list for the next dental visit.
On 9/5/24 the dental note documented Resident #32 was on the schedule to be seen for treatment, but the dentist ran out of time, so he was not seen.
IV. Staff interviews
The SSD was interviewed on 10/15/24 at 12:46 p.m. The SSD saidResident #18 requested to be seen by a dentist on 9/19/24 and was not referred to a dentist until 10/4/24. SSD said timely referral was considered to be within a week unless it was an emergency. She said when the dentist was at the facility on 10/10/24, he did not see half of the residents.
The SSD said Resident #32 was discharged from the facility to the hospital for surgery and was gone for a few months. She said when he came back from the hospital he was put back on the list to be seen by the dentist. She said she thought he was seen in August 2024. She said she would need to look to see if she was notified of the dental appointment mentioned by the medical doctor in March 2024.
The SSD said appointments for ancillary services were posted on the facility's communication board. She said the CNAs should be informing residents when the dentist was coming to the facility.
The director of nursing (DON) was interviewed on 10/15/24 at 5:00 p.m. The DON said ancillary services should be offered to all residents. She said she did not know often residents were referred for ancillary services. She said residents needing to be seen by the dentist should be seen at least every six months.
The DON said social services was responsible for scheduling ancillary appointments, along with the interdisciplinary team (IDT) involvement. She said ancillary services should be arranged and scheduled timely.
The nursing home administrator (NHA) was interviewed on 10/15/24 at 6:00 p.m. The NHA said social services was responsible for scheduling ancillary services. She said she recognized the SSD needed help to be able to submit referrals and complete her job duties timely. She said ancillary services should be submitted timely.V. Resident #51
A. Resident status
Resident #51, age greater than 65, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included lymphedema, heart disease and obesity.
The 9/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for dressing and personal hygiene.
B. Resident interview
Resident #51 was interviewed on 10/9/24 at 9:37 a.m. Resident #51 said she requested to see the dentist in September 2024, on a Friday. She said the dentist came on a Thursday instead and she was not notified or taken to see the dentist. Resident #51 said she still wanted to see the dentist and did not know when or if she was scheduled to see the dentist.
C. Record review
A 9/5/24 appointment progress note documented Resident #51 was not seen by the dentist on that date and was placed on the reserve list for the next dental visit.
-A review of the dental reserve list failed to show documentation of the resident's name on the list to see the dentist at the next visit to the facility.
Review of Resident #51's comprehensive care plan, revised on 8/12/24, revealed a care plan focus for ancillary services, to include dental needs. The goal was to provide ancillary services to maintain and improve the residents quality of life as needed or requested. The intervention for oral health was to ensure oral health and prevent dental issues by scheduling regular dental check ups and cleanings.
A review of the October 2024 CPO revealed the resident had physician's orders to see a dentist as needed.
D. Staff interviews
The DON was interviewed on 10/14/24 at 1:00 p.m. The DON said she was not aware that Resident #51 had requested to see the dentist and would look into why she was not seen.
The SSD was interviewed on 10/15/24 at 12:49 p.m. The SSD said the facility was having trouble with dental services from the existing provider and they had been looking for a backup dental provider. The SSD said Resident #51 did not have a dental emergency so she was referred to another dentist.
-However, there was no documentation in Resident #51's EMR to indicate a referral to another dentist had been made.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Failure to ensure glucometers were cleaned appropriately following use; and,
A. Professional reference
According to the Bas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Failure to ensure glucometers were cleaned appropriately following use; and,
A. Professional reference
According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 2257-2258, Select and clean a fingerstick site with an alcohol-based (or other antiseptic) pad. Allow the site to dry thoroughly. This helps protect the patient from infection by removing some surface microorganisms.
B. Facility policy and procedure
The Blood Sampling Capillary Finger Stick policy and procedure dated, September 2014, was provided by the nursing home administrator (NHA) on 10/15/24 at 6:00 p.m. It revealed in pertinent part, Wipe the area to be lanced with an alcohol pledget. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use.
The Administering Medications policy and procedure dated, April 2019, was provided by the NHA on 10/15/24 at 6:00 p.m. It revealed in pertinent part Staff follows established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions) for the administration of medications.
C. Observations
During a continuous observation on 10/10/24, beginning at 8:43 a.m. and ending at 10:00 a.m., the following was observed:
At 9:02 a.m. licensed practical nurse (LPN) #2 entered Resident #3's room to obtain the resident's blood sugar level with a glucose monitor LPN #2 used a personal hygiene wipe (not an alcohol wipe) to clean the hand of Resident #3 prior to completing a fingerstick for glucose monitoring. LPN #2 proceeded to use the same personal hygiene wipe to clean the glucometer before immediately placing the glucometer back in its plastic storage bag and exiting the room.
At 9:07 a.m. LPN #2 returned Resident #3's room with a Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (milliliters). LPN #2 cleaned the resident's abdominal injection site with a personal hygiene wipe and proceeded to administer the insulin injection to the resident.
D. Staff interviews
LPN #2 was interviewed on 10/10/24 at 9:25 a.m. LPN #2 said she cleaned Resident #3's fingers with a personal hygiene wipe because an alcohol prep pad could falsely increase the blood glucose reading. LPN #2 said she was instructed to use the personal hygiene wipe by the director of nursing (DON).
LPN #2 said the glucometers should be cleaned with an alcohol prep pad after each use.
-However, LPN #2 had been observed using a personal hygiene wipe to clean the glucometer after using it to obtain Resident #3's blood glucose level (see observation above).
LPN #2 said she used an alcohol prep pad to clean a resident's skin prior to the administration of insulin.
-However, LPN #2 had been observed using a personal hygiene wipe, instead of an alcohol wipe, to clean Resident #3's abdomen prior to the injection of the insulin (see observation above).
The DON and the regional clinical consultant (RCC) were interviewed together on 10/15/24 at 5:02 p.m. The DON said all the residents at the facility had their own glucometers and did not share. The DON said the glucometers should be cleaned according to manufacturer recommendations. She said the glucometers used at the facility should be cleaned with a bleach wipe, adhering to the manufacturer's recommended dwell time (the amount of time a disinfectant needs to remain wet on a surface to kill germs and achieve the desired level of disinfection).
The DON said, prior to performing a finger stick for glucose monitoring, Resident #3's finger should have been cleaned with soap and water or an alcohol prep pad and allowed to dry. The DON said it was important to clean the site prior to the injection in order to prevent infection, bloodborne illness or cross contamination. The DON said LPN should have cleaned the resident's injection site with an alcohol prep pad prior to administering the injection.
E. Facility follow up
On 10/10/24 at 10:45 a.m. a document was provided by the marketing director (MKD) along with the DON. The document was dated 10/10/24 at 10:13 a.m., during the survey. It documented that LPN #2 had been confused regarding cleaning Resident #3's finger for the fingerstick blood sugar and the injection site. The document indicated LPN #2 was educated by the DON regarding the proper procedure after the observation.
IV. Failure to ensure PPE was worn appropriately and appropriate infection control procedures were followed during wound care for a resident on EBP
A. Professional references
The Centers for Disease Control and Prevention (CDC) (2022), Donning and doffing personal protective equipment (PPE), was retrieved on 10/17/24 from: https://www.cdc.gov/niosh/learning/safetyculturehc/module-3/8.html
read in pertinent part, Donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure. The gown should fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. The gloves should extend to cover the wrist of the isolation gown.
According to the Basic Nursing third edition, Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022), page 1669-1673 read in pertinent part, Don the gown. [NAME] gloves. If you are wearing a gown, make sure that the glove cuff extends over the cuff of the gown. If skin is visible between the gown and the glove, tape the glove cuff to the gown cuff, covering all visible skin. To provide complete protection of hands and wrists, no skin should be visible between the glove and gown.
B. Observations
During a continuous observation on 10/10/24, beginning at 1:33 p.m. and ending at 2:06 p.m., the following was observed:
The assistant director of nursing (ADON) directed the wound care nurse (WCN) and certified nurse assistant (CNA) #1 to don PPE of a gown and gloves prior to entering Resident #45's room, who was on EBP.
-They did not perform hand hygiene prior to putting on the PPE.
After CNA #1 entered the room, the ADON directed CNA #1 to wash her hands. CNA #1 entered the resident's bathroom, performed hand hygiene and donned new gloves.
-CNA #1 had exposed wrists, as her gown sleeve was not tucked inside her gloves.
The ADON opened a clean trash liner and stood at the foot of the bed while the WCN performed the resident's wound care.
-The ADON's wrists and watch were exposed, as her PPE gown sleeves were not tucked inside her gloves. The ADON directed the WCN to wash his hand multiple times throughout the wound care process.
The ADON directed the WCN to sign and date the dressing. Wearing the same gloves he had used to perform the wound care, the WCN reached his gloved hand under his PPE gown to retrieve a marker from his scrub pocket to time and date the dressing.
C. Staff interviews
The DON said, prior to entering a room with EBP, facility staff should have performed hand hygiene and then donned a gown and gloves. The DON said that wrists, watches and bracelets should not have been exposed while wearing a gown and gloves.
The DON said, in order to prevent the potential spread of infection, staff should not reach under a protective gown to retrieve items from their pockets while wearing PPE.
Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.
Specifically, the facility failed to:
-Ensure housekeeping staff followed proper infection control procedures for cleaning resident rooms;
-Ensure residents were assisted with hand hygiene prior to meals;
-Ensure glucometers were cleaned appropriately following use; and,
-Ensure personal protective equipment (PPE) was worn appropriately and appropriate infection control procedures were followed during wound care for a resident on enhanced barrier precautions (EBP).
Findings include:
I. Failure to follow proper infection control procedures for cleaning resident rooms
A. Professional reference
According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 10/23/24 from https://www.cdc.gov/handhygiene/providers/index.html, Cleaning your hands reduces the spread of potentially deadly germs to patients.
Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers.
Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations.
Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom.
When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers.
Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin.
B. Facility policy and procedure
The Cleaning and Disinfecting of Resident Rooms policy, revised August 2013, was received from the nursing home administrator (NHA) on 10/15/24 at 6:37 p.m. It read in pertinent part,
Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.
Environmental surfaces will be disinfected (or cleaned) on a regular basis (daily, three times per week) and when surfaces are visibly soiled.
Manufacturers' instructions will be followed for proper use of disinfecting (or detergent) products.
Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled.
Perform hand hygiene after removing gloves.
C. Manufacturers guidelines
The manufacturer guidelines for the Micro-Kill Q3 disinfectant used by the facility were retrieved on 10/28/24 from https://www.medline.com/media/catalog/Docs/MKT/LITe21856_OTH_MicroKill%20Q3%20Technical.pdf. It read in pertinent part,
Micro-Kill Q3 is a concentrated one-step disinfectant formulated for general hospital cleaning and the disinfection of hard, nonporous, non-food surfaces. Micro-Kill R3 is EPA (environmental protection agency) approved for use against SARS-CoV-2 (cause of COVID-19). Requires a three-minute contact time for many bacteria and viruses. Eliminates odors and is fragrance-free. Soft surface spot sanitizer treatment.
D. Housekeeping observations
On 10/15/24 at 8:40 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER], a double occupancy room with EBP in place. HK #1 put on gloves and entered the room.
HK #1 sprayed Micro-Kill Q3 disinfectant on the door handle of the residents' room and immediately wiped it off. She proceeded to wipe the overbed table on one side of the room and then the other overbed table on the other side of the room.
HK #1 sprayed, and immediately wiped off, the first resident's walker, fan and dresser then proceeded to wipe the other resident's dresser with the same rag before walking into the bathroom.
HK #1 sprayed and immediately wiped the grab bar, the light switch and the towel bar in the residents' bathroom. She walked back to the resident's trash can and removed the trash bag. She put the trash bag in the receptacle on her cart and removed her gloves. Without performing hand hygiene, HK #1 put on new gloves and returned to the room.
HK #1 checked the temperature of the residents' refrigerator and went back to her cart to write down the temperature on the log sheet. She went back to the refrigerator and placed the temperature log back in its holder.
HK #1 went back to her cart and removed a dirty mop head, put a new dry mop head on the mop and proceeded to dry mop both sides of the room. She put the mop back on her cart, without removing the dirty mop head, her gloves or performing hand hygiene, and retrieved the toilet bowl cleaning wand from her cart.
HK #1 went back into the bathroom and cleaned the toilet bowl with the wand. After cleaning the toilet bowl, HK #1 wiped the top of the toilet with a paper towel. She did not spray the top of the toilet with disinfectant. She removed a urine output measuring cup from the top back of the toilet and used the urine-soiled paper towel it was sitting on to wipe the toilet seat and the area where the urine output measuring cup had been sitting.
HK #1 sprayed the bathroom mirror with glass cleaner and immediately wiped it off with a paper towel. Then she wiped the sink with a paper towel that was wet with water. She did not spray the area with disinfectant. HK #1 removed the trash from the bathroom and replaced the trash can liner. She removed her gloves and put new gloves on without performing hand hygiene. HK #1 poured disinfectant on the floor and wet mopped the entire room and bathroom. She swept the trash from the pile she made while mopping the floor. HK #1 finished cleaning the room at 8:52 a.m.
-HK #1 did not perform hand hygiene before she started cleaning room [ROOM NUMBER].
-HK #1 did not perform hand hygiene between glove changes.
-HK #1 did not use separate rags or mop heads for each side of the residents' room or the bathroom.
-HK #1 did not clean all of the high touch surfaces in the residents' room.
-HK #1 did not allow the disinfectant to remain on surfaces for any amount of time before wiping it off.
-HK #1 did not clean the toilet from an area of cleaner to dirtier.
-HK #1 did not change her gloves or perform hand hygiene after cleaning the toilet and before cleaning the residents' mirror and sink.
On 10/15/24 at 9:10 a.m. HK #2 was observed cleaning room [ROOM NUMBER], a double occupancy room. HK #2 put on gloves and sprayed the bathroom with disinfectant. She returned to the residents' room and sprayed the disinfectant on the first resident's call light and overbed table and immediately wiped them down. She wiped the resident's dresser, the phone, items on the dresser and the top of the refrigerator. HK #2 documented the temperature of the refrigerator then moved to the other side of the room.
Without changing rags or changing gloves and performing hand hygiene, HK #2 sprayed the second resident's overbed table and nightstand and wiped them down immediately. HK #2 dropped the rag on the floor, picked it up and used it to wipe down the bottom of the overbed table and the table the resident's refrigerator was on. She got a new rag at 9:12 a.m. and sprayed the other overbed table and wiped it down immediately, then wiped the resident's shelf and the top of the dresser. HK #2 picked up the second resident's remote for the television but did not wipe it down. She sprayed and immediately wiped down the front of the dresser.
HK #2 got a new rag and wiped the second resident's call light, then sprayed, and immediately wiped off, the wall and cable protector near the resident's bed. HK #2 sprayed and immediately wiped down the resident's nightstand, then wiped the light switch.
At 9:16 a.m. HK #2 put on new gloves without performing hand hygiene. HK #2 cleaned the residents' toilet with the toilet wand. Without changing gloves or performing hand hygiene, she got a new rag and cleaned the sink with the rag which was wet with water. She dried the sink with paper towels. HK #2 wiped the towel rack and the soap dispenser. She wiped the top of the toilet with paper towels, raised the toilet seat and wiped the toilet with the same paper towels.
HK #2 removed her gloves but did not perform hand hygiene and proceeded to spread floor cleaner in the bedroom and bathroom. She mopped the floor of one side of the bedroom without gloves on. After mopping the first side of the room, she put new gloves on, put a new mop head on and mopped the other side of the bedroom and the bathroom floor. HK #2 put another new mop head on and mopped the entire bedroom floor a second time. HK #2 finished cleaning the room at 9:23 a.m.
-HK #2 did not perform hand hygiene before she started cleaning room [ROOM NUMBER].
-HK #2 did not perform hand hygiene between glove changes.
-HK #2 did not use separate rags for each side of the residents' room or the bathroom.
-HK #2 did not clean all of the high touch surfaces in the residents' room.
-HK #2 did not allow the disinfectant to remain on surfaces for any amount of time before wiping it off.
-HK #2 did not clean the toilet from an area of cleaner to dirtier.
-HK #2 did not change her gloves or perform hand hygiene after cleaning the toilet and before cleaning the residents' mirror and sink.
E. Staff interviews
HK #1 was interviewed on 10/15/24 at 8:52 a.m. HK #1 said she used odor control, Microkill concentration disinfectant for high touch areas, glass cleaner and soap. She said she always sprayed the disinfectant and immediately wiped the surface down. She said she was not aware of any contact time requirements for the cleaning solutions used.
HK #2 was interviewed on 10/15/24 at 9:23 a.m. HK #2 said she had been with the facility for ten years. She said she was trained by the housekeeping manager when she first started. She said she was not aware of any contact time requirements for the cleaning solutions used.
The housekeeping supervisor (HKS) was interviewed on 10/15/24 at 9:35 a.m. The HKS said she had been employed at the facility since June 2024. She said she was responsible for training new staff and she also had new staff train with two other housekeepers before they were able to clean on their own. The HKS said the proper way to clean residents' rooms was to perform hand hygiene, put gloves on, take disinfectant and odor control solution and spray the sink, toilet and call light, get the trash and remove it from the room, clean each side of the room separately and with a different rag for each side, sweep each side of the room and clean the bathroom last, mop the entire room using a different mop head for each side of the room, and mop the bathroom last. She said it was important to clean high touch surfaces, such as the call lights, overbed tables, bathroom doorknob, main doorknob, window sills, remote controls for the beds and televisions and light switches. The HKS said the regular housekeeper had called in today (10/15/24) and HK #1 was filling in but she normally worked in the laundry room.
The NHA was interviewed on 10/15/24 at 9:42 a.m. The NHA said it was important to clean residents' rooms in a specific manner to prevent the spread of infection. She said each side of the residents' rooms should be cleaned separately and the rooms should be cleaned from the cleanest area to the dirtiest area.
II. Failure to ensure residents were assisted with hand hygiene prior to meals
A. Observations
During a continuous observation of the lunch meal service in the dining room on 10/15/24, beginning at 11:37 a.m. and ending at 12:02 p.m., the following observations were made:
At 11:40 a.m. a resident touched the wall and the cart by the door of the kitchen to request coffee. He was directed back to his table. He was not offered hand hygiene.
At 11:40 a.m., a resident was sitting at her table with gloves on. The resident was folding utensils into napkins for other residents to use at mealtime. She reached into the bag on her wheelchair and continued folding utensils into napkins without changing her gloves. She touched the straw in her cup and took a drink then continued folding utensils into napkins.
-She did not remove her gloves or perform hand hygiene after reaching into her personal bag or touching the straw in her cup.
