NORTHBRIDGE HEALTH CARE CENTER
For profit - Corporation
145 Beds
ATHENA HEALTHCARE SYSTEMS
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
21/100
#183 of 192 in CT
Photo by Northbridge Health Care Center
Photo by Northbridge Health Care Center
Photo by nahid pavreen
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Northbridge Health Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #183 out of 192 facilities in Connecticut, placing it in the bottom half of all nursing homes in the state and last in Greater Bridgeport County. The trend is worsening, with issues increasing from 1 in 2023 to 22 in 2024, and the facility has been cited for serious deficiencies, including a critical incident where a resident at risk for elopement left the facility unnoticed. Staffing is rated as average, with a 36% turnover rate that is slightly below the state average, but there is less RN coverage than 94% of other Connecticut facilities, which is concerning. While the facility faces $16,801 in fines, which is average, the overall care quality remains poor, as evidenced by specific incidents like failing to provide adequate supervision to prevent falls or elopement.
- Trust Score
- F
- In Connecticut
- #183/192
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 36% turnover. Near Connecticut's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $16,801 in fines. Higher than 90% of Connecticut facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Connecticut. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
21/100
Bottom 5%
Review needed
1 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 1 issues
2024: 22 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (36%)
12 points below Connecticut average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Connecticut average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 36%
10pts below Connecticut avg (46%)
Typical for the industry
Federal Fines: $16,801
Below median ($33,413)
Minor penalties assessed
Chain: ATHENA HEALTHCARE SYSTEMS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 life-threatening 1 actual harm
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident # 1) reviewed for verbal communication, the facility failed to protect the Resident from verbal abuse. The findings include:
Resident # 1 was admitted to the facility on [DATE] with diagnoses that included Parkinsons Disease, unspecified dementia, and generalized anxiety disorder.
The quarterly MDS dated [DATE] identified Resident # 1 had moderate cognitive impairment, was incontinent of bowel and bladder and required assistance with care with activities of daily living.
The care plan dated 10/18/2024 identified an ADL deficit. Interventions included the assistance of one for ADLs and transfer via Hoyer lift.
The nurse's note dated 12/13/2024 at 1:20 PM identified that a NA was overheard using foul language to the Resident.
Review of the facility documentation dated 12/13/2024 identified that the Resident was yelling to get out of bed, NA#1 went into the Residents room and asked the Resident what she/he needed and the Resident stated to get out of bed, NA#1 told the Resident to give her a minute and the Resident asked again to get out of bed, then the Resident stated fuck you and NA#1 responded fuck you too.
The APRN assessed the Resident on 12/13/2024 and directed to provide emotional support and follow up with social services and psychiatry.
Review of the Interview with Resident #1 and RN #1 on 12/13/2024 identified that she asked the Resident if NA#1 used foul language and the Resident said yes, we use foul language to each other. Further review identified that the Resident was not offended by the statement because they were only fooling around and he/she did not fear NA#1 and he/she would like NA#1 to continue to care for her/him.
Interview with Person #1 on 12/18/2024 at 10:05 AM identified that the Resident was calling for a while, approximately twenty minutes, NA#1 came in and asked the Resident what he/she wanted and the Resident responded that he /she wanted to get up, NA#1 responded then get up, the Resident responded that she/he could not get up, NA#1 responded saying I guess you will have to wait and don't turn the light on again, the Resident then said fuck you and NA#1 responded fuck you too you and don't turn the light on again.
Interview with NA#1 on 12/13/2024 at 10:18 AM identified that the Resident is a jovial person and they laugh together, the Resident wanted to get out of bed and NA#1 told her/him that she would be with her/him in a minute and the Resident said fuck you, fuck you and NA#1 replied with ok, with a smiling face and said fuck you, fuck you back in a laughing manner. Further interview identified that NA#1 and the Resident talk to each other like that all the time and she did not think that it was done in an abusive manner because that is the way the Resident talks.
Interview with Resident #1 on 12/18/2024 at 11:41 AM identified that she/he did not recall anyone using swear words when they talked with her/him and if anyone did she/he would tell them to get out.
Interview and review of the facility documentation with the DNS on 12/13 2024 at 1:00 PM identified that verbal abuse was substantiated and NA#1 was terminated on 12/17/2024.
Review of the facility policy Abuse, Neglect and Exploitation dated 2/2023 identified that the facility protects the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of property.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled Resident (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled Resident (Resident # 1) reviewed for an allegation of abuse, the facility failed to investigate the allegation.
The findings include:
Resident # 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, weakness and difficulty in walking.
The admission MDS dated [DATE] identified Resident # 1 had severely impaired cognition, was frequently incontinent of bowel and bladder and required maximum to total assistance with activities of daily living.
The care plan dated 10/14/2024 identified that the Resident was at risk for falls due to the recent admission, decreased endurance/strength and generalized weakness. Interventions included an assist of one with ambulation and rolling walker and instruct to ask for assistance prior to attempting to transfer or ambulate as needed.
Review of the nurse's progress note dated 10/30/2024 at 10:05 PM by the DNS, identified that the DNS was called to the unit to assess Resident #1, who was observed on the floor, upon arrival the Resident was partially lying on the right side on the bedside mat, and no signs or symptoms of bleeding were noted. The Resident identified that he/she was coming from the bathroom. The progress note at that time further identified the Resident also reported significant right hip pain and with the assistance of 3 staff, the Resident rolled to her/his back without significant pain. Additionally, when the right hip was palpated the Resident reported significant pain and denied pain to other sites. APRN #1 was notified and directed to send Resident #1 to the emergency room for evaluation for significant right hip pain, increased confusion and possible head strike.
Review of the facility documentation, titled Incident Description, dated 10/30/2024 identified an unwitnessed fall with significant right hip pain, increased redness to the right side of the face and possible head strike.
An interview with the DNS on 11/14/2024 at 1:28 PM identified that on 10/30/2024, after the fall Resident #1 was sent to the hospital. Subsequent to the resident transfer, the DNS stated she received a call from the social worker at the hospital who stated that Resident #1 was hit in the face by a nurse. The DNS further indicated that no other information was provided as to where or when it occurred. The DNS stated that she wrote a note about the phone call, but unfortunately, she has not followed up on it yet (16 days later). Further interview identified, that when the Resident left, she/he had redness on the right side of her/his face and the face was swollen and the resident could barely open her/his eyes. She further stated she should of immediately started an investigation, but did not.
According to the policy Abuse, Neglect and Exploitation Section V. Investigation of Alleged Abuse, Neglect, and Exploitation dated 2/2023 identified: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation occur.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and staff interviews for two one of four residents (Resident #2) review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and staff interviews for two one of four residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from abuse. The findings include:
1.
A. Resident #1 had a diagnosis of anxiety, vascular dementia without behavioral disturbance and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, was independent with mobility, and had no behaviors. The Resident Care Plan (RCP) dated 8/19/2024 identified Resident #1 had impaired cognition and accusatory behaviors. Interventions directed to decrease visual or auditory stressors.
B. Resident #2 had a diagnosis of depressive episodes. The quarterly MDS dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was alert and oriented and had no behaviors. The RCP dated 8/5/2024 identified Resident #2 had behaviors of swearing and using profanity towards staff. Interventions directed to redirect negative comments and behavior and to educate on inappropriate behavior.
Facility incident report dated 10/6/2024 at 6 PM identified RN #1 and LPN #1 witnessed Resident #1 calling Resident #2 a retard. Resident #1 continued to call Resident #2 names, stated he/she would punch Resident #2 in the face and attempted to wheel him/herself towards Resident #2, and staff separated the residents. Resident #1 was placed on one-to-one (1:1) observation and a psychiatric telehealth visit was initiated.
Psychiatric APRN note dated 10/6/2024 at 7:13 PM identified Resident #1 was not a danger to self or others and discontinued the 1:1 observation.
The facility summary dated 10/14/2024 identified Resident #1 would remain on every 30-minute safety checks.
Interview with RN #1 on 10/30/2024 at 11:33 AM identified on 10/6/2024 she witnessed Resident #1 calling Resident #2 an inappropriate name. The residents were separated and as Resident #1 was going in the opposite direction he/she continued to call Resident #2 inappropriate names and then Resident #1 started coming back towards Resident #2 and threatened to punch her/him in the face, and staff again separated the residents. Resident #1 was placed on 1:1 monitoring and was seen by a psychiatric APRN who discontinued the 1:1 monitoring and started every 30-minute checks.
Interview with RN #2 on 10/30/2024 at 12 PM identified she was the supervisor on 10/6/2024 when the incident occurred. RN #2 stated Resident #2 was talking to another resident when Resident #1 interrupted the conversation and Resident #2 told him/her to stay out of the conversation. Resident #1 responded by saying he/she was going to punch Resident #2 and called Resident #2 a name. Staff separated the residents and placed Resident #1 on 1:1 monitoring. RN #2 stated she spoke with Resident #1 who stated he/she did threaten Resident #2 but that he/she would not actually hit the other resident. Both residents were seen by the psychiatric APRN, and the APRN discontinued the 1:1 monitoring and placed Resident #1 on every 30-minute checks.
Interview with the DNS on 10/30/2024 at 1:42 PM identified on 10/6/2024 staff witnessed Resident #1 being verbally aggressive towards Resident #2 she substantiated the allegation of abuse. The DNS stated the incident should not have occurred, and both residents had no further altercations afterwards.
Review of facility Abuse, Neglect, and Exploitation policy directed in part, abuse means the willful infliction of injury, unreasonable confinement, intimidation, punishment, verbal abuse, sexual abuse, physical abuse, mental abuse, which can include staff to resident abuse and resident to resident altercations.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and staff interviews for one of four residents (Resident #4) rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and staff interviews for one of four residents (Resident #4) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse in a timely manner. The findings include:
Resident #4 had a diagnosis of adjustment disorder with depressed mood. The quarterly MDS dated [DATE] identified Resident #4 had a BIMS score of seven (7) indicating severe cognitive impairment and had no behaviors in the prior seven (7) days. The RCP dated 9/4/2204 identified Resident #4 had verbally inappropriate behaviors. Interventions directed to decrease auditory stressors when over stimulated.
The facility incident report dated 10/9/2024 at 11 AM identified a family member reported that Resident #4 stated NA #1 was intentionally aggressive and yelled at Resident #4 to get back to his/her room.
The facility summary dated 10/18/2024 identified when NA #1 asked Resident #4 if he could help him/her, the resident did not answer so NA #1 repeated the question. NA #1 indicated he had directed Resident #4 could go back to his/her room and NA #1 would come to provide the requested care. Resident #4 then became upset, and raised his/her hand to hit NA #1 and attempted to hit NA #1 using the phone at the nursing station. NA #1 then walked away from Resident #4 and reported the incident. NA #2 was a witness to the exchange and stated the allegation did not occur.
Review of facility paper incident report signed by Administrator #2, dated 10/9/2024 identified an allegation of staff to resident verbal abuse occurred on 10/5/2024. The report identified LPN #2, NA #1 and NA #3 witnessed the incident. The form further indicated the physician, family and police were notified. The form did not identify the State Agency was notified; the line to indicate when the State Agency was notified was blank.
Record review failed to identify a nursing note regarding the allegation on 10/5 or 10/9/2024.
Interview and review of LPN #2's written statement dated 10/5/2024 with LPN #2 on 11/5/2024 at 11:12 AM identified on 10/5/2024 Resident #4's family member reported NA #1 was rough in the way NA #1 was speaking with the resident and made Resident #4 feel uncomfortable. LPN #2 interviewed NA #1 and NA #1 indicated Resident #4 attempted to hit him, and LPN #2 switched NA #1's assignment to not provide care for Resident #4. LPN #2 stated she did not witness the alleged interaction between Resident #4 and NA #1, and reported the allegation to RN #3.
Interview and record review with RN #3 on 11/5/2024 at 11:40 AM identified on 10/5/2024 she was the shift supervisor and was notified Resident #4 was upset because he/she wanted to use the phone earlier in the day to call a family member but was told it was not time yet and was directed back to his/her room. When RN #3 went to ask Resident #4 what happened the resident could not explain the event that transpired. RN #3 further indicated the incident was not witnessed, and the family member indicated the incident occurred earlier that day at an unknown time. RN #3 stated she did not recall if she had notified the Administrator or DNS of the allegation.
Interview with NA #1 on 11/5/2024 at 2:30 PM identified around 4 PM he saw Resident #4 at the nursing station and asked if the resident needed help. Resident #4 did not answer and then Resident #4 grabbed the phone and it seemed like he/she was going to hit NA #1 with it and NA #1 said you cannot hit people. NA #1 then said I am just here to help you, lets go back to your room to see what you need but the resident did not respond. NA #1 denied he was verbally or physically aggressive with the resident.
Although attempted, an interview with NA #3 was not obtained during the survey.
Interview and record review with the DNS on 11/6/2024 at 10:43 AM identified Administrator #2 completed the investigation for the incident that occurred on 10/5/2024. The DNS stated allegations of staff to resident abuse were investigated by the Administrator, and resident to resident incidents were investigated by her. The DNS indicated the incident occurred on 10/5 and was not reported to administration until 10/9/2024. The DNS stated it should have been reported to administration on 10/5/2024 when the incident occurred.
Interview with Administrator #2 on 11/5/2024 at 12:09 PM identified the allegation could not be substantiated due to no one witnessed the event. Administrator #2 stated the allegation was made on 10/5/2024 (a Saturday). The Administrator stated there was no ADNS at the time of the incident, on 10/9/2024 a statement dated 10/5 was found in the ADNS mailbox. Administrator #2 indicated the incident should have been reported when it occurred, and she did not know why it was not reported to administration timely.
Review of facility Abuse, Neglect, and Exploitation policy dated 2/2023 directed to report all alleged violations immediately, but not later than 2 hours after the allegation is made.
Jun 2024
18 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, review of facility documentation, and interviews for 1 of 6 residents at risk for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews, review of facility documentation, and interviews for 1 of 6 residents at risk for elopement (Resident # 8), the facility failed to implement interventions for a resident identified at risk for elopement. Resident #8 was able to exit the facility without staff knowledge and was found 0.6 miles away from the facility by law enforcement. This failure resulted in a finding of Immediate Jeopardy (IJ). The finding includes:
Resident #8's diagnoses included paranoid schizophrenia, dementia, depression, anxiety disorder and psychosis.
The clinical record identified Person # 3 as Resident # 8's conservator.
The quarterly Minimum Data Set (MDS) assessment, dated 2/23/2024, indicated Resident #8 as moderately cognitively impaired and noted no wandering behaviors had occurred at the time of the assessment.
The Resident Care Plan (RCP) dated 3/14/2024 for at risk of leaving the facility with a desire to go home, noted tendency to cut off wander guard. Interventions included: the application of a wander guard bracelet, picture identification and description of Resident #8 to all departments and staff located near exits (including the reception desk) to re-direct the resident if seen near an exit, encourage the resident to come with staff and assist Resident #8 with finding his/her own room, bathroom and nursing unit as needed.
On 5/9/2024 the facility transferred Resident # 8 to the hospital at 5:59 PM for a psychiatric evaluation due to behavioral changes. Prior to the transfer at approximately 5:30 PM Resident # 8's wander guard was removed by staff.
An elopement and wandering evaluation, completed and dated 5/30/2024 (readmission) at 8:21 PM, indicated Resident #8 was at risk for wandering and elopement.
The readmission nursing assessment, dated 5/30/2024 at 8:39 PM, failed to reflect the nursing staff implemented measures to address Resident #8's risk for elopement.
A Brief Interview for Mental Status (BIMS) assessment, completed 5/31/2024 at 11:32 AM, indicated Resident #8 was severely cognitively impaired.
The Emergency Medical System (EMS) Run sheet, dated 6/16/2024 at 5:06 PM, indicated the EMS team was called to respond at 5:01 PM and arrived at 5:06 PM to find Resident #8 on a side street in the same city (0.6 miles away from the facility, across a 4-lane divided busy street, outside temperature was 73 degrees and no precipitation) with a bystander. The EMS form indicated Resident #8 was crying and stated s/he could not go on and did not want to live anymore. The EMS form further indicated Resident # 8 was assisted to a stretcher and transported to the closest hospital arriving at the acute care facility at 5:19 PM.
A nursing progress note, dated 6/16/2024 at 11:49 PM, indicated at about 7:30 PM the writer was alerted by the charge nurse Resident #8 was not found in his/her room. The note indicated at the same time a phone call was received from an acute care facility indicating Resident #8 was at the hospital. The note further indicated the Director of Nursing Services (DNS), Administrator, Advanced Practice Registered Nurse (APRN) were notified, and a message was left for the responsible party to call the facility for an update on Resident #8's status.
Observation on 6/17/2024 at 9:59 AM identified Resident #8's bedroom was located at the end of the hallway near the elevators that have a coded keypad to access usage.
A review of the facility investigation, dated 6/16/24, included a handwritten document with Dietary Aide #2's name, no date/time and no signature, the statement indicated Dietary Aide #2 was on the elevator after delivering the last meal truck to the fourth floor. The elevator stopped on the third floor and a resident unknown to the Dietary Aide #2 got on the elevator and the elevator stopped at the first floor. Dietary Aide #2 indicated s/he did not know where the resident on the elevator went when the elevator stopped on the first floor.
The facility investigation statement dated 6/16/2024 (no time) written by Nurse Aide (NA) #3 indicated Resident #8 was seen walking around in the hall. At 7:00 PM when s/he went to Resident #8's room to provide care the resident was not there at which time NA # 3 reported to the charge nurse the resident was not present.
The facility investigation dated 6/16/2024 (no time), with Licensed Practical Nurse (LPN #13) indicated the nurse aide assigned to Resident #8 reported to him/her at 7:10 PM s/he was unable to locate Resident #8 who was not in his/her room or bathroom. LPN #13 indicated looking for the resident everywhere. LPN #13 further indicated after speaking with the Receptionist #1, a call came to the unit from the hospital that identified Resident #8 was there.
On 6/17/2024 at 10:55 AM the Administrator indicated the facility was currently investigating a Reportable Event involving Resident #8 who eloped (left unattended and without staff knowledge) from the facility on Sunday 6/16/2024. The location where Resident #8 was found, and exact time was unknown to the administrator at that time. The Administrator indicated Resident #8 went down the elevator with Dietary Aide # 2 and then exited the building out the front entrance. Although Receptionist #1 was on duty, and a book containing pictures and descriptions of residents at risk of eloping (including Resident # 8) was present at the desk.
Receptionist # 1 was unaware Resident # 8 had exited the building. The Administrator indicated the police found Resident #8 on 6/16/24 and brought the resident to an acute care facility. This resulted in a finding of Immediate Jeopardy (IJ).