At 11:44 a.m. another resident wheeled himself into the dining room with one of his hands on the wheel of his wheelchair. He gave staff a high five at 11:48 a.m. He was not offered hand hygiene after touching the wheel of his wheelchair.
At 11:56 a.m. the resident wrapping utensils into napkins coughed into her glove. She touched her table and then the armrest on her wheelchair before continuing to wrap utensils.
-She did not remove her gloves or perform hand hygiene after coughing into her glove.
At 11:58 a.m. a female resident was wheeled to her table and shook hands with another female resident. She was not offered hand hygiene.
Staff began serving drinks to residents at 12:00 p.m. A male resident reached into the beverage cart and got his own sweetener at 12:01 p.m.
Staff began serving food trays at 12:02 p.m. There was a moist towelette provided to each resident but residents were not reminded or encouraged to use the wipes and assistance was not offered or provided to open the towelette package.
-None of the residents above were observed performing hand hygiene.
B. Staff interviews
The director of nursing (DON) and the regional clinical consultant (RCC) were interviewed on 10/15/24 at 5:01 p.m. The DON said residents were provided with wipes or a warm washcloth before meals. She said staff should offer hand hygiene to residents, or at least open the towelette package, for them.
The RCC said providing hand hygiene for residents was important to help prevent the spread of infection.
May 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#72) of three residents had the right to participate i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#72) of three residents had the right to participate in the development and implementation of his or her person-centered plan of care out of 31 sample residents.
Specifically, the facility failed to:
-Conduct care plan/conference meetings for Resident #72; and,
-Ensure either the resident or the responsible party was involved in the care conferences.
Findings include
I. Facility policy and procedure
The Care Planning Interdisciplinary Team policy, revised March 2022, was received from the nursing home administrator (NHA) on 5/19/23 at 3:40 p.m. It revealed in pertinent part, the interdisciplinary team is responsible for development of resident care plans. The resident, the residents family and/or the residents legal representative/guardian or surrogate were encouraged to participate in the development of and revision to the resident's care plan. Care plan meetings were scheduled at the best time of day for the resident and family when possible. If it is determined that participation of the resident or representative is not practicable for the development of the care plan, and explanation is documented in the medical record.
II. Resident #72
A. Resident status
Resident #72, age [AGE], admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included, chronic obstructive pulmonary disease (airway blockage affecting breathing), atrial fibrillation (abnormal heart function) and hypertension (high blood pressure).
The 4/14/23 minimum data set (MDS) assessment revealed the resident had a cognitive intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required one person physical assistance with transfers, bed mobility, dressing, eating, toileting and personal hygiene.
B. Resident interview
Resident #72 was interviewed on 5/15/23 at 2:49 p.m. He said he had not had a care conference since being in the facility. He said he would have liked care conferences to know what his plan was at the facility. He said he was discharging this week.
C. Record review
Resident #72 electronic medical records were reviewed and there were no progress notes in charts for care conferences since his admission on [DATE].
III. Staff interviews
The social service director (SSD) was interviewed on 5/18/23 at 10:32 a.m. She said care conferences were scheduled quarterly for long term residents or if they request one. admission care conferences occurred 72 hours after admission. Staff to attend the care conferences were from the following departments: social services, nursing, therapy, activities and dietary. The SSD said the care conference was documented in the resident ' s electronic medical record with a summary of the discussion. The SSD acknowledged there was no admission care conference for Resident #72. She said the facility missed his care conference and he was discharging from the facility today 5/18/23. The SSD said the facility did not hold a discharge conference for Resident #72 either.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the resident's right to receive services in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for two (#21 and #54) of five residents reviewed out of 31 sample residents.
Specifically, the facility failed to:
-Follow the physical therapy discharge plan to install a pole in the resident's room for the purpose of assisting the Resident #21 with transferring; and,
-Provide a Resident #54 with a call light option that was conducive to her abilities.
Findings include:
I. Facility policy
The Accommodation of Needs, revised March 2021, was provided on 5/19/23 at 3:41 p.m., by the nursing home administrator (NHA). The policy read in pertinent part:
The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment are evaluated upon admission and reviewed on an ongoing basis.
In order to accommodate the individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.
II. Resident #21
A. Resident status
Resident # 21, age under 65, was admitted on [DATE]. According to the April, 2023 computerized physician orders (CPO), diagnoses included left sided weakness/partial paralysis, traumatic brain injury, dysfunction of bladder, hypertension, seizures and chronic pain.
The 4/6/23 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.
B. Resident interview and observation
Resident #21 was interviewed on 5/18/23 at 11:15 a.m. The resident stated he had never had a transfer pole in his room. The resident said his family gave the facility a pole for his use several weeks before and the facility had not yet installed it in the resident room. The resident stated the pole was in an office at the facility. The resident said he wanted to be able to use the transfer pole in his room.
At 11:20 a.m., a therapy transfer pole was propped against a wall in the social service director's (SSD) office.
C. Record review
The care plan for Resident #21, revised 3/16/23, included the addition of nursing rehabilitation/restorative care to include active range of motion to upper extremities. The resident could use a bicycle.
-The resident's care plan did not address the use of a pole for transfers.
Physical therapy (PT) documentation regarding transferring and planned use of pole in his included in part:
-2/20/23 Response to treatment: continues to demonstrate progress in transfers with use of transfer pole with and without pivot discs. Plan to continue training nursing staff when available to progress toward use of a transfer pole in the room for bed mobility and transfers.
-2/23/23 Discharge recommendation: Continue with use of a transfer pole with pivot discs for functional transfers in the room.
Restorative nursing documentation was reviewed through 5/14/23. Documentation included range of motion to upper extremities and use of bicycle.
-The documentation did not include the use of a transfer pole.
D. Staff interviews
The director of therapy services (DTS) was interviewed on 5/18/23 at 12:14 p.m. The DTS stated if a resident needed a restorative program, a time was set up for therapy to train the restorative aids and the therapist would communicate with restorative nursing. The DTS reviewed documentation for Resident #21 and stated he was discharged from physical therapy on 3/1/23. Therapy recommendation at discharge was to continue the use of a transfer pole with a pivot disc, and restorative nursing was to provide assistance with transfers. The DTS acknowledged the transfer pole had not been utilized or installed in the room. The DTS stated the maintenance department was responsible for installing equipment such as the transfer pole. The DTS stated the SSD had the transfer pole that the family had brought in for Resident #21, approximately two weeks ago.
The DTS waited to install the pole, as this resident had been hospitalized for a few days and the DTS wanted physical therapy to evaluate the abilities of Resident #21 prior to installing the pole. She said make sure he could transfer with the pole in the therapy room prior to use in his own room. The DTS stated that she did not know why a pole was not installed prior to May 2023. She said she was not initially sure if the pole was allowed in this facility, as some facilities did not allow poles to be used in resident rooms.
-However, the facility had other residents using transfer poles in their rooms.
Certified nurse aide (CNA) #3 was interviewed on 5/18/23 at 2:00 p.m. CNA #3 stated Resident #21 was in an active range of motion program, came in to ride a bike and wore a splint on his left arm. Resident #21 was able to stand with one person assist. The CNA had not used a transfer pole when doing restorative therapy with Resident #21.
E. Facility follow-up
The facility provided documentation on 5/19/23 from the NHA regarding a process being developed to enhance communication to all parties for residents being discharged from therapy services.
PT evaluated Resident #21 on 5/18/23 and has initiated therapy for use of transfer pole and sitting, balancing and strengthening lower extremities. Interdisciplinary team will arrange for the facilities department to install a transfer pole after physical therapy has determined the resident can safely use the pole and has communicated this to the team.
III. Resident #54
A. Resident status
Resident #54, age [AGE], was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included quadriplegia (paralyzed in all four limbs), asthma, voice and resonance disorder (poor sound quality when speaking), shortness of breath, asthma, contractures of right and left shoulder, and right hand (hardening of muscles or tendons leading to rigidity of joints), tracheostomy (surgical opening in neck to allow airflow to lungs), anoxic brain damage (brain injury caused by lack of oxygen for duration over four minutes), anxiety and depression.
The 3/8/23 MDS assessment revealed the resident had severe cognitive impairment and a brief interview for mental status was not conducted. A staff assessment for cognition revealed Resident #54 was able to recall the location of the room, staff name and faces, and she knew she was in a nursing facility. She required extensive assistance of two staff members for bed mobility, transfers, dressing, and toilet once; and, one staff member for eating and personal hygiene. Resident #54 had adequate hearing without use of hearing aids, speech was unclear (slurred or mumbled words), she was usually understood verbally with enough time provided and she was able to understand others with clear comprehension.
B. Observation and interview
On 5/15/23 at 4:46 p.m. Resident #54 was observed lying in bed, with a tracheostomy tube providing her with air. A ventilator machine was located on the bedside table approximately two feet from the head of Resident #54's bed. The ventilator machine was on making constant noise that added difficulty with hearing Resident #54 in conversation. The bed was against the wall so that right side of Resident #54's body was aligned with the wall. Two call lights were plugged into the same wall bed was against, cords were observed between bed and wall with the actual call light devices on floor, both were out of reach of Resident #54.
Resident #54 was not able to speak loud enough to engage in conversation and noise from the tracheostomy machine added difficulty with conversation. Resident #54 said she used a voice box. Resident #54 said she never had access to a callight. She said her needs were met only when staff approached her. She said staff assisted with repositioning and medication management often. She said she had to grunt loudly to get staff's attention if she had a need. She said she was physically unable to push the call light button if it was in reach. She said she has never been offered an alternative call light device.
On 5/16/23 at approximately 10:00 a.m. both call lights were observed out of reach of Resident #54; one being on the floor behind the bed and the other on top of covers, approximately six inches from the resident's right hand. At approximately 1:00 p.m. both call lights were observed to of reach for Resident #54; one on the floor behind the bed, and the second was tied to a small shelf approximately six inches above the bed and approximately four inches from the right hand of Resident #54.
On 5/17/23 and 5/18/23 the call lights remained in locations of the previous day. One on the floor behind the bed, and the second was tied to a small shelf approximately six inches above the bed and approximately four inches from the right hand of Resident #54.
On 5/18/23 at approximately 10:00 a.m. Resident #54 said she was not able to reach the closest call light and no staff had confirmed she could when the call light was placed.
C. Record review
The 3/23/23 care plan revealed Resident #54 was a high risk for falls related to bed mobility. The interventions, in pertinent, revealed the call light was to be within reach and Resident #54 encouraged to use it for assistance and she needed prompt responses to all requests for assistance.
The 3/15/23 physical therapy evaluation and plan of treatment did not indicate call light use was evaluated.
-No other therapy evaluations were conducted, nor were there any current orders for therapy services.
The 5/18/23 therapy note (during the survey) revealed Resident #54 had been screened for use of pancake call light after being identified on survey. It revealed in part, the DTS had screened Resident #54 for pancake call light (soft, round, device that did not require much pressure from its user to be activated). Resident #54 was able to independently apply pressure to call light with call light placed under her left hand. Resident #54 was able to understand and implement instructions five out of five times for how to activate the device.
D. Staff interviews
Certified nurses aide (CNA) #4 was interviewed on 5/18/23 at 10:04 a.m. He said Resident #54 could not use the call light. He said she was quadriplegic and could not reach, grab or push the call light. He said he had not seen alternative call light devices used. He said Resident #54 was dependent on staff to meet all her needs. He said they look in on her often or she would make a grunting noise to get staff's attention. He said he could only hear her grunt if he was directly outside her room.
Licensed practical nurse (LPN) #3 was interviewed on 5/18/23 at 10:07 p.m. She said Resident #54 did not use her call light. She said she did not know why Resident #54 did not use her call light. She said she was not aware of other call light devices being offered to Resident #54. She said Resident #54 was dependent on staff to meet her needs. She said Resident #54 was frequently checked on by staff and that was how her needs were met. She said she was unaware of any methods used by Resident #54 to gain staff's attention.
LPN #6 was interviewed on 5/18/23 at 10:30 a.m. She said Resident #54 did not use her call light because she was quadriplegic and did not have use of her hands. She said she did not know if other call light devices had been offered. She said Resident #54 was dependent on staff to meet her needs. She said Resident #54 yelled out for help when she needed assistance. She said she had never heard Resident #54 call out.
The DTS was interviewed on 5/18/23 at 10:55 a.m. She said Resident #54 received restorative services to maintain or improve function of both hands. She said Resident #54 was provided a washcloth in both hands for a duration of time. She said this method assists with positioning the fingers away from the palm to decrease stiffness or tightening of muscle and protects skin from moisture. She said the restorative department verbalized a desire for Resident #54 to be seen by occupational therapy recently. She said it was verbalized in passing and she did not know specifics of intention for Resident #54 being seen by occupational therapy. She said she would include an assistive call light device for information for occupational therapy. She said she did not know if Resident #54 has been offered any alternative call light devices in the past. She said she did not know how Resident #54 gained staff attention for meeting her needs.
The director of nursing (DON) was interviewed on 5/18/23 at approximately 12:30 p.m. She said she was not familiar with Resident #54. She said she had been employed with the facility for only a week. She said a resident with limited mobility and who were dependent on staff should have access to a call device or be assessed for an alternative device.
The DTS was interviewed again on 5/18/23 at approximately 3:30 p.m. She stated she had assessed Resident #54's ability to use a pancake call light today (5/18/23). She said a pancake call light was a soft, round, device that did not require much pressure from its user to be activated. She said Resident #54 was provided instructions on use of the call light and was successful in implementing those instructions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to make prompt efforts to resolve a grievance for one (#60) of six re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to make prompt efforts to resolve a grievance for one (#60) of six residents reviewed for grievances out of 31 sample residents.
Specifically, the facility failed to act on a report of a missing passport, driver's license/ID, and social security card for Resident #60.
Findings include:
I. Facility policy
The Grievances/Complaints, Recording and Investigating policy, revised April, 2017, was provided by the social services director (SSD) on 5/18/23 at 3:00 p.m. It read in pertinent part:
Upon receiving a grievance and complaint report, the grievance officer will begin an investigation into the allegations.
The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended within ____(number not filled in on policy) working days of the filing of the grievance or complaint.
II. Resident #60
Resident #60, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO), diagnoses included traumatic brain injury, history of central nervous system infection, history of falling, osteoporosis and thrombocytopenia (blood disorder).
According to the 3/9/23 minimal data set (MDS) assessment, the resident had no behavioral concern identified, he had a moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 11 out of 15.
III. Resident interview
Resident #60 was interviewed on 5/17/23 at 2:30 p.m. He said that he was missing his passport, ID and social security card. He said he reported this many months ago, when I lived in the last room. He said the facility had not followed up on the missing items. He said that the social services director (SSD) had told him next week when he had asked her about follow-up.
IV. Record review
On 5/18/23 at 1:13 p.m.,the SSD provided a copy of the 1/12/22 grievance, which revealed the resident's report of missing his passport and other ID that had last been seen on the bedside table of the resident.
V. Staff Interviews
The SSD was interviewed on 5/17/23 at 2:55 p.m. She said that she remembered something about the resident's report of missing passport, ID and social security card. The SSD stated she was able to identify the report of missing IDs that happened in March 2023. The SSD stated that she would find additional information.
The SSD was interviewed again on 5/18/23 at 11:01 a.m. The SSD stated the resident's brother had mentioned at the care conference on 3/9/23 that his IDs were still missing. The SSD said she was not aware of the IDs missing until brother told her on 3/9/23. The SSD said that she followed up by checking with the business office on approximately 3/13/23, to see if the documents were located there. She said she had not done additional follow up after 3/13/23. The SSD stated she spoke with the resident this morning and she had completed a replacement application for the driver's license/ID. Her next plan was to submit a replacement application for the social security card and the passport.
The nursing home administrator (NHA) was interviewed on 5/18/23 at 3:45 p.m. The NHA said he assigned responsibility of investigating grievances to each department. He said after the SSD filled out the grievance form, she met with NHA and they investigated. The NHA said that he was made aware of this resident missing IDs sometime before February 2023.
VI. Facility follow-up
On 5/19/23 at 4:18 p.m., the SSD provided documentation which confirmed an appointment was scheduled to renew Resident #60s driver's license (appointment scheduled on 5/23/23).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #21
A. Resident status
Resident # 21, age under 65, was admitted on [DATE] and readmitted [DATE]. According to May...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #21
A. Resident status
Resident # 21, age under 65, was admitted on [DATE] and readmitted [DATE]. According to May 2023 computerized physician orders (CPO), diagnoses included left sided weakness/partial paralysis, traumatic brain injury, dysfunction of bladder, hypertension, seizures and chronic pain.
The 4/6/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15.
B. Record review
The comprehensive care plan for Resident #21 was reviewed on 5/17/23.
-The care plan had not been revised and updated to include the addition of IV antibiotic therapy after return from hospitalization.
The CPO revealed the following orders:
-Admit to skilled services for antibiotic IV therapy, starting 5/10/23.
C. Staff Interviews
Licensed practical nurse (LPN) #4 was interviewed on 5/18/23 at 1:13 p.m. LPN #4 stated the resident's care plan should have been updated, due to the addition of antibiotics. LPN #4 stated that she did not think the care plan was updated after Resident #21 came back from the hospital.
The DON was interviewed on 5/18/23 at 1:50 p.m. The DON stated the resident's care plan should be updated after hospitalization. The DON said the care plan should be updated the next day after the resident returns from the hospital. The DON stated the readmission nurse would update the care plan after return from the hospital. The DON stated the interdisciplinary team reviewed residents who were admitted /readmitted at each morning meeting.
Based on observations, record review and interviews, the facility failed to develop a comprehensive care plan that included measurable objectives needed to provide effective and person centered care for two ( #29 and #21) out of 31 sample residents.
Specifically, the facility failed to:
-Ensure Resident #29's bed height preference was on the comprehensive care plan; and,
-Revise Resident #21's care plan to include intravenous (IV) administration of antibiotics after hospitalization.
Findings include:
I. Facility policy and procedure
The Comprehensive Care Plan policy, revised March 2022, was provided by the nursing home administrator (NHA) on 5/19/23 at 3:41 p.m. It read in pertinent part, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. The care plan interventions should be derived from information obtained from the resident and his/her family/responsible party, with possible discretionary modifications resulting from the comprehensive assessment. The comprehensive, person-centered care plan should: include measurable objectives and time frames; describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments).
The comprehensive, person-centered care plan should be developed within seven days of the completion of the required MDS (minimum data set) assessment (admission, annual, or change in status).
The interdisciplinary team should review and update the care plan when: the resident has been readmitted to the facility from a hospital stay.
II. Resident #29
A. Resident status
Resident #29, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included Parkinson disease, contractures (hardening of muscles or tendons leading to rigidity of joints) of multiple sites and reduced mobility.