On 6/17/2024 an interview and record review with the DNS at 11:20 AM indicated it is facility policy to page a Dr. Hunt (emergency paging system to locate a missing person) over the intercom system in the event a resident was missing. The DNS indicated staff did not follow facility policy Dr. Hunt at the time Resident # 8 was identified missing. Review of the physician's orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) with the DNS from 5/30/2024(re-admission date) through 6/16/2024 failed to reflect a physician's orders for re-application of Resident # 8's wander guard to monitor the resident's location per facility policy for a resident at risk for elopement. The DNS was unable to provide evidence that a wander guard bracelet was applied to Resident # 8 between 5/30/2024 through 6/16/2024 or any other interventions to monitor Resident # 8's location in the facility.
Interview with Receptionist #1 on 6/17/2024 at 4:35 PM indicated Resident #8 must have been with a visitor and exited the building when s/he pressed the button to unlock the front entrance door for the visitor to leave. Receptionist # 1 also indicated the incident occurred on Father's Day which was a busy day because s/he was watching the computer monitor looking forward outside the window where the transportation vehicles pick up and drop off residents and watching for visitors wanting to enter and exit the facility. Receptionist #1 further indicated s/he pressed the button to unlock the front entrance door not realizing a resident at risk was with the visitor. Receptionist # 1 further indicated s/he was aware of the elopement risk book and location. However, the day of the incident s/he did not see a wander guard on anyone and did not hear an alarm go off when s/he let the visitor exit.
Interview on 6/18/2024 with the Director of Nursing Services (DNS) and Administrator at 1:30 PM indicated the staff noted Resident #8 on the unit at the beginning of the shift (3:00PM) and actively walking on the unit around 3:00 PM-4:00 PM. The DNS and Administrator further indicated through staff interviews they were able to identify that Resident #8 was on the elevator with Dietary Aide #2 around 4:30 PM to 4:45 PM before meals arrived onto the unit about 5:00 PM. The Administrator indicated s/he viewed the video surveillance on 6/17/2024 to determine the time Resident #8 was on the elevator with Dietary Aide #2 and the surveillance video showed Resident #8 exiting the front entrance of the building at 4:37 PM.
Interview with the DNS and the Administrator on 6/18/2024 at 1:35 PM indicated at time of Resident # 8's readmission on [DATE] the facility had 8 wander guard bracelets available for use and currently the same 8 bracelets are available for use now. The DNS indicated when a resident is admitted /readmitted an elopement evaluation is completed. If found at risk for elopement the nurse who completed the evaluation is responsible for notifying the supervisor that a wander guard is needed for the resident. The wander guard bracelets are locked in the supervisor's office so the supervisor would need to provide the bracelet to the nurse for application to the resident. Resident #8 was evaluated and found at risk for elopement on 5/30/2024, the charge nurse should have followed the facility policy, updated the supervisor regarding the outcome of the evaluation, obtained physician orders to apply a wander guard bracelet and notified responsible party.
The hospital's Initial Psychiatric Evaluation, dated 6/20/2024 at 9:37 AM, indicated Resident #8 was found on the street after eloping in an impulsive and disorganized manner from the skilled nursing facility. The evaluation further indicated Resident #8 was found on the street disheveled and tearful and brought to the Emergency Department for an evaluation. Resident # 8 was assessed and verbalized at the hospital s/he wanted to self-harm without a clear plan at which time Resident # 8 was admitted to the acute care facility under a Physician's Emergency Certificate (PEC).
Interview with Licensed Practical Nurse (LPN #14), on 6/20/24 at 9:45 AM, indicated s/he was working on 5/30/2024 when Resident #8 was readmitted . LPN #14 further indicated s/he collected data for the completion of the elopement evaluation on 5/30/2024 but s/he did not inform the supervisor Resident #8 was at risk for elopement. LPN # 14 also indicated the license staff is responsible for applying wander guard bracelet to residents. LPN #14 could not explain why s/he did not notify the supervisor Resident # 8 required a wander guard bracelet on 5/30/24.
On 6/20/2024 at 10:21 AM interview with Registered Nurse (RN #6) who was the RN supervisor on 5/30/2024 when Resident #8 was readmitted to the facility. RN #6 indicated the evaluations (including elopement risk) are completed by the charge nurses and indicated the admitting nursing supervisor is responsible for reviewing the evaluations and if a resident is at risk put safety precautions in place per the policy.
On 6/20/2024 at 11:20 AM interview and facility document review with the DNS indicated the 24-hour supervisor paper report for 5/30/2024 through 6/16/2024 did not reference Resident #8 was at risk for elopement or the need for a wander guard bracelet.
Interview with RN #6 on 6/20/24 at 11:20 with DNS further indicated s/he did not receive any report regarding Resident #8 from the off going supervisor.
An interview on 6/20/2024 at 1:05 PM with Nurse Aide (NA #3) assigned to Resident #8 indicated s/he last saw Resident #8 around 5:00 PM or just before the incident. Resident # 8 had not made any attempts to leave the unit that evening. NA#3 indicated s/he noticed Resident #8 was missing at around 7:00 PM when s/he went to Resident # 8's room to provide PM care and was told by the charge nurse to look for the resident.
Interview with Licensed Practical Nurse (LPN) #13 on 6/24/2024 at 8:58 AM indicated s/he did not call Dr. Hunt before looking downstairs first and talking to Receptionist #1. LPN # 13 further indicated once s/he was back on the unit s/he received a call from the hospital informing her/him Resident #8 was at the hospital.
On 6/25/2024 at 8:58 PM an interview with LPN #13 s/he on 6/16/2024 worked from 7:00 AM through 11: 00 PM as the charge nurse caring for Resident #8. LPN #13 indicated s/he saw Resident #8 walking in the hall on the unit at 3:00 PM when s/he arrived on duty and recalls a nurse aide indicated Resident #8 had been crying. LPN #13 administered Resident #8 her/his 4:00 PM medications and the resident was in her/his room at that time. Later Resident #8 came to LPN #13 in the hall during medication pass and complained of a headache at which time s/he LPN # 13 provided medication to relieve the headache. At 7:00 PM the nurse aide reported Resident #8 was missing at which time s/he stopped the medication pass and began to look for Resident # 8.
Attempts to interview Dietary Aide #2 during the survey were unsuccessful.
The facility policy titled Elopement consists of screening all residents for risk of elopement, implement preventive strategies for those identified at risk, institute measures for resident identification at the time of admission, and conduct missing resident procedures as warranted. The policy defines elopement as the inability of a resident who is not capable of protecting him or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter harm's way.
The Administrator was presented with the Immediate Jeopardy Template on June 16, 2024, at 5:20 PM for F 689 Free of Accident Hazards/supervision /devices.
The facility submitted the following IJ removal plan on June 17 and 18, 2024:
1. The facility conducted an in-house audit of all residents at risk for elopement on 6/17/24 and 6/18/24.
2. All staff have been in serviced on the facility elopement and wander guard policy, Dr. Hunt policy, Medical Doctor and family notification and Leave of Absence policy and indicated all policy remains current.
3. All staff have been educated if a resident on admission and readmission triggers for at risk for elopement to place a wander guard on the resident. Staff have been educated to obtain a physician's order for the wander guard, to conduct checks per facility policy.
4. An Interdisciplinary meeting was held to review all residents at risk for elopement and current residents with wander guards.
5. RN supervisor and charge nurse will check all wander guards for placements, to ensure evaluations are completed, physician's orders for wander guard and care plans when a resident is noted at risk for elopement upon admission and readmission.
6. Wander guard book check for pictures on all units
7. The Receptionist will report and review all residents at risk for elopement at mealtime and at shift change.
8. Dr. Hunt Drill conducted 6/17/24 on the 3:00 PM to 11:00 PM shift
9. Audit tool created for all residents with wander guards for tracking and placement. The facility will perform evaluation on admission, readmission, random audits will be conducted weekly time 4 and monthly times 3. The DNS and designee.
a. On 6/17/2024 an interview and record review with the DNS at 11:20 AM indicated staff did not follow procedure for paging a Dr. Hunt at the time Resident # 8 was identified missing on 6/16/24.
On 6/20/2024 at 10:21 AM interview with RN #6 indicated she did not hear a page for Dr. Hunt to indicate a resident was missing.
An interview on 6/20/2024 at 1:05 PM with NA # 3 indicated s/he did not hear a Dr. Hunt paged.
Interview on 6/20/2024 at 6:06 PM with supervisor, RN #7 who worked 7:00 AM -7:00 PM on 6/16/2024 indicated s/he did not hear a page for Dr. Hunt initiated while she was on duty.
On 6/25/2024 at 8:58 PM an interview via phone with. LPN #13 identified no Dr. Hunt was paged when the resident was noted missing.
b. A review of the facility removal plan for the Immediate Jeopardy dated 6/18/24 identified RN # 9 the 3-11 PM supervisor on 6/19/24 at 3 :25 PM placing the transmitter near the wander guard device without pressing the button to activate the device to validate functioning per manufacture directions. Interview with RN # 9 identified s/he had been educated recently on the facility policy and procedure for transmitter use and thought she was doing it correct. Interview with the DNS and the Administrator at the time of the incident identified they would conduct an in-house education with all RN supervisors again to ensure they are aware of how to use the transmitter to test for wander guard functioning every shift. This resulted in the facility not having the removal of the Immediate Jeopardy.
c. Observations on 6/20/24 on the 3-11 PM at 4:45 PM to 5:00 PM of the receptionist desk where the location of residents at risk for elopement picture book is located failed to identify Resident # 88 picture in the book per facility removal plan for Immediate Jeopardy. Interview with the Administrator and DNS on 6/20/2024 identified that they have several residents who wander guard location is on the wheelchair and not the resident's persons such as: Residents # 17, # 30, # 55, # 75 and # 97 wander guards are located on the resident's wheelchair. The Administrator also indicated that Resident # 88 refused to have his/her picture taken. The Administrator further indicated s/he did not inform the resident's conservator and the physician of the resident's refusal to have his/her picture taken for at risk for elopement. After inquiry, the Administrator indicated s/he would follow up with the conservator this evening and the physician. The DNS and Administrator also indicated they would follow up with Residents #17, # 30, # 55, # 75 and # 97 location of wander guard by having a discussion in an interdisciplinary meeting to ensure the facility is appropriately monitoring and supervising resident at risk for elopement. However, the state agency could not remove the facility Immediate Jeopardy based on the removal plan was not implemented.
2. Interview with the DNS and the Administrator on 6/18/2024 at 1:35PM identified the function of the wander guard bracelets for all residents are checked on the night shift by the nursing supervisor per physician's orders and the facility obtained a transmitter from a sister facility to initiate the checks and a log to track functioning of the wander guard because there was not one in facility prior to the 6/16/2024 incident of Resident #8 elopement. The Administrator indicated the transmitter is used to check the function of the wander guard bracelets for all residents during the night shift. However, the transmitter had been broken since the middle of April 2024.
An interview with the Administrator on 6/18/20254 at 2:00PM indicated the delay in obtaining another transmitter was due to administrative staff member resigning without notice. She/he became sidetracked and did not order the transmitter to check the function of the wander guard bracelets. The Administrator re-ordered the transmitter on 6/17/2024, after surveyor inquiry and provided an invoice (146 days later.
Interview with LPN #14 on 6/20/24 at 9:45 AM indicated working 11-7 AM shift at the facility identified s/he was not made aware the transmitter to check the function of the residents wander guard bracelets was broken.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, for 1 of 2 residents observed for accidents for (Resident #9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, for 1 of 2 residents observed for accidents for (Resident #99), the facility failed to ensure a resident was assessed for self-medication administration. The findings include:
Resident #99's diagnoses included diabetes mellitus, arthritis, and depression.
The nursing evaluations for self-administration of medications dated 12/22/2023 and 2/27/2024 indicated Resident # 99 did not desire to self-administer medications.
The MDS assessment dated [DATE] identified Resident #99 was cognitively intact exhibiting no behaviors of rejecting care. The MDS further identified the resident as independent with transferring and requiring setup assistance for eating.
A care plan dated 6/8/2024 identified Resident #99 had a deficit in performing Activities of Daily Living (ADL) due to generalized weakness. Interventions included: providing assistance when needed and keeping the call bell and other needed items within reach. The care plan did not identify the resident who was able to self-administer medications.
On 6/13/2024 at 10:07 AM, observation of Resident #99 identified two medication cups containing pills next to the resident's breakfast tray on the tray table. One medication cup contained two white oblong tablets, three round white tablets, one orange capsule, two small green tablets, and one green oblong tablet. The second medication cup contained one yellow oblong tablet, six round white tablets of various sizes, and one white half-tablet. An interview with Resident #99 indicated that s/he had requested the medications to be left in his/her room while s/he ate breakfast. Resident #99 also indicated s/he separated the medications into two cups; one cup contained the medications they were going to take, and the second cup contained the medications Resident # 99 did not want to take that morning.
On 6/13/2024 at 10:20 AM, an interview with Licensed Practical Nurse ( LPN) #10 identified that during the morning medication pass, the resident requested his/her medication be left at the bedside so Resident # 99 could see the medications and had agreed to call the nurse when s/he was ready to swallow the medications. LPN#10 indicated s/he left the medications with the resident because it was the resident's preference. However, LPN#10 indicated he did not know Resident # 99 had been evaluated for self-administration of medication. LPN #4 further identified that when a resident can self-administer medication, there would be an order and a care plan.
On 6/17/2024 at 3:37 PM a chart review and interview with the Director of Nursing Services ( DNS) identified Resident #99 had not been evaluated for self-administration of medication. Additionally, the DNS indicated a resident would first be evaluated to self -administer medication if the resident wanted to have his/her pills at the bedside.
The facility policy for oral medication administration indicated that the nurse administering medication should stay with the resident until the resident has swallowed the medication.
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 clinical record review and staff interviews for 1 of 3 residents reviewed for pain for (Resident #100), the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews for 1 of 3 residents reviewed for pain for (Resident #100), the facility failed to ensure the physician was notified of a resident new and ongoing pain after a fall. The findings include:
Resident #100 was admitted on [DATE] with a diagnosis that included dementia, repeated falls, and osteoporosis.
A quarterly MDS assessment dated [DATE] identified Resident #100 was severely cognitively impaired and required extensive assistance for bed mobility. Additionally, the MDS indicated the resident could not verbalize the presence of pain but had vocal complaints and protective body movements or postures as indicators of pain. The MDS further indicated the resident received hospice care and exhibited daily indicators of pain or possible pain.
A physician's order dated 6/6/2022 directed to assess the resident's pain every hour and medicate if needed per order for pain, and to follow up with hospice/MD if the pain is uncontrolled with the regimen.
A physician's order dated 6/14/2022 directed to administer 5 milligrams (mg) of Morphine every 4 hours scheduled for pain. Additionally, physician orders dated 6/14/2022 directed to administer 5 MG of Morphine every hour as needed for moderate pain and 10 mg of morphine every hour as needed for severe pain.
A nursing progress note by LPN #12 dated and signed on 6/15/2022 at 4:02 PM indicated Resident # 100 appeared to be holding his/her left leg and exhibited symptoms of pain at the beginning of the shift (7:00 AM to 3:00 PM shift). The nursing progress note further indicated that a left hip x-ray taken during the shift 7-3 PM shift identified a fracture, and the resident was taken to the hospital on 6/15/2024 at 2:24 PM.
A review of the Medication Administration Record (MAR) from 6/1/2022 through 6/15/2022 identified Resident #100 was evaluated for pain every hour, and the resident's pain was consistently at zero from 6/1/2022 through 6/15/2022. On 6/15/2022, Resident #100 was evaluated as having a pain level of 5 (moderate pain) on 6/15/2022 at the following times: 3:00 AM, 4:00 AM, 5:00 AM, 6:00 AM, and 7:00 AM, the MAR indicated the resident received a scheduled dose of Morphine at 4:00 AM.
A further review of nursing progress notes did not identify an assessment by a registered nurse addressing the new continued pain. Additionally, the nursing progress notes do not indicate that a provider was contacted when the resident first exhibited moderate pain at 3:00 AM (one hour after the resident's unwitnessed fall) or at 4:00 AM when the resident was noted to have difficulty sleeping and having facial expressions of pain. The nursing progress notes did not indicate that the APRN was notified of the resident's new ongoing pain post-fall until 6:30 AM.
A nursing progress note by the nursing supervisor Registered Nurse (RN#4) dated and signed on 8/15/2022 at 2:25 AM identified Resident #100 had an unwitnessed fall on 8/15/2022 at 1:45 AM. The nursing note indicated the resident had facial grimaces with no complaint of pain post fall and that Advanced Practice Registered Nurse (APRN #3) had been updated.
A nursing progress note by LPN #11 dated and signed 8/15/2022 at 6:48 AM identified at 4:00 AM Resident #100 was having difficulty sleeping and exhibiting facial expressions of pain. Additionally, the nursing note indicated at 6:30 AM the resident was awake with continued expressions of pain. The nursing note further indicates LPN #11 made attempts to call the hospice service with no return call back.
A further review of nursing progress notes did not identify an assessment by a registered nurse addressing the new continued pain. Additionally, the nursing progress notes do not indicate physician or APRN was contacted when the resident first exhibited moderate pain at 3:00 AM (one hour after the resident's unwitnessed fall) or at 4:00 AM when the resident was noted to have difficulty sleeping and having facial expressions of pain. The nursing progress notes did not indicate that the APRN was notified of the resident's new ongoing pain post-fall until 6:30 AM.
In an interview on 6/18/2024 at 1:39 PM, LPN# 11 indicated she did not recall details of the incident and the only thing she remembered was Resident # 100 had fallen and had received an x-ray.
Attempts to contact RN #4 were unsuccessful.
Attempts to contact APRN #3 were unsuccessful.
On 6/18/2024 at 1:56 PM an interview with APRN #1 indicated he did not know if a physician was notified during the night shift when the resident was experiencing pain. Additionally, APRN #1 indicated that his rationale for ordering an x-ray in the day shift on 6/15/2022 was due to the resident's fall and continued complaints of pain.
On 6/20/2024 at 11:20 AM, an interview with the DNS indicated there should have been an intervention addressing Resident #100's ongoing pain and staff should have investigated why the resident was having increased pain, especially considering the resident had a recent fall.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 sampled resident (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 sampled resident (Resident #189) reviewed for abuse, the facility failed to ensure resident was free from verbal abuse from staff. The findings include:
Resident #189's diagnoses included adjustment disorder, type 2 diabetes mellitus and hypotension.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitive intact and required supervision for eating, limited assistance with bed mobility and transfers. MDS additionally indicated Resident 189 presented with feeling of hopelessness and feeling down/depressed.
The care plan dated 5/19/22 identified Resident #189, has signs of history of depression. Interventions included: to encourage verbalization of feelings, provide emotional support as needed and for psychiatric consult.
The nursing progress note dated 6/23/22 at 9:33 PM identified a report was received that a resident was being verbally abused by the charge. The note further identified an investigation was initiated and the police were notified.
The Reportable Event dated 6/23/22 indicated Licensed Practical Nurse (LPN #6) called Resident #189 an prick and asshole.
Interview with psychiatric consultant supervisor on 6/18/24 at 11:35AM regarding the incident reported on 6/23/22 identified the agency no longer has a record of the incident. She indicated the staff who witnessed the incidents is no longer employed with the company and whatever information the agency had about the incident was given to the nursing home.
Interview with the Director of Nursing Services (DNS) on 6/18/24 at 12:35 PM who was not in her/his current position at the time of the incident, the facilities procedures direct the staff be removed from the resident's care, an investigation started, which include interviewing all persons involved, alerting the Administrator, notifying the police and state agency. The DNS also indicated the perpetrator would be placed on administrative leave until further notice.
Interview with Administrator on 6/18/24 at 12:45 PM identified the incident was reported by psychiatric consultant staff. She reported the incident occurred during a 7-3 PM shift and expressed statements were taken from staff and residents regarding the allegations, the staff was removed from the resident's care pending investigation. LPN # 6 is no longer employed by the facility secondary to substantiated verbal abuse.
Attempts to interview the psychiatric consultant were unsuccessful.
Attempts to interview LPN #6 were unsuccessful.
Review of the Abuse Prohibition policy dated September 2020 with update 2024 indicated, the facility has the responsibility to ensure that each resident has the right to be free from abuse.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, review of the clinical record, facility documentation, facility policy and interviews for the 1 of 1 sampled resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, review of the clinical record, facility documentation, facility policy and interviews for the 1 of 1 sampled resident (Resident #189) reviewed for abuse, the facility failed to report and allegation of verbal abuse to an outside state agency timely. The findings include:
Resident #189's diagnoses included adjustment disorder, type 2 diabetes mellitus and hypotension.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as cognitive intact and required supervision for eating, limited assistance with bed mobility and transfers. MDS additionally indicated Resident 189 presented with feeling of hopelessness and feeling down/depressed.
The care plan dated 5/19/22 identified Resident #189, has signs of history of depression. Interventions included: to encourage verbalization of feelings, provide emotional support as needed and for psychiatric consult.
The nursing progress note dated 6/23/22 at 9:33 PM identified a report was received that a resident was being verbally abused by the charge. The note further identified an investigation was initiated and the police were notified.
The Reportable Event dated 6/23/22 indicated Licensed Practical Nurse (LPN #6) called Resident #189 an prick and asshole.
Interview with Administrator on 6/20/24 at 11:01 AM indicated I don't believe it was reported to other state agency outside Department of Public Health.
Attempts to contact the other state agency were unsuccessful.
Review of the Abuse Prohibition policy dated September 2020 with update 2024 indicated, if resident abuse has been confirmed a copy of the mandated reporter Form for Long-term care Facilities should be sent to the Connecticut Department of Social Service.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 residents reviewed for elope...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 6 residents reviewed for elopement ( Resident #8), the facility failed to revised the resident's plan care timely regarding the need for wander guard device and for 1 2 of sampled residents, (Resident #88) reviewed for hospice, the facility failed to ensure the resident care plan was revised to reflect a change in code status for a resident receiving end of life care. The findings included:
1. Resident #8's diagnoses included paranoid schizophrenia, dementia, depression, anxiety disorder and psychosis.
The clinical record identified Person # 3 as Resident # 8's conservator.
The quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #8 as moderately cognitively impaired and noted no wandering behaviors had occurred at the time of the assessment.
The Resident Care Plan (RCP) dated [DATE] for at risk of leaving the facility with a desire to go home, noted tendency to cut off wander guard. Interventions included: the application of a wander guard bracelet, picture identification and description of Resident #8 to all departments and staff located near exits (including the reception desk) to re-direct the resident if seen near an exit, encourage the resident to come with staff and assist Resident #8 with finding his/her own room, bathroom and nursing unit as needed.
On [DATE] the facility transferred Resident # 8 to the hospital at 5:59 PM for a psychiatric evaluation due to behavioral changes. Prior to the transfer at approximately 5:30 PM Resident # 8's wander guard was removed by staff.
An elopement and wandering evaluation, completed and dated [DATE] (readmission) at 8:21 PM, indicated Resident #8 was at risk for wandering and elopement.
The readmission nursing assessment, dated [DATE] at 8:39 PM, failed to reflect the nursing staff implemented measures to address Resident #8's risk for elopement.
A Brief Interview for Mental Status (BIMS) assessment, completed [DATE] at 11:32 AM, indicated Resident #8 was severely cognitively impaired.
The Emergency Medical System (EMS) Run sheet, dated [DATE] at 5:06 PM, indicated the EMS team was called to respond at 5:01 PM and arrived at 5:06 PM to find Resident #8 on a side street in the same city (0.6 miles away from the facility, across a 4-lane divided busy street, outside temperature was 73 degrees and no precipitation) with a bystander. The EMS form indicated Resident #8 was crying and stated s/he could not go on and did not want to live anymore. The EMS form further indicated Resident # 8 was assisted to a stretcher and transported to the closest hospital arriving at the acute care facility at 5:19 PM.
A nursing progress note, dated [DATE] at 11:49 PM, indicated at about 7:30 PM the writer was alerted by the charge nurse Resident #8 was not found in his/her room. The note indicated at the same time a phone call was received from an acute care facility indicating Resident #8 was at the hospital. The note further indicated the Director of Nursing Services (DNS), Administrator, Advanced Practice Registered Nurse (APRN) were notified, and a message was left for the responsible party to call the facility for an update on Resident #8's status.
Observation on [DATE] at 9:59 AM identified Resident #8's bedroom was located at the end of the hallway near the elevators that have a coded keypad to access usage.
A review of the facility investigation, dated [DATE], included a handwritten document with Dietary Aide #2's name, no date/time and no signature, the statement indicated Dietary Aide #2 was on the elevator after delivering the last meal truck to the fourth floor. The elevator stopped on the third floor and a resident unknown to the Dietary Aide #2 got on the elevator and the elevator stopped at the first floor. Dietary Aide #2 indicated s/he did not know where the resident on the elevator went when the elevator stopped on the first floor.
A review of the clinical record from [DATE] through [DATE] failed to reflect that the facility had revised Resident # 8's plan of care to address the need for a wander guard per elopement assessment and per facility practice.
Interview with Licensed Practical Nurse (LPN #14), on [DATE] at 9:45 AM, indicated s/he was working on [DATE] when Resident #8 was readmitted . LPN #14 further indicated s/he collected data for the completion of the elopement evaluation on [DATE] but s/he did not inform the supervisor Resident #8 was at risk for elopement. LPN # 14 also indicated the license staff is responsible for applying wander guard bracelet to residents. LPN #14 could not explain why s/he did not notify the supervisor Resident # 8 required a wander guard bracelet on [DATE].
On [DATE] at 10:21 AM interview with Registered Nurse (RN #6) who was the RN supervisor on [DATE] when Resident #8 was readmitted to the facility. RN #6 indicated the evaluations (including elopement risk) are completed by the charge nurses and indicated the admitting nursing supervisor is responsible for reviewing the evaluations and if a resident is at risk put safety precautions in place per the policy and updating the plan of care.
2. Resident #88's diagnoses included dementia and failure to thrive.
The admission clinical record identified Resident #88 was not responsible for self.
The physician's orders dated [DATE] directed Resident #88 start receiving hospice services and Do Not Resuscitate, DNR (no life saving measures).
The Resident Care Plan (RCP) dated [DATE] identified Resident #88's Advanced Directives which directed DNR/DNI (do not intubate or provide an artificial airway to assist with breaths).
The Advanced Directive Code Status dated [DATE] identified Resident #88 would have all resuscitation efforts performed (in the event s/he required life saving measures).
A social worker progress note dated [DATE] at 3:20 PM identified a meeting was held with the Interdisciplinary Team and responsible party. Resident #88 was admitted into hospice. Advanced Directive were reviewed, and the responsible party was considering changing the code status to Full Code/ CPR (cardiopulmonary resuscitation or life saving measures). Hospice would be contacted to follow up with the responsible party to discuss code status and plan of care.
A nursing progress note dated [DATE] at 12:05 PM identified Advanced Directives were discussed with Resident #88 who expressed wishes for DNR/ DNI (do not intubate). The responsible party made the final decision for a full code and Resident #88's clinical record was updated.
The physician's orders dated [DATE] directed Resident #88 as Full Code (implement life saving measures if necessitated).
The Resident Care Plan was not revised to reflect the change in Resident #88's code status.
An interview and clinical record review with Social Worker (SW #1) with the Corporate Social Worker in attendance on [DATE] at 12:34 PM identified the Interdisciplinary Team (IDT) was responsible for overseeing a resident receiving hospice services. The responsible party had considered a Full Code status, so SW #1 referred them to hospice social services for discussion. SW #1 identified she did not follow up on the resident's code status any time between [DATE] to present but noted the code status was changed to Full Code on [DATE].
An interview with the Corporate Social Worker on [DATE] at 12:34 PM identified that social services were involved in the hospice referral process and care planning of services and the IDT managed ongoing care. S/he did not know if hospice spoke with the responsible party regarding the resident's code status. However, s/he would expect the care plan to match the code status.
A review of the facility policy for care planning identified the care plan was developed by the IDT for each resident and includes measurable objectives and timelines to accommodate preferences, special medical, nursing, and psychological needs. The care plan is evaluated and revised as needed or at least quarterly.
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 clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record reviews, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #6) reviewed for nutrition, the facility failed to evaluate the medical needs of a resident identified with significant weight loss in a timely manner and for 1 of 3 sampled residents (Resident #82) reviewed for dental services, the facility failed to ensure a resident was assessed for safe food consumption while awaiting dental services for a broken denture and for 1 of 1 resident ( Resident # 84) reviewed for utilization of ACE wrap, the facility failed to apply the ACE wrap as prescribed and for 1 of 3 sampled residents, (Resident #88) reviewed for hospice, the facility failed to ensure a change in code status was communicated to a community specialty service for a resident receiving end of life care and for 1 of 3 residents for ( Resident # 126) who utilized oxygen, the facility failed to obtain a physician's order for the oxygen. The findings include:
1. Resident #6 's diagnoses included dementia, anemia, and hypertension.
The annual Minimum Data Set, MDS assessment dated [DATE] identified Resident #6 required one person assist with bed mobility and supervised assist with eating.
The Resident Care Plan dated 1/5/24 identified Resident #6 had the potential for impaired nutrition related to impaired cognition and advanced age. Interventions directed to assist with meals as needed, monitor intake and complete nutritional assessments as needed.
The Nutritional assessment dated [DATE] identified Resident #6's current weight was 136.7 lbs, noted impaired cognition, advanced age, variable intake while on a mechanically altered diet. Laboratory results reflect adequate hydration and slightly depleted protein stores with extra protein provided in supplements. Resident #6's Body Mass Index or BMI (measures body fat) was 24.2 (normal 18.5 to 24.9) and within her/his desired weight range. There were no new recommendations.
The Weight record dated 4/16/24 identified a documented weight of 113lbs. reflecting a 23.7 lb. or 17.34% weight loss from the previous month with no documented re-weight.
An Advanced Practice Registered Nurse, APRN progress note dated 4/24/24, eight days following the significant weight discrepancy identified since last review, weights were trending down to 110.4 lbs. from 137.5 lbs. in March 2024. Per record review intake was 25-50% of meals with set-up assist with self-feeding. Resident #6 was identified with moderate protein calorie malnutrition as evidenced by BMI of 19.55, loss of body fat and muscle mass, labile weight and appetite which was anticipated with advancing disease. The plan included increasing supplements to 240 cc, starting Remeron 7.5. mg to help with appetite, monitor weight weekly and encourage small snacks in between meals.
An internal dietitian to nursing communication form dated 4/25/34, nine days after the identified discrepancy, identified on 3/1/24, a weight loss greater than 10% loss in 180 days. New ancillary orders included adding Power Cereal at breakfast, diet was downgraded to mechanical soft diet and a dental consult was submitted.
A Nutritional Progress note dated 5/9/24 identified a weight of 109 lbs reflecting a 20.7%, 28.5 lb weight loss from the previous month. Power Cereal was added at breakfast.
The physician's orders dated 5/2/24 directed a level II dysphagia mechanically altered diet) moist and soft-textured foods that are easy to chew). The physician's orders dated 5/10/24 directed Power Cereal at breakfast for weight loss.
An interview with APRN #2 during the survey identified she previously provided services to the facility and had evaluated Resident #6 for weight loss. APRN #2 identified that although she may have been notified at an earlier time regarding Resident #6's significant weight loss, she would typically wait to put in any new orders until she was completed a monthly review for a resident long standing dementia with anticipated weight loss as Resident #6.
An interview with Medical Doctor, MD #2 (primary physician) on 6/20/24 at 11:00 AM identified that although no harm resulted in the delay, he would expect residents to receive a medical evaluation as soon as the weight discrepancy was known.
A review of the facility policy for Food First/Nutrition/Weight dated 8/2015 with update 2024 directed that weights are documented in the clinical record and a significant weight loss/gain of 5% in 30 days or 10% on 6 months the interdisciplinary team, dietitian, physician, and family are notified. The weight loss is reviewed by the dietary team and responsible party and interventions implemented as appropriate and monitored weekly.
2. Resident #82 's diagnoses included dementia, anorexia, and dysphagia.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #82 as severely cognitively impaired and independent with activities of daily living skills.
A quarterly Nursing assessment dated [DATE] identified Resident #82 exhibited no chewing or swallowing difficulties and had upper dentures that had no broken areas and were worn regularly.
The physician's orders dated 6/8/24 directed a regular diet with thin liquids.
The Resident Care Plan dated 6/9/23 identified Resident #82 used partial dentures. Interventions directed to monitor/document/report any signs of oral/dental problems needing attention.
A social service progress note dated 6/9/23 identified the responsible party had questions regarding dentures and indicated the resident be referred to the dentist for an evaluation of the lower dentures.
An electronic correspondence (email) to the Director of Nursing Services (DNS) dated 6/9/24 at 1:17 PM identified Resident #82's responsible party was requesting broken dentures be evaluated with no response.
A review of the clinical record did not include a documented assessment for safe food consumption while waiting for a dental evaluation.
An interview and clinical record review with the Director of Rehabilitation on 6/21/24 at 3:27 PM identified Resident #82 was not receiving and specialized rehabilitation services during the time the broken denture was reported and had no documented therapy notes Resident #82 was referred for an evaluation of safe food consumption during that time. The Director of Rehabilitation identified nursing was able to assess for any difficulties with chewing or swallowing and would notify rehabilitation services for any signs exhibited to determine if further services were required.
An interview with Speech Therapist, SLP #1 on 6/21/24 at 3:42 PM identified just prior to 6/9/24, Resident #82 was receiving a regular diet with thin liquids. SLP #1 identified she had not provided services to Resident #82 following the documented broken denture on 6/9/24. SLP #1 further identified that although there were some residents who could tolerate a regular diet with broken or missing dentures, nursing staff could assess for any difficulties in chewing and swallowing and refer to therapy if any abnormalities were identified.
An interview with the Director of Nursing Services (DNS) on 6/21/24 at 4:02 PM identified there was no documentation that Resident #82 was assessed for safe food consumption following the report of broken dentures on 6/9/24. The DNS further identified Resident #82 should have been evaluated at the time the damaged denture was reported to determine if s/he could eat and drink adequately.
A review of the facility policy for Dental Services/Dentures dated 4/2015 updated 2024 directed dental services will be provided to each resident, as needed, by a qualified dentist as part of the facility's oral health program. Staff will assist in obtaining routine and emergency dental care. For lost or stolen dentures, the facility must promptly, within three days refer the resident with lost or damaged dentures for dental services. If the referral does not occur within three days the facility must provide documentation of what was done so the resident can still eat and drink adequately while waiting for services.
3. Resident #84's diagnosis included Congestive Heart Failure (CHF), cardiomyopathy, and end stage renal disease.
A physician's order dated 4/1/24 identified the resident as on a fluid restriction of 1000 ml daily.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #84 as severely cognitively impaired and required maximum assistance for personal hygiene and dependent for showering and toileting.
The Resident Care Plan dated 5/23/24 identified the resident had Congestive Heart Failure. Interventions included monitoring weights as ordered and a fluid restriction of 1000 ml daily.
A nurse's note dated 6/9/24 at 6:40 PM written by LPN # 15 identified Resident # 84 returned to facility at 12 :00 PM today following brief Emergency Department (ED) visit for elevated blood pressures. BP- 174/66 (Normal Range 120/80), P- 67, T-97.5, RR-18, O2 sat- 98% on 2L NC.
Observation on 6/12/24 at 12:13 PM identified Resident # 84 was on oxygen at 2.5 liters per minute via nasal cannula.
In an interview and observation with LPN #3 on 6/18/24 at 9:43 AM identified Resident #84 is supposed to be on oxygen, however s/he cannot locate the physician's order. LPN #3 found a discontinued order for oxygen on 3/11/24. Observation made with LPN #3 confirmed that Resident #84 was wearing nasal cannula, O2 at 2.5L/min. O2 saturation was at 99% on room air.
Interview with APRN #1 on 6/18/24 at 09:54 AM identified Resident #84 should be on oxygen. APRN # 1 indicated s/he did not discontinue the oxygen on 3/11/24. After surveyor inquiry, APRN #1 entered an oxygen physician's order.
Review of the Oxygen Administration Nasal Cannula Policy dated 4/15 with update 2024, directed in part, to deliver low flow oxygen per the physician's order.
Although requested, a facility policy for physician orders was not provided.
4. Resident #88's diagnoses included dementia and failure to thrive.
The admission clinical record identified Resident #88 was not responsible for self.
The physician's orders dated 4/16/24 directed Resident #88 start receiving hospice services and Do Not Resuscitate, DNR (no life saving measures).
The Resident Care Plan (RCP) dated 4/16/24 identified Resident #88's Advanced Directives which directed DNR/DNI (do not intubate or provide an artificial airway to assist with breaths).
The Advanced Directive Code Status dated 4/17/24 identified Resident #88 would have all resuscitation efforts performed (in the event s/he required life saving measures).
A social worker progress note dated 4/18/2024 at 3:20 PM identified a meeting was held with the Interdisciplinary Team and responsible party. Resident #88 was admitted into hospice. Advanced Directive were reviewed, and the responsible party was considering changing the code status to Full Code/ CPR (cardiopulmonary resuscitation or life saving measures). Hospice would be contacted to follow up with the responsible party to discuss code status and plan of care.
A nursing progress note dated 5/15/2024 at 12:05 PM identified Advanced Directives were discussed with Resident #88 who expressed wishes for DNR/ DNI (do not intubate). The responsible party made the final decision for a full code and Resident #88's clinical record was updated.
The physician's orders dated 5/15/24 directed Resident #88 as Full Code (implement life saving measures if necessitated).
The Full Code/ CPR (cardiopulmonary resuscitation or life saving measures). Hospice would be contacted to follow up with the responsible party to discuss code status and plan of care.
The clinical record did not include documented communication to hospice of Resident #88's change to full code status.
An interview with the Director of Nursing on 6/17/24 at 12:20 PM identified the Full Code status should have been communicated by facility staff to hospice.