The 3/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of two staff with bed mobility, transfers, and toileting; and, extensive assistance of one staff member for dressing and personal hygiene. He required setup only for eating.
B. Observation
On 5/15/23 at 2:14 p.m. Resident #29 was observed lying in bed with a height of approximately three feet from ground with frame and mattress, his bedside table positioned across his body over upper thighs and hips.
Resident #29 was interviewed on 5/15/23 at 2:14 p.m. He said the height of the bed makes it easier for him to use the urinal. He said he could lower the bed enough so he could put the urinal under the table and between his legs. He said if the table or bed were lower he would not be able to use the urinal independently. He said this was his preference.
On 5/16/23, 5/17/23 and 5/18/23 the bed and bedside table was observed to be at previous mentioned height and position when occupied by Resident #29.
C. Record review
The care plan, dated 3/22/23, revealed Resident #29 was at risk for falls related to deconditioning (functional changes following a period of inactivity or sedentary lifestyle) with the goal of minimizing risk of injury through the next review date. The interventions for meeting the goal included anticipating and meeting the needs of Resident #29.
-Review of the resident's comprehensive care plan did not reveal the resident preferred the height of the bed and bedside table to accommodate his urinal needs.
D. Interviews
Licensed practical nurse (LPN) # 1 was interviewed on 5/17/23 at 1:18 p.m. She said she did not know why Resident #29's bed was at the height it was. She said he was particular and it was his choice.
Certified nurse aide (CNA) #4 was interviewed on 5/17/23 at 1:22 p.m. He said he did not know why Resident #29 had his bed at the height it was. He said Resident #29 was decisional and able to use the bed remote as he chooses.
The director of restorative services (DRS) was interviewed on 5/17/23 at 1:34 p.m. He said he did not know why Resident #29 had his bed at the height it was at.
The social services director (SSD) was interviewed on 5/17/23 at 1:42 p.m. She said she did not know why Resident #29 had his bed at the height it was at. She could not find a care plan for bed height on this day. She said she would look into it.
The assistant director of nursing (ADON) was interviewed on 5/17/23 at 2:30 p.m. She did not know why Resident #29 had his bed at the height it was at.
The SSD was interviewed again on 5/18/23 at 12:29 p.m. She said the resident's care plan was revised on 5/18/23 to reflect his preference of bed height.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (#61) of two residents reviewed for comm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (#61) of two residents reviewed for communication out of 31 sample residents were provided appropriate treatment and services to maintain or improve their abilities.
Specifically, the facility failed to ensure Resident #61 had access to a whiteboard for his communication needs.
Findings include:
I. Facility policy and procedures
The Activity of Daily Living (ADLs), Supporting policy and procedure, revised March 2018, was by the nursing home administrator (NHA) on 5/19/23 at 3:42 p.m. It read in pertinent 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 independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with communication (speech, language, and any functional communication systems). Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate.
II. Resident #61
A. Resident status
Resident #61, under age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included encephalopathy (altered brain function), malignant neoplasm of brain (brain tumor), cognitive communication deficit (difficulty thinking and using language) and hearing loss.
The 5/3/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. He required extensive assistance of one staff member with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. It further revealed Resident #61 had moderate difficulty with hearing, used hearing aids, his speech was unclear (slurred or mumbled words), he was usually able to be understood and could usually understand others. His vision was adequate.
B. Observation and interview
Resident #61 was interviewed on 5/15/23 at 3:12 p.m. He used non-verbal communication by pointing at his ears and shrugging his shoulders when asked a question. The resident was asked if he had a whiteboard or paper available as a means of communication. The resident shook his head back and forth to indicate no. He said he had used a white board in the past, he said he would use a white board if one were available. He said he did not know where to find a white board for his use.
No whiteboard was observed to be available for Resident #61, nor was Resident #61 observed wearing hearing aids on the survey from 5/15/23 to 5/18/23.
C. Record review
The care plan dated, 4/26/23, revealed Resident #61 had difficulties with communication related to profound bilateral hearing loss and used a whiteboard to communicate. It revealed Resident #61 had been seen by an audiologist in May 2021 and received hearing aids in August 2021. The interventions revealed staff were to ask yes/no questions if appropriate, reduce environmental noise (television, radio), use simple, brief, consistent words/cues, use alternative communication tools as needed. It revealed Resident #61 was able to read and write on a white board, he required this for communication and staff were to ensure it was available and functioning for his use. The care plan revealed activities staff were aware of a communication deficit and the intervention was to speak loud and clear for the resident to hear or use the white board to communicate.
III. Staff interviews
The activities assistant (AA) was interviewed on 5/18/23 at 9:57 a.m. She said she was aware of Resident 61's hearing deficit. She said she communicated with Resident #61 by speaking loudly or non-verbal communication of Resident #61 moving his head back and forth for no, up and down for yes. She said he was able to understand her if she spoke loud enough. She said she knows to interact with Resident #61 in this manner because his care plan indicated to do so.
Certified nurses aide (CNA) #5 was interviewed on 5/18/23 at 10:00 a.m. She said she was aware of Resident #61's hearing deficit. She said she communicated with Resident #29 by writing questions down on paper for him to read. She said this method worked well. She said she used questions that Resident #61 could respond yes or no to. She said Resident #61 had hearing aids but he often declined to use them.
Licensed nurse practitioner (LPN) #5 was interviewed on 5/18/23 at 12:20 p.m. She said she was aware of Resident #61 communication deficit. She said she spoke loud and asked him yes or no questions. She said she did this because he would shake his head for yes or no or gave her a thumbs up or down. She said she had never written anything for him to read as a means of communication.
The activities director (AD) was interviewed on 5/18/23 at 2:41 p.m. She said she was aware of Resident #61's communication deficit. She said she was aware of him being careplanned to use a white board for communication. She said she was not aware Resident #61 was missing his whiteboard. She said she would provide Resident #61 with a new whiteboard.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to provide appropriate care and services to main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to provide appropriate care and services to maintain the activities of daily living for two (#2 and 71) of five residents who required extensive assistance out of 31 sample residents.
Specifically, the facility failed to:
-Ensure Resident #2 and Resident #71 received consistent showers according to their preference and plan of care; and,
-Ensure Resident #71 received regular nail care according to her preference and plan of care.
Findings include:
I. Facility policy
The Shower/Bath policy, revised February 2018, was provided on 5/19/23 (a day after the survey exit). The policy read in part:
The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin.
Document the date and time the shower/tub bath was performed and document reasons for refusal and the interventions taken.
The Fingernails/Toenails care policy, revised February 2018, was provided by the facility on 5/19/23. The policy read in part:
The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming.
Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.
II. Resident #2
A. Resident status
Resident #2, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included multiple sclerosis, depressive disorder, epilepsy and dementia.
According to the 4/7/23 minimum data set (MDS) assessment, Resident #2 was cognitively intact with a brief interview for a mental status score of 15 out of 15. The MDS assessment revealed Resident #2 required extensive assistance from one person with personal hygiene, activities of daily living (ADLs) and for showers. The MDS showed no rejection of care for Resident #2.
B. Observation and resident interview
Resident #2 was interviewed on 5/15/23 at 10:44 a.m. The resident said she was not receiving consistent showers.
She said the staff often told her there were not enough staff available to be able to complete her shower. She said she preferred receiving her showers as scheduled because she did not want to smell bad when she went to activities.
Resident #2 was interviewed again on 5/17/23 at 3:33 p.m. She said she still had not received her shower. She said the staff did not provide a make-up shower day when they were unable to complete her shower as scheduled.
C. Record review
The activities of daily living care plan, initiated on 7/22/16 and revised on 4/12/23, revealed Resident #2 had an ADL self-care performance deficit and was at risk for a decline in ADL function due to her diagnosis of multiple sclerosis.
The interventions included: providing showers two times per week. Checking nail length, cleaning, and trimming as tolerated on bath days.
The point of care task documentation revealed the resident preferred to have her showers on Wednesdays and Saturdays, early morning.
-A review of the shower documentation from 4/15/23 through 5/18/23 revealed Resident #2 received showers five out of eight opportunities.
-A review of the resident's medical record and shower documentation revealed there were no progress notes to indicate a refusal of showers for Resident #2.
D. Staff interviews
Licensed practical nurse (LPN) #5 was interviewed on 5/18/23 at 9:20 a.m. LPN #5 said Resident #2 had an ADL performance deficit and shower aides were responsible for the resident's showers. LPN #5 said the shower aides were supposed to report all shower refusals to the unit nurse. LPN #5 said she would try at a different time to encourage the resident to shower when the shower aides reported any refusal to her.
Shower aide (SA) #2 was interviewed on 5/18/23 at 10:05 a.m. SA #2 said Resident #2 preferred her showers early in the morning and it was unusual for her to refuse to shower. SA #2 said she would try again at different times when residents refused their shower and she reported to the unit nurse when she was unable to complete a resident's shower. SA #2 said she would document a refusal on the shower documentation when the unit nurse confirmed the refusal after talking to the resident.
The director of nursing (DON) was interviewed on 5/18/23 at 11:40 a.m. The DON said showers were to be completed by the resident's preference and according to the resident's plan of care. The DON said the shower aides reported every care refusal to the unit nurse; if every attempt to complete the resident shower failed, the shower aides had to have a make-up day.
III. Resident #71
A. Resident status
Resident #71, over the age of 65, was admitted [DATE]. According to the May 2023 CPO, the diagnosis included abnormality of gait and mobility, muscle weakness, history of falling and age-related osteoporosis (a condition that develops when bone mineral density and bone mass decrease).
The 2/3/23 MDS assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. The resident required extensive assistance from one person for bed mobility, transfers, dressing and personal hygiene.
The MDS assessment bathing/shower portion was marked as did not occur during the review period.
Resident #71 had no rejection of care and no behaviors.
B. Observation and resident interview
Resident #71 was observed on 5/15/23 at 1:25 p.m. She was lying in bed watching television in her room.The resident said she had not received her shower for three weeks. She said the shower aide informed her she would have her shower the next day but it did not occur.
The resident's fingernails were approximately half an inch long over the nail bed and had a brown substance color when she pulled her hands out from under the covers while in bed.
Resident #71 said her nails were the longest she had ever had them. Resident #71 said she preferred to have them trimmed and cleaned.
Resident #71 was observed on 5/17/23 at 3:00 p.m. The resident was in her room lying in her bed. The resident said she had not received her shower and her fingernails were still long and had not been trimmed.
Resident #71 was observed on 5/18/23 at 10:00 a.m. She said she had still not received her shower and fingernail care.
C. Record review
The ADL care plan, initiated 1/29/23, revealed Resident #71 had an ADL self-care performance deficit. Interventions included one person assistance with bathing as tolerated by the resident, checking nail length, trim and clean on bath days and as necessary. Offer a bed bath if the resident declines a shower.
-A review of the shower documentation from 4/15/23 through 5/18/23 revealed Resident #71 received showers on four out of eight opportunities.
-A further review of the May 2023 shower documentation revealed staff documented at 1:59 p.m. Resident #71 refused to shower on 5/15/23. The same day the resident reported a concern of not receiving consistent showers.
-The point of care shower documentation revealed Resident #71 had not received a shower in 10 days.
-The facility failed to provide an additional three months shower log documentation when requested.
D. Staff interviews
Certified nurse aide (CNA) #7 was interviewed on 5/18/23 at 9:05 a.m. CNA #7 said Resident #71 was easy to work with and did not usually refuse care. CNA #7 said CNAs and shower aides performed fingernail care. CNA #7 said Resident #71 had long fingernails and could be better kept clean to prevent infections.
LPN #5 was interviewed on 5/18/23 at 10:30 a.m. LPN #5 said Resident #71's fingernails were long. LPN #5 said staff were responsible to provide fingernail care and showers for the residents. LPN #5 said Resident #71 fingernails were long and dirty. She said she would trim and clean them as soon as she completed medication pass.
The DON was interviewed on 5/18/23 at 11:40 a.m. The DON said all nursing staff were responsible for nail care and showers. The DON said resident nails should be checked anytime staff interacted with the residents. The DON said if a resident refused a shower and nail care they should offer it again at a different time of the shift. The DON said resident nails should be trimmed and cleaned as needed and on shower days. The DON said dirty and long fingernails could lead to infections and skin integrity. The DON said the shower aides and CNAs were to report and document any refusal of showers and provide a make-up shower day for the missed shower.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure one (#40) out of 31 sample residents receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure one (#40) out of 31 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.
Specifically, the facility failed to investigate, determine origin and monitor a bruise to Resident #40's wrist.
Findings include:
I. Resident status
Resident #40, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included atherosclerotic heart disease (plaque buildup in the arteries supplying blood to heart), reduced mobility and dementia.
The 3/3/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required extensive assistance of two staff members with transfers; and, extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene.
II. Observation and interview
On 5/15/23 a skin discoloration was observed on Resident #40. It was located on her lower right, inner arm, below her wrist. It was approximately two inches in length, 1.5 inches in width and round in shape. It was purple in color.
Resident #40 was interviewed on 5/15/23 at 3:30 p.m. She did not know what caused the skin discoloration.
III. Record review and interview
A review of the May 2023 CPO revealed Resident #40 had a diagnosis of atherosclerotic heart disease (plaque buildup in the arteries supplying blood to heart) and was prescribed an anticoagulant. She was to have weekly skin assessments conducted on Wednesdays, and staff were to monitor for bleeding and bruising for use of an anticoagulant.
The 4/24/23 comprehensive skin assessment revealed no existing or new skin concerns.
The 5/3/23 comprehensive skin assessment revealed no existing or new skin concerns.
The 5/10/23 comprehensive skin assessment revealed no existing or new skin concerns.
The 5/17/23 comprehensive skin assessment revealed no existing or new skin concerns.
On 5/17/23 at approximately 3:00 p.m. licensed practical nurse (LPN) #1 was interviewed about the comprehensive skin assessment on 5/17/23 for Resident #40. She said she did not notice the bruise when conducting an earlier assessment on 5/17/23.
LPN #1 then approached Resident #40, observed the skin discoloration and asked Resident #40 if she knew how she received it. Resident #40 informed she did not know how the skin discoloration was acquired.
A second comprehensive skin assessment was conducted on 5/17/23. It revealed a bruise noted to right wrist of Resident #40 being 5.5 centimeters (cm) in length and 4.5 cm in width. It revealed notifications were made to the physician, the resident's responsible party, the director of nursing (DON), the assistant director of nursing (ADON) and the social worker (SW).
The 5/17/23 progress note revealed LPN #1 indicated the resident had a bruise to her right inner wrist that was 5.5cm X 4.5cm, dark purple in color, circular shape. When LPN #1 asked Resident #40 what happened she was unable to give a description. LPN #1 reported she did not notice a bruise on the morning of the assessment and the skin discoloration was first observed on 5/15/23. LPN #1 reported she notified the DON, the ADON, the SW, the primary care physician and the power of attorney (POA) for Resident #40.
IV. Staff interviews
Shower aide (SA) #1 was interviewed on 5/17/23 at 3:10 p.m. She said Resident #40 received showers on Thursdays. She said she had not seen any skin discoloration on her arms. She said she did not know where skin discoloration came from. She said she reported any skin abnormalities to the nurse.
Certified nurses aide (CNA) #4 was interviewed on 5/17/23 at 3:20 p.m. He said he had not noticed any skin discoloration on the arm of Resident #40. He said he did not know where skin discoloration came from. He said skin abnormalities were reported to the nurse.
CNA #6 was interviewed on 5/17/23 at 3:34 p.m. She said she had not noticed any skin discoloration for Resident #40. She said if she had she would report it to the nurse.
The DON was interviewed on 5/18/23 at 12:29 p.m. She said on yesterday (5/17/23) LPN #1 informed her of skin discoloration on wrist of Resident #40. She said an incident report was initiated to determine the cause. She said an investigation was being conducted because Resident #40 had a diagnosis of dementia, with a BIMS score of four and was unable to tell staff how she acquired the skin discoloration.
-The facility investigation was not provided by exit on 5/18/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#83, #187 and #24) of six out of 31 sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#83, #187 and #24) of six out of 31 sample residents who required respiratory care were provided such care and services consistent with professional standards of practice.
Specifically, the facility failed to:
-Ensure a physician's order was obtained for Resident #83 and Resident #187 for use of supplemental oxygen; and,
-Ensure Resident #24's supplemental oxygen was on correct order liter flow per physician's order
Findings include
I. Facility policy and procedure
The Oxygen administration policy, revised October 2010, received from the nursing home administrator on 5/19/23 at 3:40 p.m. revealed in pertinent part, the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician order.
Documentation in medical record includes: rate of oxygen flow, route, frequency, and duration.
II. Resident #83
A. Resident status
Resident #83, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included deep vein embolism (blood clot), respiratory failure (oxygen exchange complication) and hypertension (high blood pressure).
The 4/7/23 minimum data set (MDS) assessment revealed the resident had a cognitive intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required one person's physical assistance with personal hygiene and dressing. Set up assistance for bed mobility, transfers, eating and toilet use. The resident was using oxygen at home and in the facility.
B. Observations and resident interview
Resident #83 was observed on 5/15/23 at 3:34 p.m. in her room wearing a nasal cannula with oxygen running on 3.5 liters per minute (lpm).
Resident #83 said she uses oxygen all the time at 3.5 lpm.
Resident #83 was observed on 5/16/23 at 3:14 p.m. receiving oxygen via nasal cannula running at 3.5 lpm while in bed.
C. Record review
The May 2023 CPO failed to reveal an order for supplemental oxygen.
The 4/20/23 careplan failed to reveal oxygen focus goal or interventions careplanned.
III. Resident #187
A. Resident status
Resident #187, age [AGE], was admitted on [DATE]. According to the May 2023 CPO the diagnoses included respiratory failure (abnormal oxygen exchange), embolism (blood clot), hypertension (high blood pressure), kidney disease (decreased kidney function) and gastroesophageal reflux disease (acid reflux).
The 4/20/23 MDS assessment revealed the resident had a cognitive intact with a BIMS score of 14 out of 15. She required two person physical assistance with bed mobility and dressing. One person physical assistance with personal hygiene, toileting, eating and transfers. The assessment failed to indicate the resident's use of oxygen.
B. Observations and resident interview
Resident #187 was observed on 5/15/23 at 2:11 p.m. on 4 lpm of oxygen via nasal cannula with a humidifier.
Resident #187 said she needed oxygen after having pneumonia (lung infection).
Resident #187 was observed on 5/16/23 at 3:12 p.m. receiving 4 lpm supplemental oxygen via nasal cannula with humidification.
C. Record review
The May 2023 CPO revealed no order for supplemental oxygen.