An interview and clinical record review with Social Worker, SW #1 with the Corporate Social Worker on 6/17/24 at 12:34 PM identified the Interdisciplinary Team (IDT) was responsible for overseeing a resident receiving hospice services. SW #1 further identified that hospice should be communicating changes to the facility and follow up. SW #1 identified she referred Resident #88 to hospice services at the responsible party's request on admission. The responsible party had considered a Full Code status, so SW #1 referred family to hospice social services for a discussion. SW #1 identified she did not follow up on the code status any time between 4/17/24 to present but noted the code status was changed to Full Code on 5/15/24. SW #1 identified she did not communicate the change to hospice.
An interview with the Corporate Social Worker on 6/17/24 at 12:34 PM identified social services were involved in the hospice referral process and the IDT for ongoing care. SW #1 would expect social services to follow up on any issues.
An interview Person #1 6/20/24 at 11:40 AM identified s/he was the Director of Nursing Services (DNS) # 2 for community hospice and was currently providing services for Resident #88. Person #1 identified Resident #88 originally had orders in place for DNR. Person #1 was not informed of Resident #88's change in code status until this week after surveyor inquiry.
A review of the facility policy for Hospice Services directed the facility communicated with hospice any changes in condition regarding resident treatment and provide any related documentation.
5. Resident # 126's diagnosis included heart failure, hypertension, and edema.
The admission Minimum Data Set assessment dated [DATE] identified Resident #126 as cognitively intact and required set up assistance with personal hygiene, oral hygiene, and maximum assistance with showering.
The Resident Care Plan dated 5/15/24 identified the resident had lower extremity edema. Interventions included weighing resident as ordered, and to observe for complications of edema.
A physician's order dated 6/7/24 directed to apply ACE wraps to bilateral lower extremities. Apply in the morning and remove in the evening.
The Treatment Administration Record for June 2024 indicated to apply ACE wraps to bilateral lower extremities. Apply in the morning and remove in the evening beginning 6/8/24.
Observation on 6/12/24 at 12:00 PM and 6/17/24 at 1:00 PM identified Resident # 126 without the benefit of the ACE wraps on her/his lower extremities.
In an interview and observation with LPN #2 on 6/17/24 at 1:00 PM, Resident # 126 did not have ACE wraps on. LPN #2 stated the resident was getting Lasix (diuretic) for her/his edema, and s/he was not aware of any other treatments. This surveyor asked if she knew there was an order written on 6/7/24 for ACE wraps. LPN #2 identified there was a physician's orders and could not explain why Resident # 126's ACE was not applied and would follow up.
LPN # 2 stated Resident # 126's ACE wrap was not applied in the morning as resident woke up at 11:25 AM and went to therapy and indicated s/he would apply them now.
Although requested, a facility policy for physician orders was not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #6) reviewed for nutrition, the facility failed to ensure a resident weight was obtained according to policy and failed to evaluate the resident's nutritional needs following significant weight loss in a timely manner. The findings include:
Resident #6's diagnoses included dementia, anemia, and hypertension.
The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 required one person assist with bed mobility and supervised assist with eating.
The Resident Care Plan dated 1/5/24 identified Resident #6 had the potential for impaired nutrition related to impaired cognition and advanced age. Interventions directed to assist with meals as needed, monitor intake and complete nutritional assessments as needed.
The Nutritional assessment dated [DATE] identified Resident #6's current weight was 136.7 lbs., had impaired cognition, advanced age, variable intake on a mechanically altered diet. Laboratory results reflect adequate hydration and slightly depleted protein stores with extra protein provided in supplements. Resident #6's Body Mass index or BMI (measures body fat) was 24.2 (normal 18.5 to 24.9) and within her/his desired weight range. There were no new recommendations.
a. The Weight record dated 4/16/24 identified a documented weight of 113 lbs. reflecting a 23.7 lb. or 17.34% weight loss from the previous month with no documented re-weight.
An interview with Licensed Practical Nurse, (LPN) #8 on 6/18/24 at 10:45 AM identified weights is compared with the previous weight to identify changes and any discrepancies recorded in the Advanced Practice Registered Nurse (APRN) book or reported to the nursing supervisor. S/he further indicated a re-weight would be requested if needed. LPN #8 identified although s/he documented the significant weight discrepancy on 4/16/24, s/he was unable to recall what actions s/he took to address the weight loss or discrepancy. LPN # 8 indicated s/he would have likely notified the nursing supervisor and documented the discrepancy in the APRN communication book. LPN # 8 also indicated s/he would not have notified the dietitian directly.
An interview and review of the communication dashboard (an internal communication system) with the DNS on 6/18/24 and 1:06 PM identified there was no request for re-weight following the 4/16/24 significant weight discrepancy. The DNS further identified for any weight discrepancy; the resident should be re-weighed immediately. Once a true weight discrepancy was identified, a dietary consult would be initiated and the APRN should be notified.
A review of the facility policy for Food First/Nutrition/Weight dated 8/2015 with update 2024 directed a weight loss/gain of 5lbs. or more on a resident weighing 100lbs or more, requires a reweigh for verification using the same scale and with a licensed nurse. Weights are documented in the clinical record and a significant weight loss/gain of 5% in 30 days or 10% on 6 months the interdisciplinary team, dietitian, physician, and family are notified. The weight loss is reviewed by the dietary team and the responsible party is notified and interventions implemented as appropriate. The interventions are monitored weekly.
b. The Weight record dated 4/16/24 identified a documented weight of 113 lbs. reflecting a 23.7lb or 17.34% weight loss from the previous month with no documented re-weight.
An internal dietitian to nursing communication form dated 4/25/34, 9 days after the identified discrepancy, identified on 3/1/24, a weight loss greater than 10% loss in 180days. New ancillary orders included adding Power Cereal at breakfast, diet was downgraded to mechanical soft diet and a dental consult was submitted.
A nutritional progress note dated 5/9/24 identified a weight of 109 lbs. reflecting a 20.7%, 28.5 lb weight loss from the previous month. Power Cereal was added at breakfast.
The physician's orders dated 5/2/24 directed a level II dysphagia mechanically altered diet) moist and soft-textured foods that are easy to chew). The physician's orders dated 5/10/24 directed Power Cereal at breakfast for weight loss.
An interview with Medical Doctor, MD #2 (primary physician) on 6/18/24 10:59 AM identified he would expect the dietitian to be notified within a few days of identifying the weight discrepancy.
An interview with the Administrator on 6/18/24 at 11:07 AM identified weights were discussed daily in morning report and weekly during Risk Management meetings. The charge nurses should be reporting weight discrepancies to the nursing supervisor who was expected to notify the dietitian immediately. The dietitian was not at the facility daily but could be notified by phone or remotely.
An interview with the Director of Nursing Services (DNS) on 6/18/24 at 1:06 PM identified s/he would expect the nutritionist to address a resident's nutritional needs immediately after a significant weight loss.
An interview with the Dietitian on 6/20/24 at 10:26 AM identified she provided dietary services one day a week for the facility. Weights and vital signs were reviewed during the weekly visits and an assessment completed for any resident with significant changes. The Dietitian further identified occasionally nursing staff did report weight changes, but Resident #6's weight discrepancy was not reported in this case, there was no documented reweigh and Resident #6 did not 'trigger' in the electronic clinical record that there was a significant change. The Dietitian identified she utilized a communication tool to inform the nurse of her recommendations for Resident #6. However, it is a long process to address matters timely when recommendations are placed in the medical communication book and reviewed before the physician/APRN signs the orders. The Dietitian also identified the provision of dietary services only one day a week contributed to the not addressing timely nutritional needs and indicated the facility has employed a dietary technician to assist now which was not previously in place.
Attempts to interview the Nursing Supervisor assigned 4/16/24 were unsuccessful.
A review of the facility policy for Food First/Nutrition/Weight dated 8/2015 with update 2024 directed a weight loss/gain of 5lbs. or more on a resident weighing 100lbs or more, requires a reweigh for verification using the same scale and with a licensed nurse. Weights are documented in the clinical record and a significant weight loss/gain of 5% in 30 days or 10% on 6 months the interdisciplinary team, dietitian, physician, and family are notified. The weight loss is reviewed by the dietary team and the responsible party is notified and interventions implemented as appropriate. The interventions are monitored weekly.
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, review of clinical records, facility documentation, facility policy and interviews for 3 of 4 residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, facility documentation, facility policy and interviews for 3 of 4 residents (Residents # 69, #84, and # 126) reviewed for oxygen, the facility failed to change and label the residents oxygen tubing weekly per facility policy and practice. The findings included:
1. Resident #69 's diagnoses included Acute on Chronic Congestive Heart Failure, pneumonia, Acute and Chronic Respiratory Failure.
A physician's order dated 6/4/24 directed to administer oxygen at 2 liters per minute via nasal cannula.
The Resident Care Plan dated 6/5/24 identified the resident has Congestive Heart Failure. Interventions included providing oxygen as ordered.
The admission Minimum Data Set assessment dated [DATE] identified Resident #69 as cognitively intact and required moderate assistance with toileting, personal hygiene, and maximum assistance with showering.
Observations on 6/12/24 at 12:57 PM, identified Oxygen tubing was not dated.
The Treatment Administration Record dated June 2024 directed to change oxygen tubing every Sunday night shift starting June 23, 2024. After surveyor inquiry about oxygen tubing date.
2. Resident #84's diagnosis included Congestive Heart Failure, cardiomyopathy, and end stage renal disease.
A physician's order dated 4/1/24 identified the resident as on a fluid restriction of 1000 ml daily.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #84 as severely cognitively impaired and required maximum assistance for personal hygiene and dependent for showering and toileting.
The Resident Care Plan dated 5/23/24 identified the resident had Congestive Heart Failure. Interventions included monitoring weights as ordered and a fluid restriction of 1000 ml daily.
Observation on 6/12/24 at 12:13 PM identified the resident's oxygen tubing without a date.
3. Resident # 126's diagnosis included Heart Failure, hypertension, and edema.
The admission Minimum Data Set assessment dated [DATE] identified Resident #126 as cognitively intact and required set up assistance with personal hygiene, oral hygiene, and maximum assistance with showering.
The Resident Care Plan dated 5/15/24 identified the resident had lower extremity edema. Interventions included weighing resident as ordered, and to observe for complications of edema.
A physician's order dated 5/30/24 directed oxygen via nasal cannula at 2 liters per minute.
The Treatment Administration Record for June 2024 identified the resident's oxygen tubing should be changed every Sunday beginning 6/2/24. However, based on clinical record review and observation there was no evidence that the tubing was changed on 6/9/24.
Observation on 6/12/24 at 12:35 PM identified Resident # 126's oxygen tubing without a date.
In an interview and observation with LPN #1 on 6/12/24 at 1:00 PM identified oxygen tubing should be changed every Sunday, and LPN #1 was unable to locate the date on the oxygen tubing for Residents #'s 69, # 84 and # 126.
Interview with LPN #2 on 6/17/24 at 10:30 AM identified oxygen tubing should be changed weekly and documented on the Treatment Administration Record.
Review of the Oxygen Administration Nasal Cannula policy dated April 2015 updated 2024 directed, in part, replace and date cannula and tubing weekly or when visibly soiled or damaged.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and staff interviews for 1 of 3 residents observed for pain (Resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility policy and staff interviews for 1 of 3 residents observed for pain (Resident #100), the facility failed to ensure a resident was medicated appropriately for symptoms of pain. The findings include:
Resident #100 was admitted on [DATE] with a diagnosis that included dementia, repeated falls, and osteoporosis.
A quarterly MDS assessment dated [DATE] identified Resident #100 was severely cognitively impaired and required extensive assistance for bed mobility. Additionally, the MDS indicated the resident could not verbalize the presence of pain but had vocal complaints and protective body movements or postures as indicators of pain. The MDS further indicated the resident received hospice care and exhibited daily indicators of pain or possible pain.
A physician's order dated 6/6/2022 directed to assess the resident's pain every hour and medicate if needed per order for pain, and to follow up with hospice/MD if the pain is uncontrolled with the regimen.
A physician's order dated 6/14/2022 directed to administer 5 milligrams (mg) of Morphine every 4 hours scheduled for pain. Additionally, physician orders dated 6/14/2022 directed to administer 5 MG of Morphine every hour as needed for moderate pain and 10 mg of morphine every hour as needed for severe pain.
A nursing progress note by LPN #12 dated and signed on 6/15/2022 at 4:02 PM indicated Resident # 100 appeared to be holding his/her left leg and exhibited symptoms of pain at the beginning of the shift (7:00 AM to 3:00 PM shift). The nursing progress note further indicated that a left hip x-ray taken during the shift 7-3 PM shift identified a fracture, and the resident was taken to the hospital on 6/15/2024 at 2:24 PM.
A review of the Medication Administration Record (MAR) from 6/1/2022 through 6/15/2022 identified Resident #100 was evaluated for pain every hour, and the resident's pain was consistently at zero from 6/1/2022 through 6/15/2022. On 6/15/2022, Resident #100 was evaluated as having a pain level of 5 (moderate pain) on 6/15/2022 at the following times: 3:00 AM, 4:00 AM, 5:00 AM, 6:00 AM, and 7:00 AM, the MAR indicated the resident received a scheduled dose of Morphine at 4:00 AM.
A nursing progress note by LPN #11 dated and signed 8/15/2022 at 6:48 AM identified at 4:00 AM Resident #100 was having difficulty sleeping and exhibiting facial expressions of pain. Additionally, the nursing note indicated at 6:30 AM the resident was awake with continued expressions of pain. The nursing note further indicates LPN #11 made attempts to call the hospice service with no return call back.
In an interview on 6/18/2024 at 1:39 PM, LPN# 11 indicated she did not recall details of the incident and the only thing she remembered was Resident # 100 had fallen and had received an x-ray.
Attempts to contact RN #4 were unsuccessful.
On 6/20/2024 at 11:20 AM, an interview with the DNS indicated there should have been an intervention addressing Resident #100's ongoing pain and staff should have investigated why the resident was having increased pain, especially considering the resident had a recent fall. The DNS also indicated the resident could have been medicated for pain per physician's orders for prescribed pain management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #82) reviewed for dental services, the facility failed to ensure dental services was provided following a responsible party request for an evaluation for broken dentures. The findings include:
Resident #82's diagnoses included dementia, anorexia, and dysphagia.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #82 as severely cognitively impaired and independent with activities of daily living skills.
The Resident Care Plan dated 6/9/23 identified Resident #82 used partial dentures. Interventions directed to monitor/document/report any signs of oral/dental problems needing attention.
A social service progress note dated 6/9/23 identified the responsible party had questions regarding the resident's dentures and Resident # 82 was referred to the dentist for evaluation of his/her lower dentures.
The dental consults dated 2/8/23 and 9/11/23 identified broken or missing dentures with no recommendations for replacement or repair.
The dental consults dated 9/11/23, 12/5/2023 and 2/8/24 noted Resident #82 was seen for routine dental prophylaxis without any documented request to evaluate for lower dentures.
An electronic correspondence (email) to the DNS dated 6/9/24 at 1:17 PM identified Resident #82's responsible party requested that Resident # 82's broken dentures be evaluated with no response.
An interview and clinical record review with Social Worker (SW #1) on 6/18/24 at 11:45 AM identified Resident #82's broken dentures were discussed in a care plan meeting. An email was sent to the Director of Nursing Services to address and there was no response.
An interview with the DNS on 6/18/24 at 12:02 PM identified she would expect any requests for specialty services to be acted on and the dental consult reflect the specific request for evaluation/replacement of broken dentures.
An interview with Medical Records Associate on 6/18/24 at 12:07 PM identified she was responsible for the scheduling of specialty services in the community. The Medical Records Associate further identified she had not received any specialty (dental) requests of any kind on behalf of Resident #82 for an evaluation or replacement of h/her dentures.
A review of the facility policy for Dental Services/Dentures dated 4/2015 with update 2024 directed dental services will be provided to each resident, as needed, by a qualified dentist as part of the facility's oral health program. Staff will assist in obtaining routine and emergency dental care. For lost or stolen dentures, the facility must promptly, within three days refer the resident with lost or damaged dentures for dental services. If the referral does not occur within three days the facility must provide documentation of what was done so the resident can still eat and drink adequately while waiting for services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and policy review and staff interviews for 1 of 2 residents reviewed for pressure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and policy review and staff interviews for 1 of 2 residents reviewed for pressure ulcers (Resident #57), the facility failed to ensure staff followed the appropriate infection control practices while performing a dressing change. The findings include:
Resident #57 was admitted on [DATE]. The resident's diagnoses included dementia, weakness, and a history of Extended Spectrum Beta Lactamase (ESBL) resistance.
The MDS assessment dated [DATE] indicated Resident #57 had severe cognitive impairment. The resident required extensive assistance with bed mobility and was dependent on transferring and toilet use. Additionally, the MDS indicated Resident #57 had an unhealed stage 3 pressure ulcer.
A care plan dated 5/23/2024 identified Resident #57 was incontinent of bowel and bladder and had a history of infection with ESBL (a resistant micro-organism). Interventions included maintaining precautions.
A wound specialist progress note dated 6/12/24 identified Resident #57 had a stage 3 pressure ulcer injury to the coccyx area measuring 6 centimeters (cm) long, 6 cm wide, and 3.2 cm deep, with moderate amount of serosanguineous drainage. The recommended treatment directed cleansing the wound with ¼ strength Dakin's solution for 15 minutes, then applying a Hydrofera blue dressing and to cover the area with a foam dressing.
On 6/17/2024 at 10:50 AM, observation of wound care for Resident #57 by LPN #5 and NA #2 identified a sign next to the resident's room door with instruction for staff to wear gloves and a gown when providing personal care or changing a dressing. LPN #5 gathered supplies, then performed hand hygiene with alcohol-based hand sanitizer and donned gloves without the benefit of donning a gown. NA #2 performed hand hygiene with an alcohol-based hand sanitizer and donned gloves. NA#2 then proceeded to turn Resident # 57 towards the resident's left side. LPN #5 proceeded to remove the old dressing and cleansed the wound bed with a spray called DermaKlenz ( wound cleanser). LPN #5 removed the soiled gloves and donned a new pair of clean gloves. LPN#5 did not perform hand hygiene in between changing gloves. LPN #5 then proceeded to pack the wound with gauze soaked in Dakin's solution. The resident was repositioned by LPN#5 and NA #2, who then left the room and allowed the resident to rest for 15 minutes. Upon exiting the room, LPN #5 and NA #2 removed their soiled gloves and performed hand hygiene with an alcohol-based hand sanitizer. At 11:10 AM, LPN # 5 and NA #2 returned to complete the dressing change. LPN #5 and NA #2 performed hand hygiene and donned clean gloves prior to entering the resident's room. LPN #5 and NA#2 did not don gowns. NA #2 then proceeded to turn the resident towards the resident's left side. LPN #5 removed the Dakin's-soaked gauze packing. LPN #5 removed the soiled gloves and donned a new pair of clean gloves. LPN#5 did not perform hand hygiene in between changing gloves. LPN #5 then proceeded to pack the wound with a Hydrofera blue dressing and covered the area with a foam dressing.
On 6/17/2024 at 12:37 PM an interview with LPN #5 indicated she was aware Resident # 57 was on enhanced barrier precautions and staff were required to wear gowns and gloves when performing dressing changes or providing care. LPN #5 indicated not wearing the isolation gown was an oversight. Additionally, LPN #5 indicated s/he was not aware performing hand hygiene in between glove changes was part of hand hygiene compliance.
On 6/17/2024 at 3:31 PM, an interview with the DNS identified s/he expected a signage to be posted for a resident requiring enhanced barrier precautions and for staff to follow the instructions on the appropriate personal protective equipment to use. The DNS indicated staff should wear a gown when providing wound care as part of enhanced barrier precautions.
A review of the facility policy for hand hygiene notes in part hand hygiene with an alcohol-based hand sanitizer should be performed after removing gloves. The facility policy for enhanced barrier precautions indicated the use of gowns and gloves are required when performing high-contact resident care activities, including toileting, providing hygiene, and wound care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, policy review and interviews for 2 of 3 residents (Residents #286, #28...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, policy review and interviews for 2 of 3 residents (Residents #286, #288) observed for Cardiopulmonary Resuscitation (CPR), the facility failed to maintain a copy of licensed staff CPR certification card per facility practice and failed to complete the Code Blue transcription log per facility practice and policy. The findings included:
1. Resident #286 's diagnoses included pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and asthma.
The admission Minimum Data Set assessment dated [DATE] identified Resident #286 was cognitively intact and required maximum assistance for showering and toileting and set up assistance for oral hygiene.
The Resident Care Plan dated [DATE] identified Resident #286 had pneumonia. Interventions included administering antibiotics as ordered, encouraging fluids, monitoring pulse oximetry, and providing oxygen as ordered.
A physician's order dated [DATE] directed to administer oxygen at 1 liter per minute via nasal cannula and as needed for shortness of breath, administer Cefuroxime Axetil (antibiotic) 500 mg twice daily for pneumonia and noted the resident was a full code.
A nurse's note dated [DATE] at 7:01 AM written by RN # 1, identified a charge nurse, LPN #4, informed RN#1 Resident # 286 was unresponsive. On assessment, resident confirmed with no pulse, no heartbeat, no respiration, pupils fixed and non-reactive. Full code status confirmed, and CPR initiated, 911 called.
2. Resident #287's diagnosis included type 2 diabetes with Neuropathy, vascular dementia, and heart failure.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #287 as moderately cognitively impaired and independent with toileting, showering and oral hygiene.
A physician's order dated [DATE], directed to provide CPR.
A nurse's note dated [DATE] at 5:27 AM written by LPN #13 identified Resident # 287 was observed in bed and appeared without breathing. Resident # 287 was not responsive with no blood pressure, no respiration, and no pulse. Code was initiated, LPN #13 started CPR and called 911.
The Resident Care Plan dated [DATE] identified Resident #287 as a full code and wished to receive CPR. Interventions included reviewing code status quarterly with resident and/or resident's decision maker.
Review of the facility CPR certification binder for LPN# 4 dated [DATE] identified the certification expired 1/2022. No evidence was provided to identify that LPN # 4's CPR certification was renewed in 2022.
Review of CPR certification binder for NA #1 and LPN #13 did not include any CPR certifications.
Interview with NA #1 on [DATE] at 11:41 AM identified s/he (NA #1) did not remember if s/he was certified at the time of the code she stated, I think I was, but I cannot find my card.
In an interview with Administrator, Regional Nurse, and DNS on [DATE] at 1:37 PM identified that they discard the CPR certifications once an employee has been terminated. LPN #4 and NA #1 are no longer employed by the facility. Further interview identified that all CPR certifications are kept in a binder used to track renewal dates. The Administrator stated LPN #13 was going attend the [DATE] class to get certified in CPR. LPN # 4 was hired in [DATE] and did not give the facility any documentation indicating s/he was CPR certified.
Interview with LPN #4 on [DATE] at 11:40 AM identified s/he cannot find her/his 2022 CPR certification, LPN # 4 started at a new facility and was not sure if they did the training when she got there. LPN # 4 stated that s/he has a card for February of 2023.
Review of the Cardiopulmonary Resuscitation (CPR) policy dated 10/16 directed, in part, written verification for the completion of CPR training for each health care professional and all other trained personnel will be maintained in the employee file.
3a. Resident #286 's diagnoses included pneumonia, Chronic Obstructive Pulmonary Disease, and asthma.
The admission Minimum Data Set assessment dated [DATE] identified Resident #286 was cognitively intact and required maximum assistance for showering and toileting and set up assistance for oral hygiene.
The Resident Care Plan dated [DATE] identified Resident #286 had pneumonia. Interventions included administering antibiotics as ordered, encouraging fluids, monitoring pulse oximetry, and providing oxygen as ordered.
A physician's order dated [DATE] directed to administer oxygen at 1 liter per minute via nasal cannula and as needed for shortness of breath, administer Cefuroxime Axetil 500 mg twice daily for pneumonia, resident was a full code.
A nurse's note dated [DATE] at 7:01 AM written by RN # 1, identified the charge nurse (LPN #4), informed her/her Resident # 286 was unresponsive. On assessment, resident confirmed with no pulse, no heartbeat, no respiration, pupils fixed and non-reactive. Full code status confirmed, and CPR initiated, 911 called.
Review of the facility clinical documentation identified that a Code Blue log was not located Resident # 286's file per facility practice.
b. Resident #288's diagnosis included End Stage Renal Disease, heart failure, and type 2 diabetes mellitus.
A physician's order dated [DATE] directed the resident to be a full code and to receive CPR.
The Resident Care plan dated [DATE] identified Resident #288 as a full code wishing to receive CPR. Interventions included reviewing advanced directives quarterly with resident and/or resident's decision maker.
The admission Minimum Data Set assessment dated [DATE] identified Resident #288 as cognitively intact and required partial assistance with toileting and showering and was independent with oral hygiene.
A nurses note dated [DATE] at 11:04 AM written by RN #5 identified Code Blue called secondary to resident found unresponsive. Resident # 288 was lying flat in bed on assessment with CPR being administered by facility staff and Emergency Medical Technician (EMT) were on scene to pick resident up for specialized treatment.
Review of the clinical documentation identified of the Code Blue log failed to identify the log in the resident's medical file.
Interview on [DATE] at 10:00 AM with LPN #5 identified a Code Blue log should be completed for every code. Blank forms are located on a clip board on the crash cart.
In an Interview with Administrator and Regional Nurse and DNS on [DATE] at 1:37 PM, the Code Blue Log should be in the resident's clinical record.
Review of the Cardiopulmonary Resuscitation (CPR) policy dated 10/16 given to surveyor as policy in place at time of the CPR directed, in part, that documentation in the resident's chart is to include the course of events leading up to and including CPR.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #286) obs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #286) observed for CPR, the facility failed to ensure an employee who administered CPR was appropriately trained as per facility practice and policy. The findings include:
Resident #286 's diagnoses included pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and asthma.
The admission Minimum Data Set assessment dated [DATE] identified Resident #286 was cognitively intact and required maximum assistance for showering and toileting and set up assistance for oral hygiene.
The Resident Care Plan dated [DATE] identified Resident #286 had pneumonia. Interventions included administering antibiotics as ordered, encouraging fluids, monitoring pulse oximetry, and providing oxygen as ordered.
A physician's order dated [DATE] directed to administer oxygen at 1 liter per minute via nasal cannula and as needed for shortness of breath, administer Cefuroxime Axetil (antibiotic) 500 mg twice daily for pneumonia and noted the resident was a full code.
A nurse's note dated [DATE] at 7:01 AM written by RN # 1, identified a charge nurse, LPN #4, informed RN#1 Resident # 286 was unresponsive. On assessment, resident confirmed with no pulse, no heartbeat, no respiration, pupils fixed and non-reactive. Full code status confirmed, and CPR initiated, 911 called.
Interview with LPN #4 on [DATE] at 1:50 PM identified s/he went into room and started CPR. The Nurse Aide (NA # 1) took over CPR and s/he (LPN# 4) went to call the supervisor.
A telephone interview on [DATE] at 11:41 AM with NA #1 identified s/he was checking Resident # 286 every 15 minutes as the resident was very sick. NA #1 could not remember what time it was when s/he went to check on the resident and Resident # 286 was not breathing. NA #1 called the nurse (LPN #4) to tell LPN #4 to start CPR. LPN #4 told her/him (NA #1) to call the supervisor so that a code can be called at which time NA #1 told LPN # 4 s/he did not know how to do that, so NA#1 took over CPR, LPN #4 called the supervisor who came up with the cart. NA #1 did not remember if she was CPR certified at the time of the code; she stated I think I was, but I cannot find my card. I knew what to do, I watched the nurse. When asked if she knew what the facility policy is about nurse aides doing CPR, she replied Yes, we are not supposed to. But I did not know how to call a code, so the LPN needed to do that, so I took over for her/him. LPN # 4 came right back and started doing CPR again.
Interview with Administrator, Regional Nurse, and DNS on [DATE] at 1:37 PM identified RNs, LPNs and/or any person with a valid CPR certification can perform CPR as per facility policy. However, the facility does not allow NAs to perform CPR and they do not train them to become certified. The Administrator also indicated that NA #1 was not trained and certified to perform CPR at the time of the code for Resident #286.
Review of the Cardiopulmonary Resuscitation (CPR) policy dated 10/16 given to surveyor for policy at time of code directed, in part, CPR will be done by the trained registered or licensed practical nurse or any other personnel who have completed CPR training.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Sufficient and Competent Nurse Staffing, facility documentation and interview, the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Sufficient and Competent Nurse Staffing, facility documentation and interview, the facility failed to ensure competencies were conducted for Nurse Aides and Licensed Nurses to ensure staff was competent to provide care for and meet the needs of all residents. The findings include.
An interview and review of facility documentation on 6/20/24 at 9:15 AM with the Administrator indicated mandatory in-service training was completed for all staff for the year of 2022.
However, a review of the facility mandatory in servicing identified the facility was unable to provide any competencies for Nurse Aides or licensed nurses for the years of 2022 to present.
An interview and review of facility documentation on 6/20/2024 at 2:00 PM with the Administrator found mandatory in servicing completed for all staff during the year of 2023 but was unable to provide any competencies for Nurse Aides or Licensed nurses for the years of 2022 to present. The Administrator indicated although ongoing advertising for the position of Staff Development Coordinator, the facility has not been able to fill the position since March 2023. The Administrator further indicated s/he has been conducting interviews for RN position and a RN is scheduled to start next week. S/he also indicated the monthly and annual in-servicing has continued with the assistance of the nursing supervisor and the Infection Preventionist. The Administrator indicated s/he will ensure that all staff complete in-servicing and training.
The Facility assessment dated [DATE] indicated mandatory staff training/education and competencies are conducted at orientation and at least once a year and as needed.
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 of the kitchen, review of facility documentation, review of policy and interviews, the facility failed to consistently document in the PH (check for the appropriate amount of san...
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Based on observations of the kitchen, review of facility documentation, review of policy and interviews, the facility failed to consistently document in the PH (check for the appropriate amount of sanitizer) log for the three-bay sink manual sanitizer. The findings include:
On 6/12/2024 at 11:55 AM, a tour of the kitchen with the Dietary Director identified Dietary Aide #1 manually washing pots in the kitchen's three-bay sink. Further observations identified there was a pot submerged in a pink-tinged liquid in the three-bay sink's left-most bay. The Dietary Director indicated pots and pans do not go through the dishwasher and are sanitized in the three-bay sink.
An interview with Dietary aide #1 in the presence of the Dietary Director identified s/he was unable to explain or demonstrate the procedure for checking if the sanitizing bay contained the appropriate amount of sanitizer. After prompting from the Dietary Director, Dietary Aide #1 was able to demonstrate how s/he would check the concentration of the sanitizer. However, at the time of the observation Dietary Aide #1 had difficulty in interpreting the results of the pH test strip. When the surveyor questioned the Dietary Aide about the difficulty in reading the pH test strip, the Dietary Director indicated Dietary Aide #1 had a vision problem the week prior and was having difficulty reading the test strip's result.
Dietary Aide #1 indicated s/he checked the concentration of the sanitizer prior to starting washing dishes. Dietary Aide #1 was able to identify where s/he would log the pH of the manual sanitizer.
A review of the daily temperature logs with the Dietary Director from 6/1/2024 through 6/12/2024 identified PH testing of the manual sanitizer was not documented on 6/3/2024 for breakfast, lunch, or dinner. PH testing documentation was missing for dinner for 6/4, 6/5, 6/6, 6/8/2024. The Dietary Director indicated there would have been pots to sanitize after dinner on the above days. Furthermore, PH testing documentation was missing for breakfast, lunch, and dinner on 6/9 and 6/10/2024. The Dietary Director indicated s/he did not know why PH testing would not be documented on the log and the reason maybe that staff might be forgetting to write down their results.
A review of facility policy for PH testing in manual ware washing notes PH testing is to ensure that sanitizing levels are adequate to effectively remove harmful bacteria on food contact surfaces. Additionally, the policy indicated that staff would perform tests with PH strips and record the result in the temperature log.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on review of facility documentation Sufficient and Competent Nurse staffing and interviews, the facility failed to ensure all nurse aides were monitored to ensure they received at least 12 hours...
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Based on review of facility documentation Sufficient and Competent Nurse staffing and interviews, the facility failed to ensure all nurse aides were monitored to ensure they received at least 12 hours of annual in-service training. The findings include.
Interview and review of facility document with the Administrator on 6/20/2024 at 2:50PM identified in-servicing for all staff were conducted and many in-servicing sheets were lacked the duration of time of training and who conducted the in-service. The Administrator was unable to locate any tracking/ monitoring for the nurse aides to ensure each received at least 12 hours of annual training.
An interview and review of facility documentation on 6/20/2024 at 2:00 PM with the Administrator indicated that although ongoing advertising for the position of staff development coordinator was in place, the facility had not been able to fill the position Staff Development position since March 2023.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0946
(Tag F0946)
Minor procedural issue · This affected most or all residents
Based on review of facility documents and interviews during extended survey, the facility failed to ensure effective communication of standards, policies and procedures of its Compliance and Ethics pr...
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Based on review of facility documents and interviews during extended survey, the facility failed to ensure effective communication of standards, policies and procedures of its Compliance and Ethics program to its entire staff. The findings include.
On 6/26/2024 at 2:45 PM an interview and facility document review with the Administrator who was unable to locate initial or annual in-service training that included communication of the Corporate Compliance program for all staff. The Administrator indicated annual in-service training would begin in 2024. The Administrator verified the facility's governing body operates five or more buildings.
On 6/26/2024 at 2:50 PM an interview and facility employee files with the Human Resources Director identified 4 out of 6 employee staff files were missing the Compliance Certificate Statement, kept in the employee's personnel file at the time of hire that indicated the employee received, in part, Corporate Compliance training.
Aug 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three sampled residents (Resident #1) reviewed for nutrition, the facility failed to ensure assistance with meals was provided timely for a resident who required assistance to eat. The findings include:
Resident #1 diagnoses included dementia, Asperger's syndrome, autistic disorder, dysphagia, and failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required extensive assistance with one-person for eating. The Resident Care Plan (RCP) dated 6/16/2023 identified Resident #1 was at risk for aspiration related to dysphagia. Interventions directed to perform 1:1 feeding assistance.
Continuous observations of the lunch meal on 8/1/2023 at 12:00 PM identified upon arrival to the 4th floor unit, two nurse aides (NAs) were assisting residents in the dining room by passing out their respective meals and providing assistance as needed. Two additional NAs were passing out trays throughout the unit and at 12:20 PM, NA #1 delivered Resident #1's tray to his/her room (placed the tray on the bedside table) and then left immediately to pass other resident trays. At 12:35 PM, LPN #1 was observed to provided a nebulizer breathing treatment to Resident #1. At 12:50 PM, LPN #1 began to feed Resident #1 (30 minutes after the tray was delivered to Resident #1).
Interview with LPN #1 on 8/1/2023 at 12:52 PM identified all the NAs were busy attending to other residents, so she wanted to assist them and began feeding Resident #1. LPN #1 indicated she didn't want Resident #1's food to get cold but did not verify the temperature of the food prior to feeding Resident #1. LPN #1 noted the unit normally has four (4) to five (5) NAs during the 7:00 AM to 3:00 PM shift, but for today they only had four (4), with two (2) of them regular staff on the unit.
Interview with NA #1 on 8/1/2023 at 3:00 PM identified that although Resident #1 was on her assignment, her duties for the lunch meal were to pass out trays and assist residents in the dining room along with NA #3. NA #1 indicated NA #2 was responsible to provide assistance to the residents who remained in their rooms during the lunch meal.
Interview with NA #2 on 8/1/2023 at 3:05 PM identified two (2) NAs provide residents with assistance in the dining room and the other NAs provide assistance for residents in their rooms. NA #2 identified she was not able to assist Resident #1 with his/her meal as she was attending to other residents and LPN #1 notified her that she would feed Resident #1.
Interview with the DON on 8/1/2023 at 3:30 PM identified it was her expectation for the nursing staff (NAs and nurses) to feed a resident within ten (10) minutes after a meal tray is delivered to a resident's room. The DON indicated if the tray was delivered to Resident #1 at 12:20 PM and Resident #1 was not assisted with the meal until 12:50 PM, she would consider the meal delayed/not provided timely.
No facility policy was provided for surveyor review regarding the timeliness of assisting a resident with a meal after a tray is delivered.
Dec 2021
4 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #92) reviewed for accidents, the facility failed to follow the plan of care, facility policy and professional standards related to the use of a gait belt and necessary ambulation assistance to prevent a fall with an injury, additionally, for 1 of 3 residents reviewed for accidents (Resident #22) the facility failed to provide adequate supervision of a resident with an altered mental status who was in possession of smoking material and failed to provide adequate supervision of a resident to prevent an elopement. The findings include:
1.
Resident #92 was admitted to the facility on [DATE] with diagnoses that included seizures, dementia, and paranoid schizophrenia.
A physician's order date 10/15/21 directed to transfer the resident via a stand pivot with assistance of 1 staff.
The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel and required extensive assistance for dressing, personal hygiene, transfers, locomotion on unit, and toileting with 1 person.
The care plan dated 11/12/21 identified Resident #92 was at risk for falls. Interventions included to transfer the resident via stand pivot with the assistance of 1 staff and a gait belt, ambulation with the assistance of 1 staff and a gait belt, and do not leave the resident unattended in the bathroom.
A reportable event form dated 11/30/21 at 7:25 AM indicated Resident #92 lost his/her balance ambulating to the bathroom and complained of pain in the right hip and leg. Resident #92 was alert with confusion at times, required the assistance of 1 for care and ambulation. Resident #92 was sent to emergency room.