There was an order on 5/13/23 for a bubbler to be added to the oxygen concentrators due to residents' complaints of dry nares.
Resident #187's care plan failed to have an oxygen focus, goal or interventions in place.
IV. Resident #24
A. Resident status
Resident #24, age [AGE], was readmitted on [DATE]. According to the May 2023 CPO diagnoses included asthma (breathing complications), respiratory failure (oxygen exchange complications), seizures (electrical imbalance), atrial fibrillation (abnormal heart function) and type two diabetes (insulin insufficiency).
The 4/20/23 MDS assessment revealed the resident had a cognitive intact with a BIMS score of 15 out of 15. She required two person physical assistance with transfers. One person physical assistance with dressing, eating, toileting,and personal hygiene. It indicated Resident #24 required the use of oxygen.
B. Observations and resident interview
Resident #24 was observed and interviewed on 5/15/23 at 11:13 a.m. She said she used oxygen all the time. She was receiving 3 lpm via nasal cannula at this time.
Resident #24 was observed on 5/17/23 at 1:33 p.m. on 3 lpm of oxygen via nasal cannula.
C. Record review
The May 2023 CPO revealed an order for 2 lpm of oxygen via a nasal cannula.
The 4/30/23 care plan was reviewed and revealed a focus for chronic obstructive pulmonary (COPD airway) with interventions to monitor vital signs and administer medication as ordered by the physician.
V. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 5/17/23 at 1:32 p.m. She said Resident #187 was receiving supplemental oxygen via nasal cannula at 4 lpm with a bubbler for humidification via observation. LPN #1 reviewed Resident #187's CPO and acknowledged there was no order for supplemental oxygen but one for the bubbler. She said an order was needed for oxygen and she would contact the physician to get an order.
LPN #1 verified Resident #24 was on 3 lpm oxygen via nasal cannula. LPN #1 reviewed Resident #24's physician orders and acknowledged the order for oxygen was for 2 lpm via nasal cannula and not the 3 lpm (see observation above). LPN #1 went to Resident #24's room and adjusted oxygen to correct liter flow and took her finger pulse oximetry to ensure she had an oxygen saturation above 90%. Resident #24's pulse oximetry level was 94% on 2 lpm.
LPN #1 verified there was no order for oxygen use for Resident #83 in the CPO. LPN #1 verified the resident was on 3.5 lpm via nasal cannula.
The director of nursing (DON) was interviewed on 5/17/23 at 2:58 p.m. She said residents receiving oxygen should have an order in place. Orders should include amount of oxygen, route like nasal cannula or mask, frequency of intermittent or continuous. Staff should be monitoring residents pulse oximetry to ensure they were maintaining oxygen saturation above 90%. The DON said oxygen use should be careplanned for the resident using it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment, inspection and maintenance of a bed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment, inspection and maintenance of a bed cane (fixed bed rail assistive device) was completed for one (#51) resident of three residents reviewed using bed cane for positioning out of 31 sample residents.
Specifically, for Resident #51, the facility failed to:
-Assess the resident for risk of entrapment prior to installing or using a bed cane/bed rail;
-Obtain consent from resident; and,
-Check bed rail/bed cane regularly for ongoing maintenance.
Findings include:
I. Professional reference
The U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and retrieved on 5/23/23 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines, read in pertinent part:
-Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment.
-Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan.
-The equipment (beds/mattresses/bed rails) should be inspected, evaluated, maintained, and upgraded to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors.
-The patient's needs should be re-assessed and the equipment re-evaluated if an episode of entrapment or near-entrapment occurred, with or without serious injury; this was done immediately because fatal 'repeat' events can occur within minutes of the first episode.
-The bed, mattress and any accessories should be monitored and maintained on an ongoing basis.
II. Facility policy and procedure
The Bed Safety and Bed Rail policy, revised August 2022, received from the nursing home administrator (NHA) on 5/19/23 at 3:43 p.m. revealed in pertinent part, Resident beds meet the safety specification by the hospital bed safety workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. Consideration is given to the residents safety, medical condition, comfort, and freedom of movement, as well as input from the resident and family. Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator. Bed rails are properly installed and used according to the manufacturer instructions, specifications and other pertinent safety guidance to ensure proper fit. Resident assessment to determine risk of entrapment, risk and benefit informed consent to be completed.
III. Resident #51
A. Resident Status
Resident #51, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO)diagnoses included, end stage renal disease (decreased kidney function), right hemiplegia (paralysis of one side of body), right hemiparesis (weakness or paralysis of one side of the body), congestive heart failure (fluid over [NAME] the heart), type two diabetes (insulin insufficiency) and hypertension (high blood pressure).
The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required two persons physical assistance with transfers, bed mobility, dressing, toileting and one person physical assistance with eating and personal hygiene.
B. Observation and resident interview
On 5/15/23 at 1:55 p.m. there was a bed cane on the resident's bed.
Resident #51 was interviewed on 5/15/23 at 1:56 p.m. Resident #51 said he had the bed cane for a while and used it to roll in bed at times for care. He said sometimes it gets in the way of the hoyer (medical equipment used for transferring) when being transferred in or out of bed.
On 5/18/23 at 10:00 a.m. the bed cane was on the resident's bed.
C. Record review
-There were no orders for bed cane placement or safety checks on the CPO.
-No informed consent was located in the resident's electronic medical record for bed rails.
The 3/27/23 the activities of daily living care plan for Resinet #51 had a self care deficit due to decreased mobility/coordination related to cerebral vascular accidents (stroke). Interventions in place staff to offer and assist with transfers and mobility including bed mobility.
-The care plan did not indicate the resident used a bed cane.
IV. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 5/18/23 at 10:11 a.m. CNA #1 said Resident #51 used bed canes to turn in bed as he was a two person assist for cares and mechanical lift for transfers. CNA #1 said bed canes/rails should be assessed for safety but was unsure who was responsible to check them.
Licensed practical nurse (LPN) #3 was interviewed on 5/18/23 at 12:51 p.m. She said staff should check bed canes for stability/safety and should be documented under the resident's treatments or orders. LPN #3 was unable to locate an order for bed canes for Resident #51 in the electronic medical record. She said there was no bed cane assessment or consent completed for Resident #51.
The director of nursing (DON) was interviewed on 5/18/23 at 12:54 p.m. The DON said bed canes were usually ordered by the therapy department. A consent was needed from the resident or family for use. The DON said bed canes should be monitored for placement and safety. The maintenance department was responsible for attaching the bed canes to the bed frames. The DON said it was the facility's responsibility to be monitoring the bed canes for safety, and if an issue was found it was to be reported to the maintenance department.
The maintenance director (MTD) was interviewed on 5/18/23 at 2:00 p.m He said once he received an order from the therapy department and had the supplies, the therapist was in the room to ensure proper placement on the bed during installation. The MTD said he had no monitoring system for safety checks and depended on the floor staff to report an issue. Once an issue was reported the maintenance department would go in and tighten them or fix what was needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications for one of two medication storage rooms and one of three medication storage carts.
Spe...
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Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications for one of two medication storage rooms and one of three medication storage carts.
Specifically, the facility failed to:
-Discard prepared medications on the medication cart that had not been administered to residents;
-Maintain medication storage room in a clean and orderly manner; and,
-Discard medication that had expired.
Findings include:
I. Facility policy and procedure
The Storage of Medications, revised November, 2020, was provided by the nursing home administrator (NHA) on 5/18/23. The policy heading included, the facility stores all drugs and biologicals in a safe, secure and orderly manner. The policy, in part, contained the following information:
-Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they were received.
-Nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
-Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
II. Observations and interview
On 5/17/23 at 12:30 p.m.,the medication storage room was entered with the DON. The medication room was difficult to enter and walk in, as there was an empty cardboard box containing wrap/trash behind the door. There were stacked boxes in the room, including one that was tipped on its side. The DON made a comment that there were chicken crumbs on a box which contained intravenous supplies and dusted them off. There was a crumpled empty bag labeled with a fast food name on the counter in the room. One handrail on a supply cabinet door was broken off and hanging from the cabinet.
On 5/17/23 at 12:45 p.m., a medication cart (100 hallway) was inspected in the presence of licensed practical nurse (LPN) #4. A Milk of Magnesia, 16 ounce bottle, was found in the cart with an expiration date of March 2023. The LPN #4 acknowledged it was expired, but did not remove the expired medication from the cart.
Four uncovered pill cups containing medications were on the cart, all stored in the same bin of the cart. The LPN explained that three of the pill cups contained medications for specific residents (labeled with resident name). The fourth container, which was unlabeled, included approximately 10 pills/capsules.
III Interviews
LPN #4 was interviewed on 5/17/23 at 12:35 p.m. LPN #4 stated the one unlabeled medication cup found in the medication cart (containing approximately ten pills) was pills that she had found loose within the cart. LPN #4 stated she had not disposed of the pills in the cup because she did not have a Drug Buster on the cart or nearby for disposal. LPN #4 said that the other three pill cups that were found together, which contained pills and liquid medications, were medications she was holding for the residents who were not ready to take them. LPN #4 acknowledged the medications should be discarded if the resident was not administered the medications.
The assistant director of nursing (ADON) was interviewed on 5/17/23 at 4:55 p.m. The ADON stated they have Drug Busters for disposal of medication. She acknowledged a report that there was not a medication disposal unit on the medication cart or in the medication room that was inspected. The ADON said that if a resident refused or was sleeping, medication could be locked up briefly, but not for two hours. She stated that several cups with medication should not be kept in the medication cart and should have been disposed of. The ADON said the central supply and nursing department checked the carts for expiration dates.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews the facility failed to ensure one (#39) out of five residents m reviewed was free f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews the facility failed to ensure one (#39) out of five residents m reviewed was free from a significant medication error of 31 sample residents.
Specifically, the facility failed to ensure Resident #39 was administered an accurate dose of cholecalciferol (Vitamin D) medication.
Findings include:
I. Facility policy
The Documentation of Medication Administration policy, revised April 2007, was provided by the facility on 5/19/23 at 9:25 a.m. It read in pertinent part: Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. All medication orders will be supported by appropriate care processes and practices. The physician will identify situations where medications should be tapered, discontinued or changed.
II. Resident #39
A. Resident status
Resident #39, over the age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included depressive disorder, dementia, chronic obstructive pulmonary disease (COPD) and vitamin D deficiency.
The 4/13/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance with two-person physical assistance for most activities of daily living.
B. Record review
The May 2023 CPO read cholecalciferol tablet 50,000 units, give one tablet by mouth one time a day every 12 month(s) starting on the 1st for 336 day(s) for vitamin D deficiency. The order start date was 2/1/23.
The February 2023 to 5/18/23 medication administration record indicated the resident received Vitamin D 50,000 units daily.
The February 2023 nursing progress notes documented the continuation of cholecalciferol 50,000 units weekly and rechecked vitamin D levels on 4/13/23.
-The above inconsistency with the order resulted in Resident #39 receiving 50,000 units of cholecalciferol on a daily basis beginning from 2/1/23 instead of one time per week.
The 4/13/23 pharmacist recommendation read cholecalciferol 50,000 units daily since 2/1/23. Instructions for administration were to give 1 tablet one time a day every 12 months starting on the 1st for 336 days. This order exceeds the usual once per week dosing of this tablet strength. The provider note from 2/15/23 states the dose should be 50,000 units weekly.
-There was no evidence that the 4/13/23 pharmacist recommendations and the medical director's approval to check Resident #39's vitamin D levels were followed by the facility.
-The facility provided documentation of the laboratory order for the vitamin D level on 5/19/23 (at the time of the survey) after the above concern was brought to the attention of the director of nursing (DON).
III. Staff interviews
Licensed practical nurse (LPN) #5 was interviewed on 5/18/23 at 2:45 p.m. After reviewing the order, she said the order was to be administered one time per day according to the CPO. LPN #5 said she administered 50,000 units of cholecalciferol in the morning during her shift.
The pharmacist was interviewed on the phone on 5/18/23 at 3:57 p.m. The pharmacist said she noticed the order of a large amount of cholecalciferol during April 2023 medication review and brought it to the attention of the medical director and the assistant director of nursing (ADON). The pharmacist said she had not noticed any reconciliation with her recommendation. The pharmacist said vitamin D overdose could result in calcium buildup in the blood which could lead to bone pain and kidney problems, nausea and vomiting.
The DON was interviewed on 5/18/23 at 4:15 p.m. The DON said she had not seen the pharmacist's recommendations report due to her starting one week ago. The DON said Resident #39 was receiving 50,000 units of cholecalciferol tablets one time per day. The DON said she would follow the recommendation and ensure the error was corrected. As an immediate action she stated the medication would be placed on hold and the physician would be contacted for the clarification.
The medical director (MD) was interviewed on 5/18/23 at 4:30 p.m. The MD was also the primary care physician for Resident #39. The MD said there was an error with the order. The MD said the intention was for the order to read one tablet (50,000) units per week for eight weeks and return to a recommended daily dose when the recommended vitamin D level was obtained. The MD said the facility should have checked the vitamin D levels when recommended by the pharmacist and approved by him. The MD said too much vitamin D in the system could cause calcium buildup and could result in symptoms such as vomiting, nausea, weakness, frequent urination and kidney problems. The MD said he was already contacted by the facility staff and he wrote an order for the vitamin D levels for Resident #39 to be checked as soon as possible and would change the order based on the result of the laboratory result for the vitamin D level.
-The vitamin D level laboratory result was not received by the exit date on 5/18/23.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection.
Specifically the facility failed to:
-Ensure the surface disinfectant time was followed for proper disinfection;
-Ensure resident rooms were cleaned and disinfected properly;
-Ensure staff performed proper hand hygiene; and,
-Ensure facility maintained water management program for Legionella.
Findings include:
I. Failure to clean resident rooms appropriately
A. Professional reference
According to the Center for Disease Control (CDC), Hand Hygiene Basics retrieved on 5/15/23 from: http://www.cdc.gov/handhygiene/basics.html (2019) read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings).
According to the hotel room-occupied (comet diluted) retrieved on 5/23/23 from;
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://assets.ctfassets.net/xsotn7jngs35/77XAj2JaLpnFHHyVtcpkaW/1635eb0790cb1ccc298d6bd911ce6d45/Hospitality_Binder_Hotel_Room_-_Occupied__Comet_Diluted___Spic_and_Span_3in1_Comet_DS_Bathroom_Febreze_Fabric_Refresher__eng.pdf read in pertinent part, comet toilet bowl cleaner had a surface disinfectant time of five minutes.
According to https://www.unisancolumbus.com/blog/what-is-dwell-time/ the surface disinfectant time for the Spic and Span All Purpose Cleaner read in part, dwell (surface disinfectant) time to sanitize is 5 minutes; dwell time to disinfect is 10 minutes.
B. Facility policy and procedure
The Infection Control policy and practices, revised October 2018, received from the nursing home administrator (NHA) on 5/19/23 at 3:40 p.m. revealed in pertinent part, The facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infection. All personnel will be trained on our infection control policies and practices upon hire and periodically dependent on job responsibilities.
The Handwashing/Hand Hygiene policy, revised August 2019, received from the NHA on 5/9/23 at 3:40 p.m. revealed in pertinent part, the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel should follow hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
C. Observations and staff interviews
Housekeeper (HSK) #1 was observed on 5/17/23 at 10:13 a.m. cleaning room [ROOM NUMBER]. HSK #1 applied gloves, collected disinfectant spray cleaner to the door handles to the room, then sprayed the bathroom sink and toilet. HSK #1 collected trash in the room.
HSK #1 said the disinfectant Spic and Span had a surface disinfectant time of 15 minutes and Comet toilet bowl cleaner as a surface disinfectant of five minutes.
-However, the surface disinfectant time for the Spic and Span was 10 minutes (see above).
HSK #1 collected the toilet bowl cleaner and brush, applied the toilet bowl cleaner to the toilet bowl, then scrubbed the inside of the toilet bowl with scrub brush. She then scrubbed the outside of the toilet bowl with the scrub brush from the toilet bowl rim to the floor. HSK #1 then collected dry cloth and wiped the toilet from the rim to the floor on the outside. HSK #1 collected a dry paper towel and wiped the toilet from the rim to the floor again. HSK #1 used a new dry cloth and wiped down the sink from the outside then the inside of the sink bowl, seven minutes after being sprayed with the disinfectant. HSK #1 then used a new dry cloth to wipe down the resident's night stand, bedside table, chair and the dresser eight minutes after disinfectant application. She collected the mop and mopped the floor.
-HSK #1 failed to wait recommended dwell time for disinfectant cleaners, change gloves when going from a dirty area to clean area, and failed to clean high touch areas like the call light and bed controls. HSK #1 used the scrub brush for an area other than the toilet bowl.
HSK #1 was observed on 5/17/23 at 10:30 a.m. cleaning room [ROOM NUMBER] a double occupancy room. HSK #1 applied gloves without performing hand hygiene then, knocked and entered the room. HSK #1 removed trash, then sprayed bathroom faucet, sink, and door handle with disinfectant spray. HSK #1 applied toilet bowl cleaner, scrubbed the toilet bowl with a brush then scrubbed the outside toilet bowl from the rim to the floor with the toilet bowl brush. She then wiped the sink bowl with a cloth then returned to the toilet, dipped the cloth in the toilet bowl water and scrubbed the toilet bowl on the inside, wringed the cloth out in the toilet bowl then wiped the outside of the toilet from top to bottom. The disinfectant had only been applied to surface six minutes when HSK #1 started to wipe down the surfaces. HSK #1 collected a paper towel, wiped the skin down again from the outside bowl to inside the skin bowl, then used another paper towel to wipe down the toilet from top to bottom.
-HSK #1 failed to wait recommended surface disinfectant time for disinfectant cleaners, change gloves when going from a dirty area to a cleaner area, or between the resident side of a double occupancy room, to clean high touch areas like call light, bed function control, bedside table door handles to room and phone. HSK #1 used scrub brush for areas other than the toilet bowl.
HSK was interviewed on 5/17/23 at 10:43 a.m. She said staff change their gloves between every resident room cleaned. High touch areas in resident rooms were considered door handles, bedside tables and call lights. HSK #1 acknowledged she failed to clean high touch areas in both rooms to include the call lights. She acknowledged she did not wait the full 15 minute surface disinfectant time for the disinfectant used by the facility. HSK#1 said not waiting the surface disinfectant time affected the disinfectant's ability to properly disinfect.
The housekeeper director (HSKD) was interviewed on 5/18/23 at 11:09 a.m, The HSKD said the chemical disinfectant Spic and Span and the Commet used by the facility both had a 15 minute surface disinfectant time. The surface disinfectant time was important to ensure the chemical was left on the surface long enough to react prior to being wiped down. The HSKD said high touch areas in a residents room were door handles, call light, bed controls and bedside tables. Housekeepers should enter the room and work in a clockwise manner spraying disinfectant, then collecting trash and performing other tasks while the disinfectant sits on the surface for the appropriate time. Toilets should be cleaned with toilet brush inside the bowl only and wiped down with cloths on the outside from top to bottom. If a resident room was a double occupancy, the housekeeper should change gloves between the two sides of the room along with after moving from a dirty area to cleaner area. HSKD said HSK #1 should have changed her gloves after cleaning toilets in both rooms since she returned to cleaning areas considered cleaner than the toilet.
The infection preventionist (IP) was interviewed on 5/19/23 at 12:36 p.m. She said she had no involvement with the housekeeping department and infection control practices.
The HSKD was again interviewed on 5/18/23 at 1:20 p.m. He said HSK #1 was a recent hire and had been provided education on how to properly clean a room from 5/3/23 to 5/5/23 by following another staff member each day. On 5/14/23 another HSKD from another facility within the corporation provided in service to the housekeeping staff on the correct way to clean rooms, infection control, chemical use and gloves.
II. Failure to have a water management program
A. Professional reference
According to CDC, Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 5/25/23: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html.
It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices.
Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States.
Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever.
The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.
Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review.
Seven key elements of a Legionella water management program are to:
-Establish a water management program team
-Describe the building water systems using text and flow diagrams
-Identify areas where Legionella could grow and spread
-Decide where control measures should be applied and how to monitor them
-Establish ways to intervene when control limits are not met
-Make sure the program is running as designed (verification) and is effective (validation)
-Document and communicate all the activities.
Principles: In general, the principles of effective water management include:
-Maintaining water temperatures outside the ideal range for Legionella growth
- Preventing water stagnation
-Ensuring adequate disinfection
-Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.
Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met.
A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs.
B. Facility Legionella plan
A request was made on 5/18/23 at 3:45 p.m. to the maintenance director (MTD) for the facility's plan to address Legionella. The facility was unable to provide a written water management plan/program that would reduce the risk for Legionella growing and spreading within their water system and devices.
C. Staff interview
The MTD was interviewed on 5/18/23 at 4:00 p.m. He said he had no knowledge of the last Legionella inspection the facility had performed. He provided paperwork for testing completed in 2018. The MTD verbalized he did not have a water management program and was unable to identify areas in the building where there was potential for Legionella growth.
D. Additional information received from the facility
The Developing a Water Management program to Reduce Legionella Growth and Spread in Buildings; A Practical Guide to Implementing Industry Standards, dated 6/5/16 was provided by the NHA on 5/19/23 (after survey) at 4:32 p.m.
-Although the NHA provided the program guide (see above), the facility was unable to demonstrate that the program was implemented or followed. Based on the MTD interview the last testing was completed in 2018.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to provide the appropriate treatment and services to maintain or imp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to provide the appropriate treatment and services to maintain or improve the abilities of one (#1) out of three sample residents reviewed for range of motion.
Specifically, the facility failed to ensure Resident #1 received active and passive range of motion (ROM) by way of a restorative program as indicated by the comprehensive care plan.
Findings include:
I. Facility policy and procedure
The Restorative Nursing Services policy and procedure, revised February 2017, was provided by the assistant director of nursing (ADON) on 4/3/23 at 5:20 p.m. It revealed in pertinent part,
Residents will receive restorative nursing care as needed to help promote optimal safety and independence.
Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services (physical, occupational or speech therapies).
Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.
Restorative goals and objectives are individualized and 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 #1
A. Resident status
Resident #1, age under 60, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included paraplegia (inability to voluntarily use the lower parts of the body), traumatic brain injury (TBI), muscle spasms, depressive episodes, anxiety disorder, idiopathic peripheral autonomic neuropathy (symptoms affecting the feet), acute embolism and thrombosis (clot in the blood vessel) of unspecified deep veins lower extremity bilateral (both legs, feet, and ankles), and ADHD (attention deficit hyperactivity disorder).
The 3/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with locomotion on and off the unit, and eating. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He did not reject care from staff. There were zero restorative nursing program minutes for a seven day look back.
B. Resident interview
Resident #1 was interviewed on 4/3/23 at 2:20 p.m. He said he was in a car accident which left him with quadriplegia and a traumatic brain injury. He said had not received a restorative program, or any exercise program from the facility. He said his only exercise was when he came outside on his own to smoke. He said he wanted to be able to live in an independent apartment. He said he knew his body would feel better, and get stronger if someone from the facility staff would help exercise him with both of his hands, and both legs from the knees to his feet. He said staff did not help him exercise. He said he had asked but the staff were too busy to stop and work with him. He said he felt he had declined by not having a restorative program. He said he thought he had not become stronger during his year in the facility. He said with a strengthening program from the facility he could be better prepared to go to an apartment. He said he was told by the facility staff that the facility had an exercise bike if he wanted to exercise.
C. Record review
The comprehensive care plan 3/21/22 and revised on 12/31/22 revealed,
Focus: The resident had limited physical mobility and ADL (activities of daily living) self-care performance deficit with quadriplegia and a TBI (traumatic brain injury). The resident was at a high risk for falls.
Interventions: Nursing rehab/restorative: AROM (active range of motion) and PROM (passive range of motion) program. The resident was to receive AROM to upper and lower extremities up to 15 min/3-6 days a week as tolerated. The resident was to receive PROM and stretching to BLE (bilateral extremities) for 3x30 seconds to each muscle group.
-There was not documentation of any restorative nursing visits that Resident #1 had received any AROM or PROM.
III. Staff interviews
The ADON was interviewed on 4/3/23 at 3:00 p.m. She said she had been responsible for the restorative nursing program but that starting tomorrow the facility had hired someone to specifically be responsible for the restorative nursing program. She said Resident #1 was to receive a restorative exercise program as was in his care plan. She said he received range of motion (ROM) exercises three to six times per week. She said she would look and find the documentation of his visits with restorative and provide the information.
The director of nursing (DON) was interviewed on 4/3/23 at 3:10 p.m. She said she thought Resident #1 went out of the facility to receive his restorative care and exercise program. She said it was very important that Resident #1 had ROM exercises to maintain and increase his strength. She said without a restorative program a resident could decline in strength.
Certified nurse aide (CNA) #1 was interviewed on 4/3/23 at 4:20 p.m. She said the prior company who owned the building had a place to mark when she did exercises with the resident. She said the past two months the building was with a new company who did not have a place in the computer to mark when she did exercises with the residents. She said she thought she worked with Resident #1 about one month ago to do exercises. She said she saw him go outside to smoke and thought that would be considered exercise times for him.
The ADON was interviewed again on 4/3/23 at 4:25 p.m. She said she could not locate any documentation about Resident #1's restorative program. She said the facility obviously needed an action plan immediately to fix the situation to make sure Resident #1 and all the residents received their restorative programs. She said the facility had no documentation that he had received his restorative program in accordance with his care plan. She said the only notes she could locate were from the former facility owners which was several months ago and the documentation was incomplete. She said the few notes found did not indicate what was provided for Resident #1 nor for how long he received restorative services. She said she was unaware the MDS assessments for almost a year revealed mostly zeros for Resident #1's restorative program minutes. She said she would fix the situation immediately so that Resident #1 received his restorative nursing program so that he could maintain and build his strength.
The nursing home administrator (NHA) was interviewed on 4/3/23 at 5:00 p.m. He said he would reach out to the company who had previously owned the facility (sold 2/1/23) to inquire about any restorative documentation for Resident #1. The NHA said if any documentation was found from the prior company that the resident had received a restorative program in accordance with his care plan, or anything in the facility that documented Resident #1 had received restorative services, he would email it tomorrow.
-No email documentation for Resident #1's restorative program was provided at the close of the survey on 4/3/23 or on the next day 4/4/23.
Feb 2022
7 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure two (#43 and #116) of four residents reviewed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure two (#43 and #116) of four residents reviewed out of 30 sample residents were as free from accident hazards as possible.
The facility failed to assess and implement interventions to prevent Residents #43 and #116 from falling. As a result, Resident #43's hospital records indicated a head cat scan was completed in comparison from 12/7/22 and 12/11/22 and revealed a head injury; and Resident #116 was not fully assessed after an unwitnessed fall for potential injuries.
Resident #43 had a history of falls prior to initial admission to the facility on [DATE]. The facility was aware of the resident's fall risk upon admission. The resident's medical record revealed the resident had diagnoses of dementia and Parkinson's disease with increasing confusion, poor safety awareness, impulsivity and an unsteady gait. The resident often refused to request assistance or failed to request assistance. The resident needed extensive assistance with all activities of daily living, particularly with transfers, toileting needs and bed mobility. There was no documentation that the resident refused care and assistance when it was provided. There were no documented notes that revealed the resident's ability to use the call light was assessed or that other methods of requesting staff assistance were pursued.
The resident had two unwitnessed falls from 12/6/2021 to 12/11/22. On 12/6/2022, the resident's fall occurred while going to the bathroom unassisted and resulted in her hitting her head and she developed a fist size bump on her head. She was sent to the emergency room for a cat scan. The fall on 12/11/2021 occurred as the resident was going to the bathroom unassisted. The facility failed to effectively implement care-planned interventions to prevent a fall where the resident sustained an injury, new acute subdural hemorrhage along the cerebral falx and left tentorial leaflet of her head, and occipital pain.
Additonally, the facility failed to:
-Prevent Resident #116, who was assessed to be at a high risk for falls, from experiencing a fall;
-Fully assess Resident #116 for injuries and physical decline after having an unwitnessed fall; and,
-Assess care-planned interventions after the resident's fall and implement interventions to address contributing factors of the residents fall, for Resident #116.
Findings include:
I. Facility policy
The fall management policy revised on 9/10/19 provided by the corporate nurse consultant (CNC) on 2/14/22 at 9:46 a.m. read in pertinent part: The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury.
A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs.
Procedure:
-A fall risk evaluation will be completed within the first twenty-four hours following admission, using the facility fall risk evaluation. A baseline plan of care will be initiated for residents evaluated to be at risk.
-Please note interventions are to be re-evaluated when a resident falls.
The following interventions are to be initiated and or considered:
-Assess the environment and make appropriate changes, bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable. The call light and fluids should be within reach of the resident.
-Positioning devices (low bed, fall mat, defined perimeter mattress, bolsters).
-Complete a thorough analysis of fall - time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. Interview staff and residents if able to identify potential causative.
-Educate and communicate implemented interventions to direct care staff via verbal report.
-Document in the computer the resident's response to interventions and alter interventions if they are not successful.
-If a resident experiences a fall with head injury, the fall is unwitnessed, or a resident self-reports a fall, neurological checks will be initiated.
-Review the IDT risk management to ensure complete and appropriate interventions have been implemented.
-Review that a care plan has been initiated.
-Provide revisions to the plan of care as necessary after falls
II. Resident #43
A. Resident status
Resident #43, age [AGE], was readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), pertinent diagnoses included Parkinson's, atrial fibrillation, dementia, arthritis and anxiety.
The 12/29/21 minimum data set (MDS) assessment revealed the resident had a moderate cognitive deficit with a brief interview for mental status (BIMS) score of eight out of 15. She required extensive assistance with two people for bed mobility and toileting. Extensive assistance of one person for transfers, dressing and hygiene. She had supervision of one person for meals. She had no rejection of cares. She was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning and moving on and off the toilet. She had no pain. She had a history of falls with injury.
B. Observations
Resident #43 was observed on 2/9/22 at 10:30 a.m. seated in the dining room. She was slouched in her wheelchair and looked around at the other residents in the room. She had one foot pedal on the wheelchair but her feet were on the ground. She had regular socks on without shoes. She wore oxygen and she was just sitting three feet from a table.
Resident #43 was observed on 2/10/22 at 12:05 p.m. in the dining room having lunch. She slouched in her wheelchair and her feet were on the floor. She had socks on with no shoes.
Resident #43 was observed on 2/14/22 at 9:45 a.m. sitting in front of her television. She had a fall mat up against the wall in her room and her feet were on the ground. There was a call light on the bed next to her. The bedside table was set up in front of her.
C. Record review
The nurse note dated 12/7/21 at 12:10 a.m. for Resident #43, provided by the CNC on 2/14/22, read in pertinent part: At 10:25 p.m. nurse heard a patient scream out. Upon entering the residents room she was witnessed on the restroom floor parallel to the toilet seat. She was on her back holding the back of her head. Resident was alert and oriented to person and place.The resident stated she hit her head on the way down. Her vital signs were normal. Upon assessment the pupils were equal, round, and reactive to light and accommodation (PERRLA) and intact. Her hand grasps were equal, she was able to move all extremities and a fist sized bump was felt to the back of her head. No other injuries were reported by the resident or observed by this nurse. Resident remained on the ground with a pillow to support her head until paramedics arrived. Family was called with no answer and the physician was notified. Resident stated she was aware she needed to press the call light for assistance but was unsure why she did not use it. A non emergent transport company was notified for transport to the emergency room.
The nurse note dated 12/11/22 at 9:01 a.m. for Resident #43 read in pertinent part: Resident #43 family members were visiting with her and told the nurse the resident had to use the restroom urgently. The nurse assisted the resident to the bedside commode and instructed the resident to use her call light when she was finished. Before transferring the resident to the commode she put on non skid socks. The nurse told a certified nurse aide (CNA) to check on the resident while she attended to another resident. The CNA told the nurse the resident was on the floor and she hit her head. The nurse told another CNA to go and get the registered nurse (RN). The director of nurses (DON) completed the head to toe assessment. She instructed the other nurse to call 911 because the resident was screaming in pain when moved. The paramedics arrived and transported the resident to the hospital.
-The resident received one assist for toileting and was left alone in the bathroom. She was not steady on her feet and she should have not been left alone.
-The baseline care plan for Resident #43 dated 11/28/21 was blank and incomplete for fall assessments.
The activities of daily living (ADL) care plan for Resident #43 dated on 12/5/21 read in pertinent part; Resident #43 had a decline in cognition and recent hospitalization due to a fall. The resident risk for complications related to immobility, including contractures, skin-breakdown, and fall-related injury will be minimized through the review date.The resident will improve and maintain current level of mobility through the review date. Interventions were to provide call light within reach, encourage the use of it, and answer promptly. Use a wheelchair and walker for mobility. Invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility. Monitor, document and report any signs and symptoms of immobility: contractures forming or worsening, skin-breakdown and fall related injury. Provide a gentle range of motion as tolerated with daily care. Provide supportive care, assistance with mobility as needed. Document assistance as needed. Physical and occupational therapy referrals as ordered.
The fall care plan for Resident #43 revised on 12/5/21 read in pertinent part; Resident #43 was at risk for falls related to decreased mobility, history of falls, and medication use.The resident's risk for falls will be minimized through the review date. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident and family and caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in the wheelchair. Physical and occupational therapy evaluation and treatment as ordered.Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter and remove any potential causes. Educate family caregivers and the interdisciplinary team as to the causes.
One intervention was updated on 1/13/22 to stay with the resident while using the bedside commode. No other interventions were added or updated after the 12/7/21 fall or the 12/11/21 fall.
Hospital assessment note on 12/11/22 read in pertinent part: Resident #43 complains of headache from a fall on 12/10/22 where she struck her head on the cabinet. She reports ongoing occipital head pain, denies vision or hearing change, focal numbness or tingling or weakness. There was no nausea, vomiting or loss of consciousness, confusion or other related symptoms. Head cat scan on 12/11/22 revealed : new acute subdural hemorrhage along the cerebral falx and left tentorial leaflet of her head compared to the one on 12/7/22. The plan was to check orthostatic blood pressure, evaluation from physical and occupational therapy and admit her to the hospital for observation. She was readmitted to the facility on [DATE].
Fall assessment on 12/6/21 for Resident #43 read in pertinent part; According to the nurse, Resident was aware she needed to press the call light for assistance out of bed but was unsure why she did not. She said she hit her head when she fell and had a fist size bump developed. She was sent to the emergency room for an assessment.
Fall assessment on 12/22/21 for Resident #43 read in pertinent part; The nurse assisted the resident to the bedside commode, the nurse instructed the resident to call when finished, the nurse also instructed resident not to stand up without help, the nurse gave the resident her call light and taught the resident how to use her call light as usual. Before transferring resident to the commode, the nurse put non skid socks on resident.The nurse told the residents CNA to go check on the resident while the nurse was attending to another resident that also needed help.The CNA later came to the nurse and said resident was on the floor, apparently bump her head. The nurse who happened to be the director of nurses (DON) came and did the head to toe assessment and told another nurse to call 911 because the resident was screaming in pain when moved.
The fall risk evaluation for Resident #43 dated 12/5/21 and 12/6/21 revealed: The resident was alert and oriented and had balance problems while standing, gate problems: jerking, unstable when [NAME], unsteady gait, shuffling gait. Required the use of assistive devices such as a walker, cane, wheelchair and furniture.
The fall risk evaluation for Resident #43 dated 12/11/21 revealed: The resident had periods of confusion. And gait and balance were normal. She had balance problems while walking and standing. Decreased muscular coordination and change in gait when walking through a doorway.
The December 2022 computerized physician orders (CPO)s for Resident #43 revealed;
-Diclofenac sodium gel one percent ( % ). Apply to both knees topically four times a day. Order date was 11/26/21.
-Monitor pain every shift using zero to 10 pain scale every shift. Order date was 12/09/2021.
The December 2022 medication administration record (MAR), revealed Resident #34s pain level was zero to two.
D. Interviews
Resident #43 and her family were interviewed on 2/14/22 at 12:23 p.m. Resident said she did have a few falls but she was ok. She was eating lunch in her room and family sat at bedside. Family said he was there when she fell and hit her head. He said she was left alone in the bathroom and she tried to get up and fell. He said she did not know how to use the call light and had multiple falls in the past.
Certified nurse aide (CNA) #2 was interviewed on 2/14/22 at 1:00 p.m. She said Resident #43 needed assistance for all cares. She said she was confused and did not use her call light. She said the resident was in the dining room a lot with activities and not left alone. She tried to get up on her own a few times and fell. She said the resident had a fall mat beside her bed.
Director of therapy (DOT) was interviewed on 2/14/22 at 1:35 p.m. He said Resident #43 came to the facility from home with worsening dementia and multiple falls. He said she was doing well when she first arrived at the facility but over time she made little progress during therapy and had decreased safety awareness. He said she failed to understand how or when to use the call light. The resident was very impulsive and would get up on her own and then fall. She was now a max assist for bed mobility, transfers and toileting. Recommendations to staff to have constant supervision for the resident, a fall mat and a low bed position for safety. He said he verbally told the facility staff as he was not responsible for updating care plans. He did recommend restorative rehabilitation for continued support.