An agency nurse aide, (NA #1 ' s) written statement identified she walked in front of the resident, not behind the resident, on the way to the bathroom.
A nurse's note dated 11/30/21 at 8:55 AM, written by an agency nurse, (RN #1) noted at 7:25 AM, Resident #92 was observed lying on the floor on his/her back. NA #1 was ambulating the resident to the bathroom using a rolling walker. Resident #92 complained of right hip/leg pain on assessment. Resident #92 was able to move upper extremities and left leg without discomfort. The physician was notified and ordered to send Resident #92 to the emergency room for an evaluation.
A nurse's note dated 11/30/21 at 4:35 PM identified the resident was admitted to the hospital for closed fracture of the right hip.
Although NA #1 started working at the facility on 11/18/21, and had worked 7 shifts/days, review of the agency orientation packet indicated NA #1 was educated on patient safety and the use of the gait belt for residents who transfer status is contact guard or above on 11/30/21, after Resident #92 ' s fall.
The nurse's note dated 12/3/21 at 11:04 PM indicated Resident #92 was readmitted around 3:10 PM from the hospital where status post fracture reduction. Resident #92 has wound care orders and appointment to follow.
The hospital Discharge summary dated [DATE] identified Resident #92 sustained a closed hip fracture and had surgery on 12/1/21.
A Physical Therapy Evaluation and Treatment note dated 12/4/21 indicated prior to the fall, Resident #92 required an assist of 1 for transfers, and participated in the functional maintenance program for gait. A Functional Assessment status of transfers subsequent to the fall identified Resident #92 required total dependence without attempts to initiate sit to stand due to pain limiting transfers at this time. Recommendations included that Resident #92 be to be a hoyer out of bed with assist of 2 to customized wheelchair.
A physician's order dated 12/6/21 directed to transfer the resident via a hoyer lift with the assistance of 2 staff.
Observation on 12/6/21 at 12:30 PM identified Resident #92 was sitting up in bed being set up for lunch.
Interview with the Director of Rehabilitation (DOR) on 12/6/21 at 11:30 AM noted prior to the fall with fracture on 11/30/21, Resident #92 required assistance of 1 with a rolling walker and a gait belt, and was on the functional ambulation program to ambulate up to 30 - 40 feet, 3 times a week by the therapy aide. The DOR noted the DNS informed him that NA #1 did not use a gait belt and walked in front of resident on 11/30/21 at the time of the fall. The DOR noted his expectation was that the nurse aide would stand to the side of Resident #92 to be closer to Resident #92 to hold onto the resident while walking. The DOR noted assist of 1 means hands on assistance and the expectation was to have one hand on the gait belt on the back side of Resident #92, so if Resident #92 started to lose his/her balance the nursing assistant could use the gait belt to lower the person versus the resident just falling. The DOR indicated all nursing assistants are to use a gait for resident that require assist of 1 for ambulation or need more assistance. The DOR noted Resident #92 since readmission from the hospital required a hoyer lift because of the pain, fear and anxiety.
Interview with LPN #1 on 12/6/21 at 12:00 PM noted she had just come in at 7:00 AM and was at the desk across from Resident #92's room and NA #1 came out of Resident #92's room and said the resident was on the floor. LPN #1 noted NA #1 indicated she was walking Resident #92 from the bed to the bathroom with the walker and NA #1 noted Resident #92 lost his/her balance and fell on the floor. LPN #1 noted NA #1 did not have a gait belt on Resident #92 at the time of the fall on Resident #92. LPN #1 noted when interviewed, NA #1 indicated she was standing in front of the resident and his/her walker and LPN #1 indicated that NA #1 should have been standing next to Resident #92 and all nursing assistants know they have to use a gait belt. LPN #1 noted Resident #92 was calling out in pain while on the floor. LPN #1 called for the supervisor to come assess Resident #92 while on floor. LPN #1 noted while the RN supervisor did an assessment and Resident #92 was having pain in the right leg and hip. LPN #1 noted she and NA #1 stayed with Resident #92 while RN #1 went to get a gait belt, then LPN #1, RN #1, and NA #1 applied the gait belt to Resident #92 and got the resident up and off the floor. LPN #1 indicated the expectation was NA #1 should have stood next to the resident and used a gait belt for transferring and ambulating Resident #92.
Interview with RN #1 on 12/6/21 at 12:20 PM noted LPN #1 called her, and she observed Resident #92 on the floor near the foot of the bed complaining of pain in the right leg. RN #1 did an assessment of Resident #92 and indicated she tried to bend and move Resident #92's right leg but the resident was in pain, so RN #1 indicated she wanted to send Resident #92 to the emergency room for evaluation due to the pain. RN #1 indicated NA #1 nor LPN #1 had a gait belt, so RN #1 went behind the nurses' station to the storage room and got a gait belt. RN #1 noted Resident #92 had urine on the floor, so NA #1, LPN #1 and RN #1 put the gait belt on Resident #92 and stood him/her up and placed Resident #92 on the bed until EMS arrived. RN #1 noted when Resident #92 stood up he/she yelled in pain. RN #1 noted NA #1 was ambulating Resident #92 from the bed to the bathroom on the right side of the bed and did not use a gait belt on the resident.
Interview with the nurse staffing agency coordinator, (Person #1), on 12/6/21 at 12:50 PM noted NA #1 was hired with the Agency Staffing on 11/10/21 and was first scheduled and worked at the facility on November 18th, and subsequently on the 19th, 20th, 23rd, 24th, 26th , 27th , 30th and December 1st and 2nd, 2021. NA #1 worked November 18th - 27th without general orientation.
Interview with RN #2 on 12/6/21 at 1:15 PM identified the nursing scheduler informs the nursing supervisors or RN #2 if there will be a new agency person coming to the facility. RN #2 indicated all agency staff on the first day must to do an agency orientation packet with the mandatory education before being allowed to work on the unit RN #2 indicated the expectation was the supervisor goes over the packet with the nursing assistant before they start on the unit. RN #2 noted she was responsible to keep the agency orientation packets for all agency staff and NA #1 did the orientation packet and the competency for gait belt with return demo with her after 8:00 AM on 11/30/21. RN #2 noted she did the general agency orientation packet with NA #1 on 11/30/21 after Resident #92 had fallen.
Interview with the DNS on 12/6/21 at 1:30 PM indicated during her investigation, that NA #1 was ambulating Resident #92 from the bed to the bathroom with the rolling walker and Resident #92 had fallen and was sent to emergency room and had then had to have surgery. The DNS indicated when she interviewed NA #1 and did a demonstration of what had occurred NA #1 had positioned herself in the front of the resident's walker in front of the resident and when Resident #92 was turning the corner towards the bathroom Resident #92 lost his/her balance. The DNS indicated NA #1 noted she did not use a gait belt. The DNS indicated after the incident she did education with NA #1 regarding use of the gait belt and proper positioning for transfers and ambulation. The DNS indicated prior to agency staff working at the facility for the first time, they must sign in at the supervisor office and do the general orientation packet with the supervisor before working on the units. The DNS indicated she was not aware NA #1 had worked in the facility prior to receiving the general orientation. The DNS had a log of agency staff who had signed in and did packets, but NA #1 was not on the list. The DNS noted since Resident #92 ' s fall she had done education on gait belt use and had started auditing on 12/1/21.
Interview with Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with the new agency person on the first day prior to starting on the unit.
Interview and review of the Attention Nursing Supervisor Book, undated, with the DNS on 12/6/21 at 1:50 PM indicated to make sure every agency nurse completes the posttest attached to the agency orientation packet prior to the start of the first shift and the person has to sign the signature sheet to receive the orientation packet and get access to the computer system. Review of the signature sheets dated 9/6/21 - 12/2/21 with the DNS indicated NA #1 was not on the sheets.
Interview with the DNS on 12/7/21 at 7:47 AM indicated when Resident #92 fell, the RN should have done an assessment of the resident on the floor. If Resident #92 had pain when moving the extremities, the resident should have been left on the floor and made comfortable until EMS arrived. The DNS noted her expectation was Resident #92 would stay on the floor until EMS arrived. The DNS noted since Resident #92 was in pain, something was wrong, and staff should not have moved the resident to prevent further injury. The DNS noted this was the standard of practice and facility process but was not a policy. The DNS indicated although she completed the investigation, she was not aware RN #1, LPN #1, and NA #1 moved Resident #92 off the floor and stood the resident up with a gait belt and transferred Resident #92 onto the bed prior to EMS arrival.
Interview with the Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with a new agency person on the first day prior to starting on the unit.
Interview with NA #1 on 12/7/21 at 1:10 PM indicated on 11/30/21 the regular nursing assistant gave her the assignment and reported that Resident #92 required the assistance of 1 for transfers and to get Resident #92 up and dressed first. NA #1 indicated the care card identified Resident #92 required the assistance of 1 staff but did not indicate the resident required a walker or a gait belt. NA #1 noted she sat Resident #92 on the edge of the bed and gave the resident the walker. NA #1 indicated she did not use a gait belt. NA #1 noted she stood in front of the resident and the walker to prevent the walker from tilting forward. NA #1 noted Resident #92 stood up and started to walk a few steps without an issue and then his/her left leg gave out and the resident fell onto his/her right side. NA #1 noted she was not able to reach the resident when he/she fell to try to lower the resident because Resident #92 did not have a gait belt on. NA #1 indicated she had not been provided general orientation prior to working on the unit, including when to use a gait belt. NA #1 noted after the fall she was handed an orientation packet to read and complete by herself and was given a gait belt. NA #1 noted after the fall for a few days she heard management overhead paging for staff to get a gait belt from the office. NA #1 indicated after Resident #92 fell, she, LPN #1 and RN #1 got the resident off the floor, stood him/her up, and sat him/her in a wheelchair for a few minutes. After a few minutes, the three staff again stood Resident #92 and transferred the resident onto the bed. NA #1 could not recall if Resident #92 was in pain but did recall the resident saying his/her leg was throbbing. NA #1 noted the nurse told her to dress Resident #92 after the resident was placed in bed and prior to the resident going to the hospital. NA #1 noted she dressed Resident #92 prior to leaving the facility per the nurse ' s directive.
Review of the Nursing Agency policy identified temporary agency nursing personnel are to receive an orientation from an assigned staff member of the center for fire and disaster, abuse, neglect, and mistreatment, resident rights, and center protocols specific to certified personnel. Documentation confirming orientation will be maintained in a location designated by each facility.
Review of the Gait Belt Use Policy identified gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. The gait belt provides the means of support for staff to stabilize and assist residents' balance. Gait belts must be used when physically transferring or ambulating residents.
The facility failed to provide care according to the plan of care which identified the need for a gait belt and assistance of 1 staff with ambulation. Subsequently, Resident #92 fell while walking to the bathroom without a gait belt and hands on assistance and sustained a hip fracture that required surgical intervention.
2.
Resident #22's diagnoses included alcohol abuse, anxiety, and depression.
A quarterly MDS dated [DATE] identified Resident #22 had no cognitive impairment and was independent with activities of daily living.
a. The care plan dated 6/16/21 identified Resident #22 had a history of being a smoker. Interventions included to offer a smoking cessation patch and to monitor the resident's belongings for smoking material.
A physician's order dated 8/13/21 directed Resident #22 may not have alcohol.
A nursing progress note dated 8/28/21 at 8:21 PM identified Resident #22 was observed in his/her room with a lighter. When asked to give the lighter to a staff member, Resident #22 refused. Resident #22's speech was slurred, he/she was drooling, and was unable to follow the nurse's finger when a neurological assessment was performed. The nursing note further identified Resident #22 was speaking aggressively and cursing at staff and the APRN was notified.
A nursing progress note dated 8/28/21 at 9:13 PM identified staff were monitoring Resident #22 and were awaiting a call back from the on-call provider for any new orders.
A nursing progress note dated 8/28/21 at 10:16 PM identified the nurse asked Resident #22 for the lighter and told Resident #22 if he/she did not give the lighter to the staff, he/she would be sent to the hospital. Resident # 22 replied, good.
A nursing progress note dated 8/28/21 at 10:29 PM identified Resident #22's conservator was notified that Resident #22 would be sent to the hospital. The nursing note further identified Resident #22 continued on every 15-minute monitoring.
A nursing progress note dated 8/28/21 at 11:47 PM identified before the ambulance attendants arrived, Resident #22 released the lighter to the nurse. A search of Resident #22's room identified liquid that looked like cola, and smelt like alcohol in an orange juice bottle. Resident #22 refused a search of his/her bag. The nursing note further identified, upon arrival of the ambulance attendants, Resident #22 became irate and agitated, his/her speech was slurred, and his/her gait was shuffled. After 20 minutes and several attempts to educate Resident #22 that a transfer to the hospital was for his/her safety, Resident #22 complied, and was transferred to the hospital for evaluation.
A nursing progress note dated 8/29/21 at 1:59 AM identified a RN had been notified by a nurse that Resident #22 had slurred speech and was in possession of a lighter that he/she refused to give to the nurse. A RN and nurse aide approached Resident #22 and noted Resident #22's speech was slurred. An attempt to interview and assess Resident #22 by the RN was unsuccessful after Resident #22 became very upset and yelled for the RN and nurse aide to leave him/her alone and get out of his/her room. Resident #22 was placed on every 30-minute monitoring. The on-call physicians were notified and directed Resident #22 be sent to the hospital for evaluation. Resident #22 left the facility at approximately 11:50 PM (8/28/21) for transfer to the hospital. The emergency room doctor called the facility and notified the RN that Resident #22 admitted that he/she drank approximately a ½ pint of an alcohol substance. Resident #22 also allowed a search of his/her belongings and no smoking material or alcohol substances were
found. Resident #22 returned to the facility at 1:46 AM (8/29/21) and every 30-minute monitoring of Resident #22 was resumed.
A nursing progress note dated 8/29/21 at 5:18 AM identified Resident #22 arrived back at the facility from the hospital at 1:45AM after being diagnosed and treated for alcohol intoxication.
A social worker note dated 8/30/21 at 7:15 PM identified the social worker met with Resident #22 regarding Resident #22 having a lighter and coming back into the building intoxicated after being outside. Resident #22 admitted he/she drank a little but declined to identify how he/she obtained the alcohol.
An APRN note dated 8/30/21 identified Resident #22 went to the ER on [DATE] secondary to intoxication from alcohol use and refused to tell the APRN how h/she obtained the alcohol.
Interview with the DNS on 12/7/21 at 9:42 AM identified on 8/28/21 Resident #22 was placed on every 15 - 30-minute monitoring after Resident #22 was noted with a change in mental status and observed to be in possession of a lighter. The DNS identified Resident #22 was monitored every 15-30 minutes from the time he/she was observed with the lighter and altered mental status until he/she was transferred to the hospital (approximately 3 hours and 50 minutes). The DNS further identified although Resident #22 was monitored every 15 - 30 minutes, a better intervention would have been to place Resident #22 on 1:1 observation.
Interview with RN # 3 on 12/7/21 at 10:45 AM identified he/she could not explain why Resident #22 was not placed on 1:1 observation. RN #3 further identified although he/she did not document in a nursing progress, note, he/she would have notified the DNS that Resident #22 was in possession of a lighter and suspected of being intoxicated, and was placed on every 15 - 30 minute monitoring. RN #3 identified if the DNS determined Resident #22 required additional monitoring/interventions the DNS would have notified the supervisor to implement additional interventions.
A policy regarding the supervision of residents in possession of smoking materials and/or with an altered mental status was requested but not provided.
The facility's nonsmoking policy identified residents are not allowed to keep smoking materials (i.e., cigarettes, matches, lighters, etc.).
b. A physician's order dated 7/6/21 directed that Resident #22 was medically cleared to leave the facility on a leave of absence to spend time with family and the resident must return to the facility on the same day.
A nursing progress note dated 7/22/21 at 3:38 PM identified Resident #22 requested to go home for the weekend. A nursing progress note dated 7/23/21 at 8:27 AN identified Resident #22's conservator stated nobody can take Resident #22 out over a weekend, however Resident #22 could go out daily but must return to the facility by 9:00 PM.
A physician's order dated 7/23/21 directed per Resident #22's conservator, Resident #22 may go out on a leave of absence daily but must return to facility by 9:00 PM.
A nursing progress note dated 7/24/21 at 10:12 PM identified Resident #22 had not returned from a leave of absence and the APRN was notified.
A nursing progress note dated 7/25/21 at 1:14 AM identified at approximately 12:30 AM the charge nurse notified the nursing supervisor that Resident #22 had not returned from a leave of absence. When Resident #22's family member was contacted, he/she identified being unaware of Resident #22's location. Calls were placed to Resident #22's cell phone and to another of Resident # 22's family member with no response. A review of the leave of absence sign out sheet identified Resident #22 was signed out by a different family member. A call to that family members cell phone identified the voicemail was not setup. A call to Resident #22's cell resulted with a message of not accepting calls. Resident #22's family member provided the address of the other family member, who had signed Resident #22 out for a leave of absence. The facility notified the police and requested a welfare check for Resident #22. A nursing progress note dated 7/25/21 at 3:43 AM identified the police arrived at the facility and notified the nursing supervisor that Resident #22 was not located at the address provided.
A nursing progress note dated 7/25/21 at 7:33 AM identified the RN supervisor called two local hospitals and Resident #22 was not at either hospital. The nursing note identified messages were left for the APRN and Resident #22's conservator regarding Resident #22's failure to return from a leave of absence.
A nursing progress note dated 7/25/21n at 6:11 PM identified Resident #22 returned from a leave of absence at approximately 4:00 PM and identified she had been at her boyfriend ' s house.
A Physician order dated 7/25/21 directed per Resident # 22 ' s conservator, Resident # 22 ' s leave of absence privileges were rescinded.
A Physician order dated 8/13/21 directed Resident # 22 may not have alcohol.
An elopement evaluation dated 8/30/21 identified Resident # 22 was not at risk for elopement.
A nursing progress note dated 9/8/21 at 11:17 PM identified Resident #22 came back from outside with a smell of alcohol coming from the resident. A room search identified a cup of alcohol (unknown type). Resident #22 became angry and violent.
A nursing progress note dated 9/8/21 at 11:46 PM identified Resident #22 left the facility at 11:30 PM and was transferred to the hospital.
A nursing progress note dated 9/9/21 at 12:35 AM identified the RN supervisor was called to assess Resident #22 who appeared intoxicated. A room search was done that identified a plastic cup with 4 fluid ounces. Resident #22 became belligerent and began chasing the supervisor. Resident #22 was transferred via 911.
A social worker progress note dated 9/9/21 at 4:52 PM identified the social worker contacted Resident #22's conservator regarding Resident #22 drinking in the facility.
A nursing progress note dated 9/10/21 at 7:32 PM identified at approximately 6:00 PM, Resident #22 was noted missing from the facility. A Dr. Hunt was initiated, and the police were notified.
A nursing progress note dated 9/11/21 at 2:38 AM identified Resident #22 was located by a family member who was directed to bring Resident #22 to the emergency room for evaluation.