CNA #4 was interviewed on 2/14/22 at 2:30 p.m. He said Resident #43 was not on restorative rehabilitation services.
The director of nurses (DON) was interviewed on 2/14/22 at 4:15 p.m. She said when a resident fell, an RN assessment was completed. When the fall was unwitnessed, neurological (neuro) assessments were completed every 15 minutes for the first hour, then every 30 minutes for four hours and then every 24 hours. Resident #43 did not have any neuros completed because she was sent out of the hospital for assessments. The interdisciplinary team which was the risk management team met to discuss all falls and update interventions in the care plan. The staff followed the interventions to keep the resident as safe as possible. She did the immediate assessment for Resident #43 and sent her to the hospital because she complained of severe pain. When a resident was a high fall risk, the staff had to stay with the resident for added safety. She said Resident #43 was a high risk resident and she had her call light next to her.
-Even though the resident was sent out to the hospital she returned within 48 hours. The record should have indicated neurological checks were continued upon her return.
II. Resident #116
A. Resident status
Resident #116, age [AGE], was admitted on [DATE] and was discharged from the facility to the hospital on [DATE], the resident did not return to the facility. According to the October 2021 computerized physician orders (CPO) diagnosis included history of repeated falls, generalized muscle weakness, chronic fatigue, need for assistance with personal care and cognitive communication deficits.
The 10/6/21 discharge minimum data set (MDS) assessment, revealed the resident had intact cognition with a brief interview for mental status (BIMS) and was able to obtain a score of 14 out of 15 with cuing on one of the recall questions. The resident had no negative behavioral expressions and did not reject care assistance.
The resident had no limitations in either the upper or lower extremities; but was not steady when standing and walking and needed the assistance from staff to stabilize; and used a walker assistive device while walking or a manual wheelchair to get around the facility. The resident needed extensive assistance from two staff for transfers, walking and showering/bathing; and extensive assistance from one staff with bed mobility, using the toilet, dressing and grooming.
The resident was not on a toileting program to maintain and manage continence and was occasionally incontinent of bladder and frequently incontinent of bowel. The resident was receiving occupational and physical therapy.
B. Preadmission history
Hospital report dated 10/29/21 read in pertinent part: Patient admitted to the hospital on [DATE]. History of present illness: chief complaint: weakness, ambulatory dysfunction, falling, and shortness of breath. Patient with no reported medical history besides admission to the hospital from [DATE] to 8/25/21 for COVID-19 related pneumonia and acute hypoxemic respiratory failure. The patient was then discharged to an inpatient rehabilitation facility from 8/25/21 to 9/7/21. Then discharge to home. Patient was admitted into the emergency room for severe generalized weakness, ambulatory dysfunction and repeated falling at home and continued shortness of breath. Emergency medical services (EMS) reports that on arrival the patient was unable to get up out of a chair and was unable to stand. He has been on one liter of oxygen at baseline since he left the hospital. He denies fever, dysuria, hematuria. He states he feels worse than when he had COVID-19 originally.
Physical Exam: General appearance: alert, awake; .Neck: no jugular vein distention (JVD) at the sides of the neck, no masses or swelling; .Extremities: moves all, no calf tenderness; Musculoskeletal: normal inspection; .Neurologic/ central nervous system (CNS): alert, oriented X3 (person, place and time)
C. Resident interview and observation
Resident #116 was no longer residing in the facility; observations and interviews were not possible.
D. Fall investigation
Fall investigation report quality assurance documentation dated 10/2/21; investigation completed by the previous director of nursing (DON), documented the resident had a fall on 10/2/21 at approximately 2:30 a.m. The investigation findings report revealed: Nursing description: the nurse was called to the resident's room by a certified nurse aide (CNA). Upon entering room the nurse observed the resident to be lying on his back on the floor with head towards room door near the bathroom. The resident had on non-skid socks; there were no wet spots of liquids on floor; and the call light was on the resident's bed. The resident had a bowel movement accident.
The report documented the Resident #116 told staff I didn't hurt myself, I was trying to get to the bathroom and lost my balance. When asked why the resident did not use a call light for assistance, the resident said I just really had to go.
Per the investigative report Resident #116 was assessed by the nurse on duty and was found to be free from bumps, bruises or abrasions; and the resident's range of motion and hand grip was within normal limits and at his baseline. The resident level of alertness and orientation was assessed to be at baseline. The nurse initiated neurological checks to assess potential nervous system damage related to the resident fall. The resident denied pain at the time for the post fall assessment.
Nursing staff assisted the resident off the floor and took him to the bathroom to get washed up. The resident went back to bed with the call light left within reach. The nurse reminded and encouraged the resident to use the call light for assistance.
The resident was not sent to the hospital for further assessment.
The neurological assessment flow sheet was examined and the facility nurse started the first neurological checks at 2:45 a.m. The purpose of the neurologic assessment was to detect changes in level of consciousness; pupil response; motor function: hand grasp and motor functioning of the upper and lower extremities; pain response; vital signs (blood pressure, temperature, pulse and respiration in the appropriate columns); and additional observations of potential seizures, headaches, vomiting and paralysis.
Review of the neurological flow sheet initiated after the resident's fall revealed the nurse stated neurological checks on 10/2/21 at 2:25 a.m. Per the documented schedule the nurse was supposed to conduct scheduled neurological checks every 15 minute for the first hour; every 30 minutes for the next two hours; every hour for the next three hours; every four hours for the next 16 hours; and every eight hours for the next 72 hours.
-The nurse failed to complete all neurological checks and missed the last 15-minute check at 3:45 a.m. and the next four 30 minute checks. The documenting revealed the nurse did not conduct the scheduled neurological checks because the resident was asleep.
-One of the purposes of the neurological checks was to ensure the resident was not experiencing serious side effects of potential head injury.
The investigation report identified the following predisposing and contributing factors that could have been contributing factors of the resident's 10/2/21 fall:
-Low/poor lighting in the resident room;
-Gait imbalance previous identified as a contributing factor to the resident's risk of falling;
-Prior assessment identifying the resident as being at a high risk for falls;
-Incontinence status;
-Impaired memory;
-Having a fall in past 30 days;
-Recent admissions less than 72 hours prior;
-Ambulating without assistance and being on the way to the bathroom.
The investigation report failed to document a review of the resident's care plan and current interventions to minimize the risk for the resident falling including assessment of current interventions, predisposing and contributing factors, and development and implementing additional interventions to mitigate the identified contributing factors to the resident 10/2/21 fall. The investigation also failed to identify or assess the missing 15-minute neurological checks.
E. Record review
Hospital physical therapy session progress note dated 9/27/21, read in pertinent part: Diagnosis: generalized weakness, falls, shortness of breath, and long haul effects of COVID-19. Precautions: falls, oxygen therapy, and confusion.
-Patient alert and oriented however does present with acute confusion throughout treatment (i.e. forgetting patient's role, requiring multiple cues for safety awareness .).
-Assessment/plan: Patient has demonstrated a decline in functional mobility since admission. Now requiring maximal assistance for transfers and moderate directed assistance (MODA) for short distance ambulation. Patient presenting with deficits in safety awareness, activity tolerance, gait, strength, balance, and gross functional mobility. Patient will benefit from aggressive, daily therapeutic intervention to optimize functional independence and lower fall risk.
Hospital occupational therapy session progress note dated 9/27/21, read in pertinent part: Confusion present. Able to follow simple commands with cueing for attention to task.
Maximal assistance to move from lying to sit transfer, multiple rest breaks mid-transfer.
Limited by weakness and fatigue.
Fall risk assessment dated [DATE] revealed Resident #116 was at a high risk for falls related to a number of factors including three or more diagnoses increasing risk of the resident falling. The resident had experienced three or more falls in the past 90 days; was having periods of confusion; and was having problems with walking and balance while standing and turning; and required the use of an assistive device while waking, due to unsteady gait.
The resident's health and physical report dated 9/30/21 released the resident was presenting with frequent falls and significant fatigue.
Physical therapy evaluation and plan of treatment dated 9/30/21, revealed:
-Functional Assessment: Bed mobility needed maximum assistance; transfers needed maximum assistance. Gait level surfaces needed contact guard assistance and assistive device: front wheeled walker. Walked 15 feet, observed to have forward trunk lean, decreased step length bilaterally, wide base of support, and decreased heel strike/toe off, flat weight acceptance bilaterally.
-Fall Predictors: Excessive postural sway on initial stance, impulsive ambulation and reduced insight for unsafe situations.
-Assessment summary impressions: Patient now presents with decreased strength, balance, and gait abnormalities leading to potential falls risk. Skilled physical therapy required to address aforementioned deficits in order to maximize safety and allow for discharge back into the community.
-Basic Mobility .Sit to stand substantial needed maximal assistance; chair or bed to chair transfer needed substantial/maximal assistance; toilet transfer attempted but not completed; walking needed partial/moderate assistance.
The comprehensive care plan, initiated 9/30/21 read in pertinent part: The resident is at high risk for falls related to generalized weakness secondary to past COVID-19 and pneumonia diagnosis The goal for the resident was to minimize the risk for falls. Interventions included:
-Anticipate and meet the resident's needs.
-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.
-The resident needs prompt response to all requests for assistance.
-Educate the resident and caregivers about safety reminders and what to do if a fall occurs.
-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Resident on isolation until 10/14/21 due to new admission quarantine requirements for not being fully vaccinated.
-Resident needs encouragement to ask for assistance with transfers.
-Ensure that the resident is wearing appropriate footwear or non skid socks when ambulating or mobilizing in the manual wheelchair.
-Physical therapy to evaluate and treat as ordered and as needed.
-The resident needs a safe environment with: the bed in low position at night and personal items within reach.
There was no care plan focus for toileting assistance or management of any activities of daily living (ADL) needs; and no interventions related to activity fatigue, muscle weakness, unsteady gait/balance and intermittent confusion.
Resident #116 had a fall in the early hours of 10/2/21 there were not notes in the resident medical record to document the details of the fall; the assessment of the resident following the fall; status of potential injuries after the fall; consultation with the resident's physician after the fall; or notification to the resident's representative. (cross referenced to F580).
Skilled nursing note dated 10/3/21 at 8:42 a.m., read in pertinent part: Late entry: Resident is alert. ADL/function: Resident has an unsteady gait requiring supervision. Resident has impaired balance. Resident has weakness. Mood/behavior: resident is impatient or anxious, calls a lot, failure to thrive.Nursing to manage medication administration, observe for behaviors or any changes in condition and document and report
-There was no mention of the resident falling in the skill note documented above.
Interdisciplinary team (IDT) note dated 10/4/21 at 10:30 a.m. read: IDT team meets weekly to discuss anticipated needs include: recent fall; need for moderate/maximum transfers assistance; help dressing; physical therapy; occupational therapy; speech therapy; attempt; poor cognition.
-The note did not explain any of the noted areas, assessment or outcome of the IDT meeting.
Encounter note dated 10/5/21 at 12:00 a.m., read in pertinent part: Date of service: 10/5/21.
Reason for visit: admission history and physical. History of present illness: Patient is seen in his room lying flat in bed awake and alert and in a good mood. He remains generally weak but denies being short of breath, he appears to have some short-term memory deficit but does not carry a diagnosis of dementia. He is aware of his memory difficulty. He is not complaining of headache, change in vision, change in speech or hallucinations or depression. possible cognitive deficit as above he has evidence of short-term memory deficit on today's evaluation which one cognitive assessment in the facility.
-There was no specific mention of the residents 10/2/21 fall in the facility and no assessment or further recommendations following the fall.
IDT- risk management review note dated 10/5/21 at 8:03 a.m., read: Date of incident: 10/2/21. Type of incident: unwitnessed fall. Root cause: cognitive and mobility deficit. Treatment required: N/A (not applicable). Interventions put into place: resident encouraged to use call light and ask for assistance. Referrals made: N/A; continue with therapies .
Skilled nursing note 10/7/21 at 3:35 p.m., read in pertinent part: Resident is alert. ADL/function: Resident has weakness. Resident has paralysis. Resident has no complaints of pain.
Encounter note dated 10/8/21 at 12:00 a.m., read in pertinent part: Date of service: 10/8/21.
Reason for visit: recent fall. Patient seen and examined today in his room, lying in bed, no acute distress. He is seen today to follow-up on reported fall from 10/2/21. Patient does not recall the fall however, he does deny any pain at this time. He is currently seen stable on supplemental oxygen and continues to deny any dyspnea, cough or chest pain/pressure. Patient followed by speech therapy in addition to physical and occupational therapy. He continues with significant fatigue during sessions but does feel that he is making progress.Patient denies further complaints at this time and nursing staff notes no further acute issues with the patient. Diagnosis and assessment plan: fall - Patient sustained a fall on 10/2/21 with no injuries. He continues to work with therapy though has continued fatigue. Possible cognitive deficit; as above he has evidence of short-term memory deficit on today's evaluation of one cognitive assessment in the facility.
Skilled nursing dated 10/12/21 at 11:54 a.m., read in pertinent part: ADL/function: Resident does not [TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to notify, make immediate notification to the resident representative ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to notify, make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment; initiate a resident transfer or discharge from the facility; or when the resident was involved in an accident with an injury or portent for an injury for two (#62 and #116) of three residents out of 30 sample residents.
Specifically, the facility failed to immediately inform the resident representative(s):
-For Resident #62 when the resident was transferred to the hospital for assessment and treatment of a medical illness; and,
-For Resident #116 after a fall which could have resulted in an injury with the potential for a need for physician intervention. (Cross-Referenced to F689 failure to prevent a resident fall).
Findings include:
I. Facility policy
The Physician Notification policy, revised [DATE], was received from the director of nursing (DON) on [DATE] at 1:10 p.m. It read in pertinent part:
The staff must immediately inform the resident, consult with the physician, and notify the resident's responsible party when there is a significant change in the resident's care or condition related to:
-An accident involving the resident, which results in injury and has the potential for requiring physician intervention.
-A significant change in the resident's physical, mental, or psychosocial status. Significant changes include but are not limited to: Falls with or without injury .
-A need to alter treatment significantly.
-A decision to transfer or discharge a resident.
The staff will:
-Notify the physician and responsible party/family member of identified significant changes.
-Document date, time, and party notified, and findings and details of the notification in the resident record.
II. Resident #62
A. Resident status
Resident #62, age [AGE], was readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), pertinent diagnoses cerebral vascular disease, cancer, diabetes, depression and respiratory failure.
The [DATE] minimum data set (MDS) assessment revealed the resident had a cognitive deficit with a brief interview for mental status (BIMS) of 14 out of 15. She required extensive assistance with two people for bed mobility, transfers, and dressing. Extensive assistance of one person for toilet use and hygiene. Total assistance of two persons for bathing. Total assistance of one person for meal assistance. She had a feeding tube. Tracheostomy with oxygen and suctioning.
II. Record review
Nurse note for Resident #62 dated [DATE] at 4:30 p.m. read in pertinent part: Resident went for an eye appointment today. On the way back to the facility, according to the transport person the resident said she wasn't feeling well and she wanted to go to the hospital. She was sent to the hospital.
Nurse note for #62 dated [DATE] at 5:13 p.m. read in pertinent part; Resident went to an appointment in the morning and at 5:00 p.m the facility was notified by the hospital that the resident requested to be taken to the emergency room because she was having right sided weakness. The nurse from the emergency room wanted more information about the resident. She remained in the emergency room at that time.
Nurse note for Resident #62 dated [DATE] at 6:39 p.m. read in pertinent part: Residents legal representative came to see the resident and was told the resident was in the hospital. She was upset that no one notified her of the hospitalization or change of condition. She wanted to know what hospital the resident was at and said she was on her way there to see her.
III. Interviews
Resident #62s legal representative was Interviewed on [DATE] at 1:20 p.m. She said she came to see the resident after driving two hours and found out the resident was in the hospital. She said no one notified her as she was the legal representative. She said she was upset and wanted to see the resident so she drove to the hospital.
Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:30 a.m. She said the families were notified of any change of conditions and documented with a progress note. She said even when the resident was sent to the hospital from an appointment the facility was responsible to call the family and let them know.
Director of nurses (DON) was interviewed on [DATE] at 3:30 p.m. She said families or legal representatives were notified of any changes with residents. She expected the nurse to notify them and to write a note. She said Resident #62 families should have been notified of her hospitalization.
III. Resident #116
A. Resident status
Resident #116, age [AGE], was admitted [DATE] and discharged from the facility on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia (having low oxygen supply/levels in the tissues of the body), personal history of COVID-19 generalized muscle weakness, need for assistance with personal care, history of repeated falls, cognitive communication deficit, and being prostatic hyperplasia (enlarged prostate gland can cause uncomfortable urinary symptoms)
The [DATE] minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. The resident needed extensive assistance with bed mobility, transfers, dressing, and toileting from one staff; and extensive assistance form two staff members while walking in the room.
The resident was occasionally incontinent of urine, frequently incontinent of bowel and was not placed on a toileting program (such as a scheduled toileting assistance) to manage incontinence. The resident was on oxygen therapy.
B. Record review
A medical durable power of attorney for healthcare decisions was signed by the resident on [DATE] appointing his daughter as medical durable power of attorney (MDPOA).
Hospital records provided to the nursing facility found in the resident electronic medical record documented in part: Hospital admission date [DATE]. Patient (resident) presented with impaired activity tolerance, impaired balance, generalized weakness, and recent falls, all of which are impacting the patient's ability to safely and independently perform activities of daily living (ADLs), related functional transfers and mobility.
-Living situation: prior living situation: resident was living alone in a ranch style home, most recently patient lives home with his daughter (who is from Virginia however has been staying with him 24/7 since the patient's COVID diagnosis).
-Discussed treatment with the patient's daughter.
Hospital records revealed the resident's daughter was highly involved in the resident care even prior to admission to the nursing facility.
Per the initial care conference attendance document, the facility held a care confrere meeting on [DATE]. The attendance documented that the only family personal representative in attendance, was the resident daughter/MDPOA.
-Facility staff signed their own names as attendees and then wrote the daughters name as being an attendee by phone and wrote MDPOA next to her name.
admission summary note dated [DATE] at 4:08 p.m., read in part: Resident admitted via stretcher at 10:50 p.m.Resident assisted into bed. Resident was tired and did not want to sign or look at any consents at this time. Per the resident's daughter, who stopped by to make sure her father had arrived, and said the resident usually goes to bed around 9:00 p.m .
Care conference summary dated [DATE] documented the following: the resident representative identified as the resident daughter was in attendance by phone as well as several facility staff. There were no other family/friend representatives in attendance.
-Per resident and MDPOA, there were no changes to advance directive instructions: the orders will be full code with cardiopulmonary resuscitation (CPR), if needed.
-Discharge planning: Resident admitted to the facility for skilled rehabilitation services. Discharge goals were to return home to the community. The social worker was to work with resident MDPOA and interdisciplinary team (IDT) to determine safe discharge planning.
Resident #116's comprehensive care plan developed [DATE] documented the following interventions:
-Establish a pre-discharge plan with the resident and daughters and evaluate progress and revise plan as needed; initiated [DATE];
-Evaluate and discuss with the resident and daughters the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits and needs for maximum independence; initiated [DATE]; and
-Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs: initiated [DATE].
The resident had a fall on [DATE] sometime before 2:45 a.m. There was no documentation to detail the nature or outcome of the resident fall and there was no documentation of notification to either the resident physician or MDPOA. There was no documentation of needed treatments, intervention or physician's order after the fall.
An email dated [DATE], from the facility's previous director of nursing (DON) to the MDPOA The previous DON wrote: I just left you a voicemail, as well. If you would like to call me, I will be in my office, .the reason why you were not initially notified of the fall on [DATE], was because per our system, you were not a legal contact to share any information with at that time, and it would have been a HIPPA violation of the nurse. I appreciate your time and dedication to your father.
-Despite the reference in this email that the resident daughter was listed as the resident legal representative in the resident record, there was supporting evidence in the resident record that facility staff considered the resident daughter to be the resident MDPOA. The supporting evidence was contained in the [DATE] care conference meeting and identified the daughter as the MDPOA on the attendance sheet; which staff documented because the daughter/MDPOA was on the phone and not present to write that information on the attendance sheet herself. (See above).
C. Staff interviews
Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 1:30 p.m. LPN #4 said the nurse was to notify the resident representative as soon as the resident was stable enough to leave unattended or in the care of a certified nurse aide (CNA) of any change in condition including falls, injuries, change in vital signs status, new medications and transfers to the hospital.
The Nursing home administrator (NHA), interim director of nursing (IDON) and corporate nurse Consultant (CNC) were interviewed on [DATE] at 4:00 p.m. The NHA confirmed they had not notified the resident daughter at the time of the resident fall because they did not have sufficient documentation that she was the legal representative, they did not believe she would have been legally privy to the information that the resident had an unwitnessed fall. The CNC acknowledged that the resident had confusion in some areas but the facility felt the resident had sufficient cognitive ability to understand the medical risks of a fall and the ability to make his own treatment decisions. They were not sure if Resident #116 was asked if he wanted his daughter called. The IDON was unable to comment due to lack of knowledge about Resident 116's medical status, as she was not working in the facility at the time of the resident stay.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure two (#42 and #117) of five residents who were...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure two (#42 and #117) of five residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, hygiene, dressing and grooming, out of 30 sample residents.
Specifically, the facility failed to:
-Provide timely incontinent care and repositioning for Resident #42 and #117, who required staff assistance for bed mobility and incontinence care; and,
-Provide Resident #42 positioning and set-up assistance for eating meals.
Findings include:
I. Facility policy and procedure
The Activities of Daily Living (ADL) Support policy, revised May 2018, provided by the corporate nurse consultant (CNC) on 2/15/22 at 3:01 p.m., read in pertinent 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 independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
-Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.
-Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.
-Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression.
-If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate.
-A resident's ability to perform ADLs will be measured using clinical tools, including the MDS.
-Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.
II. Resident #42
A. Resident status
Resident #42, age [AGE], was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnosis included stage3 pressure injury of the sacral region and of the right and left buttocks, muscle weakness, reduced mobility, need for assistance with personal care.
The 12/27/21 minimum data set (MDS) exam revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident did not reject care assistance and needed extensive assistance from two staff with ADLs. The resident was dependent on staff to perform all steps and tasks of toileting and bathing. The resident was able to eat by herself after receiving staff assistance to set-up the meal. The resident did not walk.
The resident was always incontinent of both bowel and bladder; had one unstageable and two stage 3 pressure injuries and was at risk of developing additional pressure injuries. She was on a pressure relieving mattress and was not on a turning or repositioning program, but was receiving nutrition or hydration intervention to manage skin problems and pressure ulcer/injury wound care.
B. Resident interview and observations
Resident #42 was interviewed on 2/9/22 at 9:50 a.m. Resident #42 was in bed with the head of the bed elevated at an approximately 45-degree angle. The resident upper body was tilted forward at the shoulders and her head was leaning forward with her chin tucked slightly downwards. The resident said she would like to get up more and start to gain strength to be more active, but the staff did not get her up that often and she usually ate her meals while in bed. Resident #42 said she felt some staff were bothered by her requests for assistance and sometimes left before all of her needs were met.
Resident #42 was observed on 2/14/22 from 9:10 a.m. to 1:00 p.m.
At 9:10 a.m. Resident #43 was lying in bed on her back, the head of the bed was elevated to approximately 90 degrees. The resident was leaning forward at the upper torso and had the shoulders with her chin angled down towards her chest.
At 10:00 a.m. to 10:31 a.m. Resident #43 was observed lying in bed; the head of the bed was elevated approximately 90 degrees. The resident was in the same position on her back, though she had slid down a bit but her upper torso and shoulders were still tilted forward.
Resident #42 was interviewed at 10:31 a.m. Resident #42 said she was doing ok, did not feel much like eating. The resident had only had a couple bites of breakfast.
For the first time during the observation, certified nurse aide #7 entered the room at 10:45 a.m. and removed the resident dishes. The CNA did not offer to help the resident with the meal or offer incontinent care or repositioning assistance. Resident #42 remained in the same position in bed.
At 12:16 p.m. CNA #6 entered Resident #42's room to deliver the residents' lunch meal. Resident #42 was still in the same position; slouched down in the bed bent forward at the shoulders and upper torso with her chin tilted towards her chest. Though the resident had free range of motion in her head and neck the position of the bed and her torso was slouched and it made it hard for the resident to keep her head up facing fully forward or be able to reach the food items on the over the bed table tray. CNA #6 set the resident meal on the over the bed table. The meal was in a foam container with an attached lid. The CNA lifted the foam lid and leaned it against two empty sippy cups that were already sitting on the over the bed table. The CNA did not pour the drinks into the sippy cups for the resident to drink from for her ease. The table tray was elevated well above the resident lap and was more than six inches from the resident. The position of the table tray made it difficult for the resident to see what was in the deep foam dish or reach the food side as the food was slightly above eye level. The CNA left the resident drinks behind the empty sippy cups and foam lid; the resident was not able to see or reach the drinks.
CNA #6 and CNA #7 left the unit at 12:22 p.m., after all the meals were delivered.
Resident #42 was interviewed at 12:24 p.m. Resident #42 said she was uncomfortable and I cannot eat when I ' m all slumped over like this; I cannot reach my food or drinks.Resident #42 wanted the drinks transferred to her sippy cups and wanted to be pulled up in bed.
At 12:28 p.m. CNA #9 was alerted to resident's needs. CNA #9 said the resident should have been positioned in bed so she was up in the bed sitting up straight; not slouched over and was able to reach her food. CNA #9 got the resident clean sippy cups, poured the drinks into the cups and cut up the resident's food. CNA #9 then said she needed to get another CNA to assist in repositioning the resident so she would be able to eat her meal.
At 1:02 p.m. CNA #6 arrived to assist in repositioning the resident. The CNAs did not provide incontinent care at that time. The resident had not been offered incontinence care for the duration of the observation from 8:30 a.m. through 1:10 p.m.
C. Record review
The comprehensive care plan revised 2/7/22 revealed the resident had:
ADL self-care performance deficit related to immobility. The resident's related goals were:
-To minimize the risk for decline in ADL function.
-To minimize the risk for complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury.
-There were no interventions for positioning or specific ADL assistance needs.
Potential for alteration in body composition integrity (muscle/fat wasting) and unintended weight changes. The resident's related goal was to minimize the risk of malnutrition.
-There were no interventions for meal assistance or positioning for maximal oral intake.
Pressure injuries and the potential for pressure injuries. The resident's related goal was risk for skin breakdown, redness, or development of blisters or discoloration. Interventions in pertinent part:
-The resident requires the bed to be as flat as possible to reduce shear.
-Avoid positioning the resident on (SPECIFY location). The location was not entered into the care plan.
-Encourage small frequent position changes.
-Educate the resident and caregivers as to causes of skin breakdown; including: transfer/ positioning requirements; importance of taking care during ambulation/mobility, good nutrition and frequent repositioning.
-If the resident refuses treatment, confer with the resident, the interdisciplinary team (IDT) and family to determine why and try alternative methods to gain compliance; and document alternative methods.
Chronic pain related to multiple wounds and immobility. The resident's goal was to minimize the resident's risk for inadequate pain relief.
-There were no interventions for non-pharmaceutical pain relief methods related to immobility.
Review of the resident's electronic medical record, specifically progress notes and task record, revealed no refusals for incontinent care or bed mobility.
The resident task record was reviewed for the past 30 days (dates 1/14/22 to 1/13/22) the record revealed the resident was dependent on staff for bed mobility positioning.
Physician's wound care note dated 2/8/22 read in part: The patient was seen today for follow up and management of the patient's wound(s) on the coccyx and abdomen.Wound Assessment: Coccyx wound is a Stage 3 Pressure Injury .has received a status of not healed.There is no change noted in the wound progression.Resident had poor judgment and was non-compliant. The patient is oriented to person, time, and place.Additional orders offload (pressure points).
-There were no physician's order to off load pressure points.
III. Resident #117
A. Resident status
Resident #117, age [AGE], was admitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnosis included stage 3 pressure injury of the sacral region and of the right and left buttocks, muscle weakness, reduced mobility, and needed for assistance with personal care.
The 2/10/22 minimum data set (MDS) assessment was in progress. The portion completed revealed the resident had severely impaired cognition; the brief interview for mental status (BIMS) was not conducted because the resident had impaired cognition and was rarely understood. The resident did not reject care.
The resident ADL needs had not been fully assessed by the MDS criteria; however, the assessment indicated the resident did not walk and was fully dependent on staff for all ADL, including eating. The resident was receiving nutrition by a gastric tube. The resident had no current pressure ulcers but was at risk for developing pressure ulcers. He was on a pressure relieving mattress and was not on a turning or repositioning program.
B. Resident interview and observations
Resident #117 was unable to participate in an interview due to impaired cognition.
Resident #117 was observed on 2/9/22 at 9:52 a.m., 10:30 a.m., 10:45 a.m., 11:30 a.m., and 12:15 p.m. On each observation, Resident #117 was asleep and lying flat on his back arms crossed.
Resident #117 was observed on 2/14/22 from 9:08 a.m. to 1:00 p.m. Throughout the observation the resident remained lying flat on his back. No CNAs entered to provide any care to resident #117 during the time of the observation. The physical therapist entered for orthotic brace management and remained in the room for approximately eight minutes; the therapist did not reposition or provide incontinent care to the resident. The resident had not been offered incontinence care for the duration of the observation from 8:30 a.m. through 1:10 p.m.
C. Record review
The comprehensive care plan initiated 2/4/22 reviewed the resident had:
An ADL self-care deficit performance deficit with interventions to provide bed mobility and incontinence care with the assistance of one to two staff.
A communication deficit and impaired cognition with interventions to anticipate resident's needs.
Bowel and bladder incontinence with interventions to check resident for incontinence often and assist with toileting as needed; and provide peri care after each incontinent episode.
A potential for pressure or moisture associated skin damage (MASD) development related to decreased movement, anticoagulation therapy, and incontinence.
III. Additional staff interviews
The director of therapy (DOT) was interviewed on 2/15/22 at 10:04 a.m. The DOT said positioning and repositioning was very important to a resident's overall health.
Resident #42 was not known to be at risk for choking but acknowledged if a resident was eating in bed it was best for residents to be positioned upright and pulled up in the bed, so they were not slouching while they were eating. The DOT said it was his recommendation that Resident #42 get up in a chair and eat at a table for best positioning.
CNA #6 was interviewed on 2/15/22 at 8:39 a.m. CNA #6 said they try to check the resident every two hours to provide repositioning assistance and incontinent care if the resident was wet. It was important to reposition and provide incontinent care to keep the resident clean and dry so they did not develop pressure sores. All residents should be positioned so they were seated up straight and not slouched while they were eating.
Licensed practical nurse (LPN) #4 was interviewed on 2/15/22 at 9:10 a.m. LPN #4 said positioning and toileting assistance was to be done for all dependent residents; when the resident woke up and at the beginning of each shift, then approximately every two hours or more if the resident was known to be a heavy wetter. Toileting and repositioning was also to be done if a resident requested assistance or as needed by other circumstances.
The interim director of nursing (IDON) was interviewed on 2/15/22 at 4:15 p.m. The IDON said residents who were dependent on staff for ADL assistance should be checked and repositioned frequently if they were soiled with urine or feces the staff should provide incontinent care. The IDON said there was no definition for frequent checks staff should continue to make rounds as appropriate to meet a resident's needs; three to four hour checks might be appropriate.
When asked to give an estimation for frequent checks for Resident #42 or #117 the IDON did not provide a timeline but said frequent checks for positioning would depend on the resident patterns, type of mattress they were using.
The IDON said resident #42 was capable of using her call light to ask staff for assistance if she needed to be changed or repositioned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#15) of three residents with limited mob...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#15) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate services, equipment, and assistance to maintain maximal mobility and services to prevent further decrease in ROM, out of 30 sample residents reviewed.
Specifically, the facility failed to ensure Resident #15 received consistent restorative services for daily splinting assistance and passive range of motion (ROM) six day a week as written in the resident comprehensive care plan based on therapy services recommendations; to address limitations related to self-care deficits due to decreased mobility and limited ROM.
Findings include:
I. Facility policy
The Restorative Nursing Services policy, revised July 2017, was provided by the corporate nurse consultant (CNC) on 2/15/22 at 3:17 p.m., read in pertinent part: 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 #15
A. Resident status
Resident #15, under the age of 65, admitted on [DATE]. According to the February 2020 computerized physician's orders (CPO), diagnoses included hemiplegia and hemiparesis (severe or complete loss of strength or paralysis) following cerebral infarction contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff worsen by inactivity) of the left hand, pain in the upper arms, and pain in the joints of left hand.
The 2/2/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The residing did not display behaviors and did not reject care assistance. The resident had left sided impairment of both the upper and lower extremities; did not walk; and was totally dependent on two staff for all activities of daily living including bed mobility, transfers, toileting, personal hygiene, dressing and grooming. The resident was receiving restorative range of motion services, to include passive range of motion (PROM).
B. Observations and interview
On 2/9/22 at 11:56 a.m. Resident #15 was observed laying in bed, he was not wearing the prescribed hand or elbow splint.
Resident #15 said he wanted to gain strength and be more active but he was dependent on staff to help him gain strength and be able to get around the community because he was totally dependent on staff to help him with exercises and to get up and get around. He said, thestaff used to provide therapy services regularly but he staff stopped coming around regularly to provide him assistance with his splints and with range of motion exercises; he was not sure why but wanted his services more regularly. The resident said he did not refuse restorative services but on occasion had asked for a delayed start when his routine pain medications were not effective to relieve pain in his left hand and asked for his as needed pain medications before starting or resuming services. When the nurse gave him a pain pill it was effective to relieve pain during therapy sessions.
On 2/14/22 at 8:43 a.m. and 3:37 p.m., Resident #15 was observed without a splint to his left hand or elbow.
On 2/15/22 at 9:56 a.m. and 1:05 p.m., Resident #15 was observed without a splint to his left hand or elbow.
C. Record review
Physician medical provider note dated 12/1/21 at 2:14 a.m., read in part: Medical necessity of visit: Nursing requested that I see the patient today. Chief complaint: . Patient reports he has no pain now, but frequently has spasms like pain in his left arm. Patient with spasms in left upper arm, per nursing reporting pain daily. Patient requesting medication to help hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Has contractures and pain to the left side. Assessment and plan: . Hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side: Continue restorative therapy. Continue Tylenol to 500 milligrams every four hours as needed for pain. Baclofen trial for muscle spasms.
Restorative progress note dated 12/16/21 at 1:37 p.m., read: PROM to left upper and lower extremity up to 20 minutes six days a week, ongoing; PROM, splint/brace assistance to left hand and elbow. Performance: Resident does not tolerate passive range of motion to left arm well. Hand splint and elbow brace applied daily. Recommendations: Continue program to increase range of motion and to prevent contractures. Repositioning frequently for comfort.
-Skilled therapy is not recommended.
The comprehensive care plan last reviewed 2/1/22 revealed the resident had an identified self-care deficit due to decreased mobility, limited ROM, contractures, lack of coordination due to left sided hemiplegia, due to effects of a stroke. This care focus was last revised on 10/28/21. The resident identified goal was participation in the facility ' s restorative program, to minimize risk of decline in ADL functioning due to immobility. Interventions included: Restorative nursing program: PROM to left upper and lower extremities, up to 20 minutes six days a week; ongoing, as tolerated and apply resting hand splint and elbow brace.
-Resident has a palmar guard for hand, wears it as tolerated to prevent increased contracture(s).
There was no documentation on the medication administration record (MAR) or the treatment administration record (TAR) to indicate the staff were monitoring the resident for splint use and duration.
The past 90 days of the resident restorative program task record for the dates of 11/12/21 to 2/12/22 was reviewed the record revealed Resident #15 did not receive restorative nursing services as the comprehensive care planned interventions prescribed. The task record failed to document any application of the prescribed splint palmar guard to the resident ' s left hand and the resident was not provided the prescribed six days per week of PROM assistance; and of the time the resident received PROM services none were to the prescribed duration of 20 minutes. The residents record failed to provide any documentation of why the resident did not receive restorative nursing services as care planned. The record showed the following dates of services:
-From 11/12/21 to 11/13/21, no services were offered or provided.
-For the week of 11/14/21 to 11/20/21, the resident had not refused any offered services and received the PROM program two times on:
11/18/21 at 10:31 a.m. for 10 minutes; and
11/20/21 at 10:10 a.m. for 15 minutes.
-For the week of 11/21/21 to 11/27/21, the resident had not refused any offered services and received the PROM program three times on:
11/23/21 at 1:59 p.m. for 15 minutes;
11/24/21 at 1:32 p.m. for 10 minutes; and
11/26/21 at 1:59 p.m. for 10 minutes.
-For the week of 11/28/21 to 12/4/21, the resident had not refused any offered services and received the PROM program four times on:
11/30/21 at 1:59 p.m. for 15 minutes;
12/1/21 at 1:59 p.m. for 10 minutes;
12/3/21 at 1:59 p.m. for 10 minutes; and
12/4/21 at 1:59 p.m. for 15 minutes.