A nursing progress note dated 9/11/21 at 12:18 PM identified Resident #22 was sent to the emergency room at approximately 3:18 AM and returned to the facility at approximately 10:00 AM. Resident #22 was placed on 1:1 observation to prevent further incident.
A nursing progress note dated 9/11/21 at 4:52 PM identified Resident #22 was readmitted to the facility at approximately 10:04 AM after being treated at the hospital for alcohol intoxication.
An APRN progress note dated 9/13/21 identified Resident #22 eloped from the facility, was found by a family member, was brought to the emergency room, and diagnosed with alcohol intoxication. The progress note identified a wander guard was placed on Resident #22. The progress note further identified Resident #22 wanted to leave the facility and was angry about his/her placement. Resident #22 refused to speak to the APRN about his/her alcohol consumption.
Interview with the DNS on 12/7/21 at 9:42 AM identified the facility did not report Resident #22's failure to return from a leave of absence to the state agency because Resident #22 had a physician's order that directed Resident #22 could go on a leave of absence, therefore the facility did not consider this an elopement. Further interview with the DNS identified on 8/28/21 when Resident #22 was found intoxicated and in possession of a lighter the facility implemented every 15 - 30-minute monitoring of Resident #22 but did not identify a need to supervise Resident #22 when h/she chose to sit outside. The DNS further identified on 9/8/21 when Resident #22 came in from the outside smelling of alcohol the facility placed Resident #22 back on every 15 - 30 minute monitoring but should have implemented an intervention to supervise Resident #22 when he/she chose to sit outside.
Subsequent to Resident #22's elopement from the facility, the facility implemented a quality improvement plan initiated regarding the prevention of elopements.
A copy of a policy regarding the supervision of residents when outside was requested but not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #92) reviewed for accidents, the facility failed to follow standards of practice after a fall to prevent further injury, for 1 of 3 residents (Resident #39), reviewed for an allegation of mistreatment, the facility failed to follow the plan of care, the facility policy and physician's order during a transfer to prevent a potential accident. The findings include:
1.
Resident #92 was admitted to the facility on [DATE] with diagnoses that included seizures, dementia, and paranoid schizophrenia.
A physician's order date 10/15/21 directed to transfer the resident via a stand pivot with assistance of 1 staff.
The quarterly MDS dated [DATE] identified Resident #92 had severely impaired cognition, was always incontinent of bladder, frequently incontinent of bowel and required extensive assistance for dressing, personal hygiene, transfers, locomotion on unit, and toileting with 1 person.
The care plan dated 11/12/21 identified Resident #92 was at risk for falls. Interventions included to transfer the resident via stand pivot with the assistance of 1 staff and a gait belt, ambulation with the assistance of 1 staff and a gait belt, and do not leave the resident unattended in the bathroom.
A reportable event form dated 11/30/21 at 7:25 AM indicated Resident #92 lost his/her balance ambulating to the bathroom and complained of pain in the right hip and leg. Resident #92 was alert with confusion at times, required the assistance of 1 for care and ambulation. Resident #92 was sent to emergency room.
An agency nurse aide, (NA #1's) written statement identified she walked in front of the resident, not behind the resident, on the way to the bathroom.
A nurse's note dated 11/30/21 at 8:55 AM, written by an agency nurse, (RN #1) noted at 7:25 AM, Resident #92 was observed lying on the floor on his/her back. NA #1 was ambulating the resident to the bathroom using a rolling walker. Resident #92 complained of right hip/leg pain on assessment. Resident #92 was able to move upper extremities and left leg without discomfort. The physician was notified and ordered to send Resident #92 to the emergency room for an evaluation.
A nurse's note dated 11/30/21 at 4:35 PM identified the resident was admitted to the hospital for closed fracture of the right hip.
Although NA #1 started working at the facility on 11/18/21, and had worked 7 shifts/days, review of the agency orientation packet indicated NA #1 was educated on patient safety and the use of the gait belt for residents who transfer status is contact guard or above on 11/30/21, after Resident #92's fall.
The nurse's note dated 12/3/21 at 11:04 PM indicated Resident #92 was readmitted around 3:10 PM from the hospital where status post fracture reduction. Resident #92 had wound care orders and appointment to follow.
The hospital Discharge summary dated [DATE] identified Resident #92 sustained a closed hip fracture and had surgery on 12/1/21.
A Physical Therapy Evaluation and Treatment note dated 12/4/21 indicated prior to the fall, Resident #92 required an assist of 1 for transfers, and participated in the functional maintenance program for gait. A Functional Assessment status of transfers subsequent to the fall identified Resident #92 required total dependence without attempts to initiate sit to stand due to pain limiting transfers at this time. Recommendations included that Resident #92 be transferred via a hoyer out of bed with assist of 2 to customized wheelchair.
A physician's order dated 12/6/21 directed to transfer the resident via a hoyer lift with the assistance of 2 staff.
Observation on 12/6/21 at 12:30 PM identified Resident #92 was sitting up in bed being set up for lunch.
Interview with the Director of Rehabilitation (DOR) on 12/6/21 at 11:30 AM noted prior to the fall with fracture on 11/30/21, Resident #92 required assistance of 1 with a rolling walker and a gait belt, and was on the functional ambulation program to ambulate up to 30 - 40 feet, 3 times a week by the therapy aide. The DOR noted the DNS informed him that NA #1 did not use a gait belt and walked in front of resident on 11/30/21 at the time of the fall. The DOR noted his expectation was that the nurse aide would stand to the side of Resident #92 to be closer to Resident #92 to hold onto the resident while walking. The DOR noted assist of 1 means hands on assistance and the expectation was to have one hand on the gait belt on the back side of Resident #92, so if Resident #92 started to lose his/her balance the nursing assistant could use the gait belt to lower the person versus the resident just falling. The DOR indicated all nursing assistants are to use a gait for resident that require assist of 1 for ambulation or need more assistance. The DOR noted Resident #92 since readmission from the hospital required a hoyer lift because of the pain, fear and anxiety.
Interview with LPN #1 on 12/6/21 at 12:00 PM noted she had just come in at 7:00 AM and was at the desk across from Resident #92's room and NA #1 came out of Resident #92's room and said the resident was on the floor. LPN #1 noted NA #1 indicated she was walking Resident #92 from the bed to the bathroom with the walker and NA #1 noted Resident #92 lost his/her balance and fell on the floor. LPN #1 noted NA #1 did not have a gait belt on Resident #92 at the time of the fall on Resident #92. LPN #1 noted when interviewed, NA #1 indicated she was standing in front of the resident and his/her walker and LPN #1 indicated that NA #1 should have been standing next to Resident #92 and all nursing assistants know they have to use a gait belt. LPN #1 noted Resident #92 was calling out in pain while on the floor. LPN #1 called for the supervisor to come assess Resident #92 while on floor. LPN #1 noted while the RN supervisor did an assessment and Resident #92 was having pain in the right leg and hip. LPN #1 noted she and NA #1 stayed with Resident #92 while RN #1 went to get a gait belt, then LPN #1, RN #1, and NA #1 applied the gait belt to Resident #92 and got the resident up and off the floor. LPN #1 indicated the expectation was NA #1 should have stood next to the resident and used a gait belt for transferring and ambulating Resident #92.
Interview with RN #1 on 12/6/21 at 12:20 PM noted LPN #1 called her, and she observed Resident #92 on the floor near the foot of the bed complaining of pain in the right leg. RN #1 did an assessment of Resident #92 and indicated she tried to bend and move Resident #92's right leg but the resident was in pain, so RN #1 indicated she wanted to send Resident #92 to the emergency room for evaluation due to the pain. RN #1 indicated NA #1 nor LPN #1 had a gait belt, so RN #1 went behind the nurses' station to the storage room and got a gait belt. RN #1 noted Resident #92 had urine on the floor, so NA #1, LPN #1 and RN #1 put the gait belt on Resident #92 and stood him/her up and placed Resident #92 on the bed until EMS arrived. RN #1 noted when Resident #92 stood up he/she yelled in pain. RN #1 noted NA #1 was ambulating Resident #92 from the bed to the bathroom on the right side of the bed and did not use a gait belt on the resident.
Interview with the nurse staffing agency coordinator, (Person #1), on 12/6/21 at 12:50 PM noted NA #1 was hired with the Agency Staffing on 11/10/21 and was first scheduled and worked at the facility on November 18th, and subsequently on the 19th, 20th, 23rd, 24th, 26th , 27th , 30th and December 1st and 2nd, 2021. NA #1 worked November 18th - 27th without general orientation.
Interview with RN #2 on 12/6/21 at 1:15 PM identified the nursing scheduler informs the nursing supervisors or RN #2 if there will be a new agency person coming to the facility. RN #2 indicated all agency staff on the first day must to do an agency orientation packet with the mandatory education before being allowed to work on the unit RN #2 indicated the expectation was the supervisor goes over the packet with the nursing assistant before they start on the unit. RN #2 noted she was responsible to keep the agency orientation packets for all agency staff and NA #1 did the orientation packet and the competency for gait belt with return demo with her after 8:00 AM on 11/30/21. RN #2 noted she did the general agency orientation packet with NA #1 on 11/30/21 after Resident #92 had fallen.
Interview with the DNS on 12/6/21 at 1:30 PM indicated during her investigation, that NA #1 was ambulating Resident #92 from the bed to the bathroom with the rolling walker and Resident #92 had fallen and was sent to emergency room and had then had to have surgery. The DNS indicated when she interviewed NA #1 and did a demonstration of what had occurred NA #1 had positioned herself in the front of the resident's walker in front of the resident and when Resident #92 was turning the corner towards the bathroom Resident #92 lost his/her balance. The DNS indicated NA #1 noted she did not use a gait belt. The DNS indicated after the incident she did education with NA #1 regarding use of the gait belt and proper positioning for transfers and ambulation. The DNS indicated prior to agency staff working at the facility for the first time, they must sign in at the supervisor office and do the general orientation packet with the supervisor before working on the units. The DNS indicated she was not aware NA #1 had worked in the facility prior to receiving the general orientation. The DNS had a log of agency staff who had signed in and did packets, but NA #1 was not on the list. The DNS noted since Resident #92's fall she had done education on gait belt use and had started auditing on 12/1/21.
Interview with Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with the new agency person on the first day prior to starting on the unit.
Interview and review of the Attention Nursing Supervisor Book, undated, with the DNS on 12/6/21 at 1:50 PM indicated to make sure every agency nurse completes the posttest attached to the agency orientation packet prior to the start of the first shift and the person has to sign the signature sheet to receive the orientation packet and get access to the computer system. Review of the signature sheets dated 9/6/21 - 12/2/21 with the DNS indicated NA #1 was not on the sheets.
Interview with the DNS on 12/7/21 at 7:47 AM indicated when Resident #92 fell, the RN should have done an assessment of the resident on the floor. If Resident #92 had pain when moving the extremities, the resident should have been left on the floor and made comfortable until EMS arrived. The DNS noted her expectation was Resident #92 would stay on the floor until EMS arrived. The DNS noted since Resident #92 was in pain, something was wrong, and staff should not have moved the resident to prevent further injury. The DNS noted this was the standard of practice and facility process but was not a policy. The DNS indicated although she completed the investigation, she was not aware RN #1, LPN #1, and NA #1 moved Resident #92 off the floor and stood the resident up with a gait belt and transferred Resident #92 onto the bed prior to EMS arrival.
Interview with the Administrator on 12/6/21 at 1:29 PM identified the expectation was the supervisor does the orientation packet with a new agency person on the first day prior to starting on the unit.
Interview with NA #1 on 12/7/21 at 1:10 PM indicated on 11/30/21 the regular nursing assistant gave her the assignment and reported that Resident #92 required the assistance of 1 for transfers and to get Resident #92 up and dressed first. NA #1 indicated the care card identified Resident #92 required the assistance of 1 staff but did not indicate the resident required a walker or a gait belt. NA #1 noted she sat Resident #92 on the edge of the bed and gave the resident the walker. NA #1 indicated she did not use a gait belt. NA #1 noted she stood in front of the resident and the walker to prevent the walker from tilting forward. NA #1 noted Resident #92 stood up and started to walk a few steps without an issue and then his/her left leg gave out and the resident fell onto his/her right side. NA #1 noted she was not able to reach the resident when he/she fell to try to lower the resident because Resident #92 did not have a gait belt on. NA #1 indicated she had not been provided general orientation prior to working on the unit, including when to use a gait belt. NA #1 noted after the fall she was handed an orientation packet to read and complete by herself and was given a gait belt. NA #1 noted after the fall for a few days she heard management overhead paging for staff to get a gait belt from the office. NA #1 indicated after Resident #92 fell, she, LPN #1 and RN #1 got the resident off the floor, stood him/her up, and sat him/her in a wheelchair for a few minutes. After a few minutes, the three staff again stood Resident #92 and transferred the resident onto the bed. NA #1 could not recall if Resident #92 was in pain but did recall the resident saying his/her leg was throbbing. NA #1 noted the nurse told her to dress Resident #92 after the resident was placed in bed and prior to the resident going to the hospital. NA #1 noted she dressed Resident #92 prior to leaving the facility per the nurse's directive.
Review of the Nursing Agency policy identified temporary agency nursing personnel are to receive an orientation from an assigned staff member of the center for fire and disaster, abuse, neglect, and mistreatment, resident rights, and center protocols specific to certified personnel. Documentation confirming orientation will be maintained in a location designated by each facility.
Review of the Gait Belt Use Policy identified gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. The gait belt provides the means of support for staff to stabilize and assist residents' balance. Gait belts must be used when physically transferring or ambulating residents.
The facility failed to provide care according to professional standards after Resident #92 fell when despite the resident reporting pain in the leg NA #1, LPN #1 and RN #1 got the resident off the floor, stood him/her up, and sat him/her in a wheelchair for a few minutes and subsequently again stood Resident #92 and transferred the resident onto the bed. Further, NA #1 was directed to dress the resident prior to EMS arrival.
2.
Resident #39's diagnoses included dementia, diabetes, glaucoma and anxiety.
The care plan dated 4/1/21 identified Resident #39 required assistance with all mobility due to a recent hospitalization resulting in weakness due to COVID-19. Interventions included to provide assistance of one with transfers with rolling walker and restorative nursing ambulation program.
A monthly physician's order dated 6/13/21 directed assistance of 1 staff for transfers and gait with rolling walker.
The quarterly MDS dated [DATE] identified that Resident #39 had no cognitive impairments, required extensive assistance of one person for walking in corridor, toilet use, personal hygiene, and two persons physical assistance with transfer and bed mobility.
A reportable event form dated 6/20/21 identified Resident #39 made an allegation that NA #2 provided rough care during a transfer and was rude to the resident. Further review identified no injury observed.
A written interview with Resident #39 dated 6/20/21 identified NA #2 was upset, rude and rough, grabbing the resident's arms while putting the resident into bed.
The resident stated that he/she had tenderness to left side of upper body secondary to heart surgery in the past. NA #2 was suspended pending facility investigation.
The facility investigation and summary report dated 6/24/21 identified the allegation of mistreatment was unsubstantiated. Further review identified NA #2 re-enacted Resident #39's transfer.
Interview and facility investigation review with RN #2 on 12/6/21 at 12:40 PM identified during re-enactment of Resident #39's transfer on 6/23/21, NA #2 demonstrated incorrect transfer technique. NA #2 grabbed the resident under his/her left arm, lifted the resident up and placed the resident onto the bed. RN #2 further identified that NA #2 failed to lock the resident's wheelchair, failed to ensure the bed was locked and failed to use a gait belt to transfer the resident per facility policy.
Interview with the Director of Rehabilitation on 12/6/21 at 1:15 PM identified Resident #39 required contact guard assist, and staff was instructed to use a gait belt and rolling walker with all transfers as a safety measure to provide gait support without pulling on the resident's body and possibly hurting the resident. Further interview identified the resident received rehabilitation services starting 6/22/21 for left shoulder pain, limited left shoulder AROM impacting participation in functional activities of daily living tasks and transfers, and increased assistance with transfers.
Interview with the DNS on 12/7/21 at 9:45 AM identified that during the facility investigation it was identified that NA #2 transferred Resident #39 onto the bed without the benefit of a 2nd persons, failed to follow facility policy on use of the gait belt, failed to implement physician's orders, plan of care and physical therapy recommendations to use rolling walker for gait and transfers. The DNS further identified that education to NA #2 was provided on use of gait belt, transfer of one assist, abuse, resident rights, customer service and fear of retaliation.
Although attempted, an interview with NA #2 was not obtained.
The facility Gait Belt Use policy identified that gait belts are used to prevent injury and/or discomfort to the resident during transfer and ambulation tasks in which staff are called upon to provide physical assistance. Gait belt use also prevents injury to staff member during resident transfer and ambulation tasks as they provide a means of support for staff to stabilize and assist residents to balance. The policy further directed gait belts must be used when physically transferring or ambulating residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on review of facility documentation and facility policy, the facility failed to ensure agency staff general training was completed prior to commencement of work on the unit. The findings include...
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Based on review of facility documentation and facility policy, the facility failed to ensure agency staff general training was completed prior to commencement of work on the unit. The findings include:
Interview with Person #1 on 12/6/21 at 12:50 PM identified NA #1 was hired via the staffing agency on 11/10/21 and was first scheduled and worked at the facility on November 18th, 19th, 20th, 23rd, 24th, 26th and 27th. NA #1 worked November 18th - 27th without general orientation to the facility.
Interview with RN #2 on 12/6/21 at 1:15PM noted the nursing scheduler informs the nursing supervisors or RN #2 if there will be a new agency person coming to the facility. RN #2 indicated all agency staff prior to working on the floor, on their first day are required to complete agency orientation with the mandatory education. RN #2 indicated the expectation was the supervisor goes over the packet with the nurse aide before they start on the unit. RN #2 noted she was responsible to keep the agency orientation packets for all agency staff and NA #1 did the orientation packet and the competency for gait belt with return demo with her after 8:00 AM on 11/30/21, 12 days after she started working at the facility.
Interview with Administrator on 12/6/21 at 1:29 PM the expectation was the supervisor does the orientation packet with a new agency person on the first day prior to starting on the unit.
Interview with NA #1 on 12/7/21 at 1:10 PM indicated the facility did not provide general orientation education when she first started at facility.
Review of facility Nursing Agency policy indicated personnel are to receive an orientation from an assigned staff member of the center for fire and disaster, abuse, neglect, and mistreatment, resident rights, and center protocols specific to certified personnel. Documentation confirming orientation will be maintained in a location designated by each facility.
Please cross reference F689, Resident #92.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure staff followed the facility dress code policy regarding hand/fingernail hygiene. The findi...
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Based on observations, facility documentation, facility policy, and interviews, the facility failed to ensure staff followed the facility dress code policy regarding hand/fingernail hygiene. The findings include:
Observations on 12/5/21 identified the following staff with extremely long fingernails:
a. Interview with NA #3 on 12/5/21 at 5:30 AM identified she was not aware that her fingernails should not be that long and indicated that the facility did not give her an in-service regarding long fingernails (nail hygiene) during orientation.
b. Interview with NA #8 on 12/5/21 at 7:16 AM identified she is from the agency. NA #8 identified she was not aware that her fingernails should not be that long and indicated that the agency and the facility did not in-service her regarding her long fingernails (nail hygiene).
Interview with RN #2 on 12/5/21 at 11:00 AM identified she was not aware of the issue. RN #2 indicated her expectation is that all nursing staff are to follow the facility employee dress code standards policy. RN #2 indicated it is an infection control issue and the facility will be in-servicing the nursing staff.
Interview with the DNS on 12/7/21 at 7:23 AM identified she was aware of the issue when it was brought to her attention. The DNS indicated that long nails have the potential to cause injuries to the residents during care. The DNS indicated the long nails are also an infection control issue due to microorganism underneath the nails. The DNS indicated an in-service will be given regarding the length of nursing staff fingernails. The DNS indicated she will educate the agencies and the agencies staff.
Review of facility employee handbook identified each employee must report to work presenting a clean, neat and professional appearance and dressed in properly fitting clothing/uniform. Good personal hygiene is of critical importance to individuals caring for the ill. Meet your responsibility to yourself and others by appropriately grooming before arriving for duty. Hands should be clean, and fingernails well-trimmed for your safety as well as our residents.
Center for Disease Control and Prevention (CDC) - Nail Hygiene
Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of some infections, such as pinworms. Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection.
Center for Disease Control and Prevention (CDC) - Hand Hygiene in Healthcare Settings-Core
Nail length is important because even after careful handwashing, Health Care Workers (HCWs) often harbor substantial numbers of potential pathogens in the subungual spaces.
Numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), corynebacterial, and yeasts.
Natural nail tips should be kept to ¼ inch in length.
A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcare associated pathogens. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing.
The facility failed to ensure staff followed the facility dress code policy regarding hand/fingernail hygiene.
Aug 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record and interviews for one of two resident's reviewed for activities (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record and interviews for one of two resident's reviewed for activities (Resident #132), the facility failed to ensure the resident was treated in a respectful/dignified manner to promote a homelike environment. The findings include:
Resident #132's diagnoses included Lewy body dementia, dysthymic disorder, general anxiety disorder and dementia with behavioral disturbance.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired, requiring extensive to total assistance from staff for most Activities of Daily Living (ADL) and indicated the resident utilized a Customized Wheelchair (CWC) as a device for mobility.
The Resident Care Plan (RCP) updated on 7/16/19 identified impaired cognition as the focus. Interventions included to encourage socialization and recreation activity, to provide Spanish speaking translator when needed and to have the call bell within reach.
On 7/30/19 at 11:10 A.M. during an interview with Person #5, Resident #132's Power of Attorney (POA) and/or responsible party, he/she indicated when she/he( Person #5) come to visit Resident # 132 the resident is often found sitting in his/her room in the dark. Although, the resident has a television in the room, the channel was observed on a non-Spanish speaking channel (Resident is Spanish Speaking only).
On 7/30/19 at 2:05 P.M and 2:20 P.M. the door to Resident # 132's room was observed as closed, upon knocking and opening the door to gain entry into the room, the surveyor observed Resident #132 lying on his/her right side in bed, in the dark with his/her eyes opened. The resident was making intermittent soft audible sounds when approached. The resident's television was off, the curtain and/or shades to the window on the other side of the room were closed and the privacy curtain between Resident #132's bed and his/her roommate (Resident #117) was closed. The room reflected a night time appearance. Resident # 132's television was identified as being off.
On 7/30/19 at 2:35 P.M. observation of Resident #132 noted the resident continued to remain in his/her bed, lying on his/her right side with his/her eyes closed. The resident's room remained dark reflecting a night time appearance and the television remained off.
A review of the nurse's note dated 7/31/19 at 8:49 A.M. written by (RN#6) identified in part that RN#6 indicated he/she informed Resident #117 that Resident#132's light and television needed to remain on. RN#6 further offered Resident #117's alternatives such as asleep mask, ear plugs which were refused. RN # 6 also indicated that by keeping the window shades closed was a comfort for Resident # 117.
On 7/31/19 at 9:43 A.M. and 10:01 A.M. identified Resident # 132's door was open and Resident #132 was observed as awake and/or with eyes opened, dressed and well groomed, sitting in his/her (CWC) at the bedside with his/her right leg flexed towards him/her . The resident's eyes was opened with his/her right leg flexed towards his/her chest. The resident's room was dark and/or lights were off, shades and/or curtains to window were closed. The resident's television was off and the privacy curtain between Resident #132's bed and his/her roommate's bed (Resident #117) was closed.
On 7/31/19 at 10:06 A.M. the Administrator was observed entering Resident # 132's, after turning on the light over Resident #132's bed, the resident was observed sitting in his/her CWC with his/her right leg flexed to his/her chest, awake and/or with eyes opened. The administrator was observed turning Resident #132's television set on for the resident.
An interview with the Administrator on 7/31/19 at 10:06 A.M. at the time of the observation identified the facility had just became aware that Resident # 117 had been turning the lights off in the room, Resident # 117 was turning Resident #132's television off. The Administrator indicated she/he turned Resident # 132's television on manually secondary to a non-working remote control and indicated she/he would have the television batteries checked.
7/31/19 10:16 A.M. interview with NA#6 indicated he/she did not turn Resident #132's television set or light off today. NA # 6 further indicated Resident # 117 would often ask him/her to turn Resident # 132's television off because Resident # 117 did not like the television on in the room. NA#6 further indicated that earlier when NA#7 came to her and reported that Resident #117 wanted NA#7 to turn off Resident #132's light and television, NA#6 told NA#7 to notify the nurse (RN#5).
On 7/31/19 at 10:18 A.M. an interview with NA#7 indicated that when he/she went to find the charge nurse (RN#5) to tell him/her Resident #117 asked her/him ( NA#7) to turn off Resident # 132's television and light in the room, he/she (NA# 7) could not find the charge nurse (RN#5). NA # 7 indicated she/he reported Resident # 117's request to the Staff Development Nurse (RN#6) instead. NA#7 further indicated it was Resident #117 who turned off Resident #132's light and television.
On 8/1/19 9:40 A.M. interview, review of the clinical record and review of observations of Resident #132 in bed and/or sitting at bedside in the dark without stimulation from television with DNS identified the facility could not provide documentation and/or evidence to reflect that when the facility first learned of Resident #117's behavior of turning Resident #132's light and/or television off on 7/31/19 at 8:39 A.M. measures and/or interventions were put in place to maintain Resident #132's and/or his/her POA's preference for having his/her (over bed) light and/or television on the room and to ensure the resident was noted in the dark in the room. The DNS further indicated that upon staff's awareness of Resident # 117's behavior of turning lights and television off in the room, the staff should have made sure Resident # 132 was not left in the dark.
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, review of the clinical record and interviews for one of two resident's reviewed for activities (Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record and interviews for one of two resident's reviewed for activities (Resident #132), the facility failed to accommodate the resident's needs and/or preferences for a Spanish speaking channel. The finding include:
Resident #132's diagnoses included Lewy body dementia, dysthymic disorder, general anxiety disorder and dementia with behavioral disturbance.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as severely cognitively impaired, requiring extensive to total assistance from staff for most Activities of Daily Living (ADL) and indicated the resident utilized a Customized Wheelchair (CWC) as a device for mobility.
The Resident Care Plan (RCP) updated on 7/16/19 identified impaired cognition as the focus. Interventions included to encourage socialization and recreation activity, to provide Spanish speaking translator when needed and to have the call bell within reach.
On 7/30/19 at 11:10 A.M. during an interview with Person #5, Resident #132's Power of Attorney (POA) and/or responsible party, he/she indicated when she/he( Person #5) come to visit Resident # 132 the resident is often found sitting in his/her room in the dark. Although, the resident has a television in the room, the channel was observed on a non-Spanish speaking channel (Resident is Spanish Speaking only).
On 7/30/19 at 2:05 P.M and 2:20 P.M. the door to Resident # 132's room was observed as closed, upon knocking and opening the door to gain entry into the room, the surveyor observed Resident #132 lying on his/her right side in bed, in the dark with his/her eyes opened. The resident was making intermittent soft audible sounds when approached. The resident's television was off, the curtain and/or shades to the window on the other side of the room were closed and the privacy curtain between Resident #132's bed and his/her roommate (Resident #117) was closed. The room reflected a night time appearance. Resident # 132's television was identified as being off.
On 7/30/19 at 2:35 P.M. observation of Resident #132 noted the resident continued to remain in his/her bed, lying on his/her right side with his/her eyes closed. The resident's room remained dark reflecting a night time appearance and the television remained off.
A review of the nurse's note dated 7/31/19 at 8:49 A.M. written by (RN#6) identified in part that RN#6 indicated he/she informed Resident #117 that Resident#132's light and television needed to remain on. RN#6 further offered Resident #117's alternatives such as asleep mask, ear plugs which were refused. RN # 6 also indicated that by keeping the window shades closed was a comfort for Resident # 117.
On 7/31/19 at 10:06 A.M. the Administrator was observed entering Resident # 132's, after turning on the light over Resident #132's bed, the resident was observed sitting in his/her CWC with his/her right leg flexed to his/her chest, awake and/or with eyes opened. The administrator was observed turning Resident #132's television set on for the resident.
An interview with the Administrator on 7/31/19 at 10:06 A.M. at the time of the observation identified the facility had just became aware that Resident # 117 had been turning the lights off in the room, Resident # 117 was turning Resident #132's television off. The Administrator indicated she/he turned Resident # 132's television on manually secondary to a non-working remote control and indicated she/he would have the television batteries checked. The Administrator also indicated she/he placed Resident # 132's television on a Spanish speaking channel.
7/31/19 10:16 A.M. interview with NA#6 indicated he/she did not turn Resident #132's television set or light off today. NA # 6 further indicated Resident # 117 would often ask him/her to turn Resident # 132's television off because Resident # 117 did not like the television on in the room. NA#6 further indicated that earlier when NA#7 came to her and reported that Resident #117 wanted NA#7 to turn off Resident #132's light and television, NA#6 told NA#7 to notify the nurse (RN#5).
On 7/31/19 at 10:18 A.M. an interview with NA#7 indicated it was Resident #117 who turned off Resident #132's light and television.
On 8/1/19 9:40 A.M. interview, review of the clinical record and review of observations of Resident #132 in bed and/or sitting at bedside in the dark without stimulation from television with DNS identified the facility could not provide documentation and/or evidence to reflect that when the facility first learned of Resident #117's behavior of turning Resident #132's light and/or television off on 7/31/19 at 8:39 A.M. measures and/or interventions were put in place to maintain Resident #132's and/or his/her POA's preference for having his/her television on the room.
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 clinical record review, review of the facility documentation, and interviews for one sampled resident reviewed for conc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of the facility documentation, and interviews for one sampled resident reviewed for concerns regarding missing item (Resident #385), the facility failed to ensure the resident's missing lower denture was investigated. The findings include:
Resident #385 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm, diabetes, seizures, depression and anxiety.
The admission assessment dated [DATE] identified the resident with full upper and full lower dentures with no broken area or teeth, dentures were regularly worn and indicated the resident had no dental or mouth pain.
The admission Minimum Data Set assessment dated [DATE] identified Resident #385 had intact cognition, required extensive assistance with bed mobility, limited assistance with transfer and personal hygiene.
The care plan dated 8/26/18 identified the resident at risk for oral and dental health problems due to edentulous mouth. The resident had full upper and lower dentures. Interventions directed to monitor, document and report any oral and/or dental problems needing attention including missing teeth.
The nurse's note dated 10/26/18 at 6:57 P.M. identified Resident #385 requested to be transferred to the hospital for an evaluation.
Further review of nurse's note dated 10/27/18 at 1:31 P.M. identified the resident who was admitted to the hospital informed the facility staff she/he will not be returning back and will send a friend to collect her/his belongings.
The nurse's note dated 10/29/18 at 7:49 P.M. identified RN # 3 received call from Person #1 inquiring about Resident # 385's dentures. RN #3 informed Person #1 that the resident's dentures had been missing, paperwork had been filled out and forwarded to SW #1. In addition, RN #3 informed Person #1 that she/he should follow up with SW #1 the next day between(9 A.M -3 P.M) and RN #2 left a message for SW #1 with Person #1's telephone number.
A review of SW #1 progress note dated 10/30/18 identified that she/he followed with Person #1 regarding dentures and indicated she/he could not leave a message for Person #1 secondary to the mailbox being full.
The nurse's note dated 11/25/18 identified that RN #3 received a call from Resident #385 at approximately 2:00 P.M. demanding that her/his medications be delivered to her/him immediately with her/his missing dentures. Resident # 385 was informed that the facility was unable to deliver her/his medications on the weekend and that she/he could send someone to pick up her/his medications from the facility (the resident had personal medications left at the facility). The resident started yelling and RN #2 collected the resident's telephone number and informed Resident # 385 that someone would follow up.
Interview with RN #2 on 7/31/19 at 11:43 A.M. identified on the evening of 10/27/18 Person #1 came in to the facility and picked up Resident #385's belongings from his/her room. At the time Person #1 reported to RN #2 Resident # 385's bottom denture was missing. Resident # 385 room and laundry area were searched for the missing dentures. However RN #2 was unable to locate the resident's denture. RN #2 indicated she/he notified Person #2 that someone would call her/him when the denture was located and indicated the facility will continue search for the denture. In addition, RN #2 wrote a nursing progress note to identify that the resident's bottom denture was reported to be missing.
A review of the Resident Concern forms and interview with the Administrator on 7/31/19 at 3:30 P.M. failed to identify that a missing item report and/or investigation was conducted when the facility was notified that Resident # 385's missing bottom denture.
Subsequent to surveyor inquiry, the facility on 7/31/19 in-serviced staff on the facility's missing property form completion process.
The facility missing property policy notes in part that a missing property log form will be completed and an investigation will be immediately initiated. Appropriate individuals will be interviewed and in the case of apparent theft, a police report will be filed.
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 review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of five...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of five residents reviewed for Nutrition (Resident #132), the facility failed to ensure the resident received Power Cereal at breakfast in accordance with physician's orders. The findings include:
Resident #132's diagnoses included Lewy body dementia, dysthymic disorder, general anxiety disorder, Adult Failure to Thrive and dementia with behavioral disturbance.
A quarterly assessment MDS assessment dated [DATE] identified the resident as severely cognitively impaired, requiring extensive to total assistance from staff for most ADL and utilized a (CWC) as a device for mobility. The assessment also noted the resident required extensive assistance of one person for eating, required mechanically altered and therapeutic diet, noted weight of 92 pounds and no weight loss.
The RCP dated 7/16/19 for Family does not want feeding tube or Remeron for appetite stimulation and weight loss may be unavoidable as dementia progresses. Interventions included: to provide assistance with meals as needed, to document percentage of solid/fluids consumed, to monitor by mouth intake at meals and snacks when needed, to monitor weights when needed, Power Cereal twice a day (lunch and dinner) and milkshake 120 ml three times a day.
A physician's orders for the month of July 2019 directed two bowls of Power Cereal for breakfast.
On 7/30/19 at 11:10 A.M. an interview with Person #5 (POA) for Resident #132 identified he/she had concerns regarding the resident's nutritional status.
On 7/3/19 at 8:03 A.M. observation of Resident #132 at breakfast identified the resident was fed pancakes, puree eggs and one 6 ounce bowl of power cereal.
On 8/1/19 at 2:45 P.M. an interview and review of the meal slip for breakfast dated 7/31/19 and 8/1/19 with the Food Service Director (FSD) identified the resident was served 6 ounce power bowl of cereal instead of two bowls as ordered by the physician. The FSD further indicated the power bowl cereal is very sweet, Resident # 132's POA does not want the resident to have too many sweets. The FSD also indicated the NA further informed the kitchen staff Resident # 132 does not need two power bowl cereals in the morning.
Although the resident's weight continues to remain stable, the FSD indicated he/she did not communicate to the dietitian that Resident # 132 was not receiving two power bowls cereal at breakfast. Subsequent to inquiry, the FSD indicated he/she would up the dietician that the resident had not been receiving two bowels of power cereal at breakfast so the dietician could conduct and assessment and follow up with the physician.
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 observation, interviews and review of facility policy and procedure for one of three medication rooms observed, the facility failed to ensure the 2nd floor medication room was maintained lock...
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Based on observation, interviews and review of facility policy and procedure for one of three medication rooms observed, the facility failed to ensure the 2nd floor medication room was maintained locked/secured in accordance with facility policy and procedure. The findings include: The finding include:
Observation of the 2nd floor medication room on 7/29/19 at 10:14 A.M. noted the medication room door was not closed completely, allowing access to the medication room with pushing the door opened.
Interview and observation with RN #4 on 7/29/19 at 10:16 A.M. noted the 2nd floor medication room door unlocked, allowing RN #4 access the medication room with pushing the door opened. RN #4 identified only licensed staff have keys to the medication door allowing access to the medication room. RN #4 indicated all medication rooms should be locked at all times. RN #4 also indicated he/she will immediately call maintenance to adjust the door to ensure the door closes/locks.
Interview and review with the DNS on 8/1/19 at 10:15 A.M. identified all medication room doors should be locked at all times and only licensed staff have access to the medication room
Facility medication storage room/medication cart policy identifies all medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. Storage for other medications will be limited to a locked medication room.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 36% turnover. Below Connecticut's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 32 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $16,801 in fines. Above average for Connecticut. Some compliance problems on record.
- • Grade F (21/100). Below average facility with significant concerns.
Bottom line: Trust Score of 21/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Northbridge Health's CMS Rating?
CMS assigns NORTHBRIDGE HEALTH CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Connecticut, 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 Northbridge Health Staffed?
CMS rates NORTHBRIDGE HEALTH CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 36%, compared to the Connecticut average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Northbridge Health?
State health inspectors documented 32 deficiencies at NORTHBRIDGE HEALTH CARE CENTER during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 29 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Northbridge Health?
NORTHBRIDGE HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ATHENA HEALTHCARE SYSTEMS, a chain that manages multiple nursing homes. With 145 certified beds and approximately 126 residents (about 87% occupancy), it is a mid-sized facility located in BRIDGEPORT, Connecticut.
How Does Northbridge Health Compare to Other Connecticut Nursing Homes?
Compared to the 100 nursing homes in Connecticut, NORTHBRIDGE HEALTH CARE CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (36%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Northbridge Health?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Northbridge Health Safe?
Based on CMS inspection data, NORTHBRIDGE HEALTH CARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Connecticut. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Northbridge Health Stick Around?
NORTHBRIDGE HEALTH CARE CENTER has a staff turnover rate of 36%, which is about average for Connecticut 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 Northbridge Health Ever Fined?
NORTHBRIDGE HEALTH CARE CENTER has been fined $16,801 across 1 penalty action. This is below the Connecticut average of $33,247. 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 Northbridge Health on Any Federal Watch List?
NORTHBRIDGE HEALTH CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.