-For the week of 12/5/21 to 12/11/21, the resident had not refused any offered services and received the PROM program four times on:
12/7/21 at 1:59 p.m. for 15 minutes;
12/8/21 at 11:14 a.m. for 15 minutes;
12/9/21 at 8:46 a.m. for 10 minutes; and
12/11/21 at 9:41 a.m. for 15 minutes.
-For the week of 12/12/21 to 12/18/21, the resident was offered the PROM program one time but refused the service on 12/15/21 at 1:59 p.m.
-For the week of 12/19/21 to 12/25/21 the resident had not refused any offered services and received the PROM program one time on:
12/23/21 at 11:06 a.m. for 15 minutes.
-For the week of 12/26/21 to 1/1/22, the resident had not refused any offered services and received the PROM program two times on:
12/29/21 at 11:02 a.m. for 15 minutes; and
12/31/21 at 10:43 a.m. for 10 minutes.
-For the week of 1/2/22 to 1/8/22, no services were offered or provided.
-For the week of 1/9/22 to 1/15/22, the resident had not refused any offered services and received the PROM program two times on:
1/9/22 at 7:30 a.m. for 15 minutes; and
1/10/22 at 1:59 p.m. for 15 minutes.
-For the week of 1/16/22 to 1/22/22, the resident had not refused any offered services and received the PROM program three times on:
1/18/22 at 1:59 p.m. for 15 minutes;
1/19/22 at 1:59 p.m. for 15 minutes; and
1/20/22 at 1:59 p.m. for 15 minutes.
-For the week of 1/23/22 to 1/29/22, the resident refused one offered services and received the PROM program one time on:
1/25/22 at 1:59 p.m. resident refused services;
1/26/22 at 11:50 a.m. for 15 minutes;
-For the week of 1/30/22 to 2/5/22 the resident had not refused any offered services and received the PROM program one time on:
2/4/22 at 1:59 p.m. for 15 minutes.
-For the week of 2/6/22 to 2/12/22 the resident had not refused any offered services and received the PROM program one time on:
2/12/22 at 1:59 p.m. for 15 minutes.
D. Staff interviews
Certified nurse aide (CNA) #4 was interviewed on 2/15/22 at 9:18 a.m. CNA #4 said he was hired into the restorative CNA position and was to provide restorative nursing services to numerous residents in the facility. Resident #15 was one of the residents he provided restorative services. Resident #15 was to receive 15 to 20 minutes of PROM twice a week on Tuesdays and Saturdays and daily splinting brace application to his left hand and elbow. CNA #15 was not aware Resident #15 was prescribed PROM services six days a week and had not read the resident care plan. CNA #15 said on Mondays he was the only CNA and was not able to get to Resident #15 due to the number of other residents needing services and there were several occasions when he was pulled to work the floor as CNA providing routine ADL services to assigned residents.
CNA #4 said Resident #15 was on occasion resistant to PROM services due to pain and services had to be put on hold while as needed pain medications were administered and had time to take effect. Once the pain medication had time to work Resident, #15 was willing to accept services. Additionally, Resident #15 required splinting/bracing services to prevent worsening of contractures in his left hand and elbow. CNA #15 was not always able to apply the splints but said the CNA should have assisted the resident to put the splints on.
The director of therapy (DOT) was interviewed on 2/15/22 at 10:58 a.m. The DOT said Resident #15 was to receive PROM to the upper and lower extremity for a duration of 10 minutes or as tolerated six times a week and daily splinting assistance to address contractures in his left hand and elbow. The resident had an extension brace for the left elbow and a resting splint for the left hand. The DOT said the resident did not typically refuse services and did not know why services had not been provided as prescribed by the doctor and recommended by the therapy department. The DOT said he did not observe any physical decline in the resident ' s functional status at this time the resident was stable as of the last time therapy assessed him a few weeks ago.
CNA #6 was interviewed on 2/15/22 at 1:07 p.m. CNA #6 said the restorative CNA was to provide PROM services and apply any splint for the resident if they were ordered. CNA #6 was not aware that Resident #15 had any splints.
The interim director of nursing (IDON) and CNC were interviewed on 2/15/22 at 4:02 p.m. The CNC acknowledged the restorative program was lacking and needed some attention to get services back up and running so residents received the services as recommended. Restorative services were important.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure appropriate care and services were provided ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure appropriate care and services were provided for incontinence care for one (#24) of three residents reviewed out of 30 sample residents.
Specifically, the facility failed to ensure Resident #24 had physician orders and a corresponding person centered care plan related to the nephrostomy bags.
Findings include:
I. Facility policy and procedure:
The Nephrostomy Tube, revised October 2010, was provided by the corporate nurse consultant (CNC) on 2/15/22 at 12:03 p.m. It read, in pertinent part, Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Empty the drainage bag once per shift and as needed. Change dressings every 1-3 days, or as ordered.
II. Resident #24
A. Resident #24 status
Resident #24, under age [AGE], was readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnosis included sepsis, urinary tract infection, and stroke.
The 12/2/21 minimum data set (MDS) assessment indicated the resident was severely impaired in decision making regarding tasks of daily life. It indicated the resident had both short and long term memory deficits. It indicated the resident was totally dependent on staff for activities of daily living and required one person physical assistance.
It indicated the resident had an indwelling catheter and was not rated for urinary incontinence.
B. Record review
The hospital discharge summary was completed on 2/3/22. It indicated the resident was hospitalized from [DATE] to 2/3/22 for sepsis, urinary tract infection, and E. coli bacteremia (infection caused by bacteria from the intenstines). It indicated nephrostomy tubes were exchanged on 1/27/22 and indicated the tubes were initially placed in December 2021.
A physician encounter note was created on 2/4/22. It indicated the resident was hospitalized from [DATE] to 2/3/22 for treatment related to E. coli bacteremia, urinary tract infection, and sepsis. It indicated the resident's nephrostomy tubes were exchanged and she was on antibiotic treatment. It indicated the resident would have further follow up with nephrology outpatient.
A bowel and bladder evaluation was completed on 2/4/22. It indicated the resident was incontinent of bowel and bladder and did not have a foley catheter. It indicated the resident's mobility status was bed rest and the resident was incontient of both bowel and bladder daily.
The incontinence care plan, initiated 2/9/22, indicated the resident had functional bladder incontinence and interventions included peri-care after incontinence episodes and monitoring for signs and symptoms of urinary tract infections.
The care plan did not include an area for nephrostomy care and services to be provided.
The CPOs were reviewed on 2/15/22 at 10:20 a.m. and revealed no orders were in place related to nephrostomy care and services.
C. Staff interviews
Licenced practical nurse (LPN) #4 and LPN #1 were interviewed on 2/15/22 at 10:41 a.m. LPN #4 said Resident #24 had a foley catheter. She said there were no orders in the chart for the catheter. She said there should be orders related to catheter size, flushing the catheter, and checking the placement. She said if there were no orders for catheter care then it had the potential for no care to be provided. She said there was a care plan for incontinence but no catheter care plan. LPN #1 said Resident #24 has a history of urinary tract infections. She said the resident recently came back from the hospital for care related to urinary tract infection. She said if a resident required catheter care and there were no physician orders then the nurse would not be alerted to check on the catheter.
D. Resident observation
The resident was observed in bed on 2/15/22 at 11:34 a.m. Two nephrostomy bags were observed on the bed on both the left and right side of the resident. Each bag was observed to be 75 percent full.
E. Staff interviews
LPN #4 was interviewed again on 2/15/22 at 11:39 a.m. She said she was mistaken when she said the resident had a catheter and confirmed the resident had nephrostomy bags. She said care needed to be provided daily and tubes needed to be changed every week. She said there were no orders in the chart for this care. She said it was her first day so she was unsure why there were no orders for this resident.
The director of nursing (DON) and corporate nurse consultant (CNC) were interviewed on 2/15/22 at 4:20 p.m. The DON said a resident with nephrostomy bags should have a nephrostomy care plan and physician orders related to draining the bags and monitoring the site.
The DON said the resident went out to the hospital at the end of January 2022 and when she returned the physician orders were not put into the chart. She said she did not know how this happened and did not know why clinical staff believed it to be a foley catheter. She said the risk of no orders for nephrostomy care could be infection.
The CNC said corresponding care was provided for the nephrostomy even though there were no orders in place. She said clinical staff continued to monitor the site and empty the nephrostomy bags.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident interviews, staff interviews, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature.
Specifically, the fac...
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Based on resident interviews, staff interviews, and the tasting of the test tray, the facility failed to consistently serve food that was palatable and at the proper temperature.
Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance, and temperature.
Findings include:
I. Facility policy and procedure
The Food Wholesomeness policy and procedure, developed 1/12/16, was provided by the corporate nurse consultant (CNC) on 2/14/22 at 5:15 p.m. It read, in pertinent part, Food temperatures are taken for serving at every meal and at the point when a resident is served a meal on a regular basis. Hot foods are cooked to above 165 degrees or per USDA (United State Department of Agriculture) Food Code and held at least 140 degrees until service.
II. Resident group interview
The resident group interview was conducted on 2/14/22 at 10:35 a.m. The residents in attendance were Resident #16, #46, #13, #33, and #54. All residents were identified by facility and assessment as interviewable.
Resident #33 said meals were served in styrofoam containers. She said the styrofoam was flimsy and made it difficult to eat the food. She said it was served in styrofoam for the past six months and food became cold when served in the styrofoam.
Resident #16 said her food was reheated frequently because it was served cold. She said breakfast was served cold more often than other meals. She said if she ate in the dining room the food would be warm but when she had a room tray her food was cold.
Resident #46 said the use of plastic and styrofoam was difficult. She said the plastic utensils were unappealing and made it difficult to cut food.
III. Test tray
On 2/14/22 at 11:45 a.m., the end of tray line for the room trays was observed. The dietary manager (DM) was completing the last of the room trays. She said she took the temperature of the food prior to serving. A test tray was prepared at 11:51 a.m. The room trays were placed on a cart and taken to the [NAME] unit. All the room trays consisted of styrofoam containers with lids and served with plastic utensils. Drinks were provided in styrofoam cups.
A test tray was sampled on 2/14/22 at 12:10 p.m. The test tray was received after the last resident on the unit was served. The test tray was served in a styrofoam container with plastic utensils. The meal was pot roast served with gravy, a roll, potatoes, and a vegetable medley. The roll was placed in the same compartment as the pot roast and gravy and had become soggy. The pot roast was measured at 103 degrees fahrenheit. The consensus among the two surveyors was that the pot roast and gravy was cold and difficult to cut with the provided utensils and the roll was soggy and bland.
IV. Staff interviews
The DM was interviewed on 2/10/22 at 12:30 p.m. She said she has been the dietary manager for two months. She said the dietary department did not have a full time dishwasher so they use styrofoam to reduce the need to wash dishes. She said she had not heard of complaints from the residents regarding the use of styrofoam.
The nursing home administrator (NHA) was interviewed on 2/14/22 at 5:08 p.m. He said there was no full time dishwasher and styrofoam plates and containers were used to reduce the need of washing dishes. He said the kitchen staff could use insulated carts in order to reduce a drop in temperature for room trays.
The registered dietitian (RD) was interviewed on 2/15/22 at 9:56 a.m. He said the kitchen staff were implementing the use of insulated carts for room trays on that day. He said the insulated carts should help the food remain warm prior to serving. He said the temperature of 103 degrees fahrenheit for the pot roast was cold and he would expect the temperature to be at 130 degrees fahrenheit.
The DM was interviewed again on 2/15/22 at 3:51 p.m. She said the temperature of 103 degrees fahrenheit for the pot roast was cold. She said she would want food served to be at 150 degrees fahrenheit when served. She said the kitchen staff started using insulated carts for the room trays as of that day.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews, and record review, the facility failed to ensure food was served and stored under sanitary conditions during meal services.
Specifically, the facility failed t...
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Based on observations, staff interviews, and record review, the facility failed to ensure food was served and stored under sanitary conditions during meal services.
Specifically, the facility failed to:
-Offer, assist or encourage resident to perform hand hygiene prior to eating meals and after eating meals and handling and throwing away trash from the meal, in one of one dining rooms and two of three units; and,
-Clean refrigerator used to store resident snacks and outside foods; date and label sandwiches for resident consumption and discard expired food items, in two of two unit refrigerators used for resident food.
Findings include:
I. Resident hand hygiene
A. Facility policy
The Assistance with Meals policy, revised July 2017, was provided by the corporate nurse consultation (CNC) on 2/15/22 at 3:01 p.m., read in pertinent part: The nursing staff will prepare residents for eating.
-The policy did not provide a policy or procedure on resident hand hygiene prior to or after meals.
B. Observations
Lunch service was observed in the main dining room on 2/9/22 from 11:15 a.m. to 12:45 p.m. Residents came to the dining room and were served drinks then served the lunch meal. Residents were observed feeding themselves handling silverware napkins and/or handling finger foods. At no point in the meal service either upon entering the dining room, before eating, or after tossing foam plates and plastic silverware into the trash while touching the inner sides of the trash can were any of the residents present offered a method of hand hygiene.
Lunch service room tray delivery on the 300 hall was observed on 2/10/22 at 11:55 a.m. Certified nurse aides (CNA) #1 and #3 were observed delivering room meals and drinks to residents who chose to eat their meals in their rooms. The CNA's delivered six trays. Neither of the CNAs encouraged or assisted any of the residents to perform hand hygiene.
Lunch service room tray deliver on the 100 and part of the 200 halls was observed on 2/14/22 from 12:16 p.m. to 1:08 p.m. CNA #6 and #1 were observed delivering room meals and drinks to residents who ate their meals in their rooms. The CNAs delivered 10 room trays to residents most of whom were bed bound. Neither of the CNAs encouraged or assisted any of the residents with hand hygiene.
C. Staff interviews
CNA #6 was interviewed on 2/14/22 at 1:30 p.m. CNA #6 said he was not told to offer to assist residents with hand hygiene when delivering room trays. CNA #6 said he would offer to assist resident hand hygiene if their hands were observed to be soiled.
Licensed practical nurse (LPN) #4 was interviewed 2/15/22 at 9:10 a.m. LPN #4 said staff were to encourage and assist residents with hand hygiene before and after using the bathroom, during bathing assistance, and before and after each meal or snack.
The infection prevention nurse (IP) was interviewed on 2/15/22 at 1:22 p.m. The IP said staff were expected to assist residents with hand hygiene before and after each meal. The facility used to have hand sani wipes to offer the resident prior to eating meals but they were so focused on other factors of infection prevention and the use of the wipes got put on the back burner. The IP said she would conduct and in service to instruct staff that regardless of the availability of the sani wipes they were to offer the resident a drop of antibacterial hand rub prior to eating meals and assist the resident with hand hygiene if they were unable to complete the process on their own.
The dietary manager (DM) was interviewed on 2/15/22 at 3:51 p.m. The DM said the kitchen had hand wipe towelettes to offer each resident prior to the meal and they were usually sent out for resident use. The CNA needed to let the kitchen know when they are out of stock so they can be refilled. The DM was not sure who was responsible for making sure the CNA's were trained to make sure the residents were assisted with hand hygiene.
II. Unit refrigerators
A. Facility policy
The Food Wholesomeness policy and procedure, developed 1/12/16, was provided by the corporate nurse consultant (CNC) on 2/14/22 at 5:15 p.m. It read, in pertinent part, Foods not in original containers are labeled and dated with opening and suggested to have a use by date. A regular cleaning schedule is maintained and initialed when used. Food service management checks the scheduled on a regular basis.
B. Observation
The resident unit refrigerator on the Hope hallway was observed on 2/14/22 at 2:50 p.m. The refrigerator contained resident snacks and drinks. A chocolate milk with an expiration date of 2/2/22 and a regular milk with an expiration date of 1/6/22 was observed. A gallon size bag of pre-made sandwiches with a date of 2/4/22 was observed on the floor of the refrigerator. A tupperware container of rice and beans was observed with a resident's name and no date.
The resident unit refrigerator on the [NAME] hallway was observed on 2/14/22 at 3:00 p.m. The refrigerator contained resident snacks and drinks. Two undated gallon size bags of pre-made sandwiches were observed.
C. Interviews
The dietary manager (DM) was interviewed on 2/14/22 at 3:15 p.m. She said she was unsure what department handled the resident unit refrigerators. She said the kitchen staff prepared sandwiches and provided snacks for the refrigerators but she did not know who ensured old items were thrown away when they expired. She said the chocolate milk, regular milk, and sandwiches were old and should not be in the refrigerator.
The nursing home administrator (NHA) was interviewed on 2/14/22 at 3:30 p.m. He said he was unsure what department handled the resident unit refrigerators. He said maybe the clinical staff were tasked with cleaning out the refrigerators. He observed the chocolate milk, regular milk, and sandwiches and said they were old and should not be in the refrigerator. He said he would look into who should be responsible for the unit refrigerators.
The NHA and CNC were interviewed together on 2/14/22 at 5:08 p.m. The CNC said dietary staff were responsible for the resident unit refrigerators. The NHA said the DM was new and started in November 2020. He said she was responsible for the resident unit refrigerators.
The dietician (DT) was interviewed on 2/15/22 at 9:56 a.m. He said the dietary staff provided snacks for the resident unit refrigerators. He said snacks such as premade sandwiches should be dated and thrown out after three days. He said if a resident's family brought in food, it should be dated. He said milk should be dated when it was opened and should be thrown out when it was past the expiration date.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 36 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Amberwood Post Acute's CMS Rating?
CMS assigns AMBERWOOD POST ACUTE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Colorado, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Amberwood Post Acute Staffed?
CMS rates AMBERWOOD POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 49%, compared to the Colorado average of 46%.
What Have Inspectors Found at Amberwood Post Acute?
State health inspectors documented 36 deficiencies at AMBERWOOD POST ACUTE during 2022 to 2024. These included: 1 that caused actual resident harm and 35 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Amberwood Post Acute?
AMBERWOOD POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 88 certified beds and approximately 85 residents (about 97% occupancy), it is a smaller facility located in DENVER, Colorado.
How Does Amberwood Post Acute Compare to Other Colorado Nursing Homes?
Compared to the 100 nursing homes in Colorado, AMBERWOOD POST ACUTE's overall rating (2 stars) is below the state average of 3.1, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Amberwood Post Acute?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Amberwood Post Acute Safe?
Based on CMS inspection data, AMBERWOOD POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Colorado. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Amberwood Post Acute Stick Around?
AMBERWOOD POST ACUTE has a staff turnover rate of 49%, which is about average for Colorado nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Amberwood Post Acute Ever Fined?
AMBERWOOD POST ACUTE has been fined $9,636 across 1 penalty action. This is below the Colorado average of $33,175. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Amberwood Post Acute on Any Federal Watch List?
AMBERWOOD POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.