ARDEN CARE CENTER
For profit - Limited Liability company
271 Beds
HIGHBRIDGE HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#164 of 192 in CT
Photo by Arden Care Center
Photo by Arden Care Center
Photo by Arden Care Center
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Arden Care Center in Hamden, Connecticut has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. Ranked #164 out of 192 facilities in the state, this places them in the bottom half of Connecticut nursing homes, and #20 out of 23 in the local county, showing limited better options nearby. The facility's trend is worsening, with reported issues increasing from 13 in 2024 to 19 in 2025, which raises red flags for families considering care here. While the staffing turnover is low at 0%, indicating staff stability, the facility has concerning RN coverage that is less than 94% of state facilities, which may affect the quality of medical oversight. Families should be aware of serious incidents, including a critical medication error that resulted in a hospital admission and a resident wandering off the premises unnoticed for over two hours, underscoring potential risks in resident safety and care.
- Trust Score
- F
- In Connecticut
- #164/192
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $110,546 in fines. Lower than most Connecticut facilities. Relatively clean record.
- 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
- 61 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 15%
Review needed
13 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 19 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Connecticut average (3.0)
Significant quality concerns identified by CMS
Federal Fines: $110,546
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: HIGHBRIDGE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 61 deficiencies on record
2 life-threatening 1 actual harm
Aug 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residen...
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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 one (1) of three (3) residents (Resident #1) reviewed for wounds, the facility failed to notify the physician when staff did not administer wound treatments. The findings include:a. Resident #1 had diagnoses that included right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The Resident Care Plan (RCP) dated 7/23/2025 identified Resident #1 at risk for skin breakdown related to multiple sclerosis, chronic recurrent osteomyelitis, actual skin breakdown to the right ankle lateral aspect, right heel, right calf, and sacrum. Interventions directed to observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed with a pillow, pat skin when drying, observe for signs of symptoms of skin breakdown, and provide wound treatments as ordered.The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with bed mobility, dependent on staff for all ADLs including transfers, was non-ambulatory and dependent on staff for mobility in the wheelchair. The MDS further identified Resident #1 had a stage one pressure injury, a stage three pressure injury, and an infection of the foot.The physician's order dated 7/30/2025 directed to cleanse back wound with normal saline, followed by calcium alginate, cover with abdominal pad, once daily at 9:00 P.M. and as needed.Review of Resident #1's Treatment Administration Record dated 8/2/2025 identified LPN #9 documented that Resident #1 refused the wound treatment. Interview with Licensed Practical Nurse (LPN) #9 on 8/26/2025 at 12:40 P.M. identified on 8/2/2025 Resident #1 refused wound treatment to h/her back wound. LPN #9 identified she did not notify the physician when Resident #1 refused wound care because LPN #9 felt since it was daily it was not a big deal. Interview with the Director of Nurses (DNS) on 8/25/2025 at 2:25 P.M. identified on 8/2/2025 when Resident #1 refused wound treatment, LPN #9 should have notified the on-call provider.Interview with MD #1(Medical Director) on 8/26/2025 at 3:33 P.M. identified on 8/2/2025 when Resident #1 refused the wound treatment, LPN #9 should have notified the on-call provider.b. Resident #1 had diagnoses that included right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The Resident Care Plan (RCP) dated 7/23/2025 identified Resident #1 at risk for skin breakdown related to multiple sclerosis, chronic recurrent osteomyelitis, actual skin breakdown to the right ankle lateral aspect, right heel, right calf, and sacrum. Interventions directed to observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed with a pillow, pat skin when drying, observe for signs of symptoms of skin breakdown, and provide wound treatments as ordered.The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with bed mobility, dependent on staff for all ADLs including transfers, was non-ambulatory and dependent on staff for mobility in the wheelchair. The MDS further identified Resident #1 had a stage one pressure injury, a stage three pressure injury, and an infection of the foot.The physician's orders dated 7/30/2025 directed to cleanse the right ankle with generic wound cleanser, followed by xeroform, cover with abdominal pad, wrap with Kerlex (gauze wrap) one time per day on the day shift, and cleanse the right lateral calf wound with normal saline, pat dry, followed by calcium alginate, and wrap with Kerlex one time per day on the day shift.Review of the Resident #1's TAR dated 8/3/2025 identified the wound treatments for Resident #1's right ankle and right lateral calf wounds were not signed off indicating that the wound treatments were not administered.Interview with LPN #5 on 8/25/2025 at 2:07 P.M. identified on 8/3/2025 she was aware that she was supposed to administer Resident #1's wound treatments to the right ankle and right lateral calf. LPN #5 identified on 8/3/2025 she did not administer Resident #1's wound treatments. LPN #5 indicated she did not have time to administer Resident #1's wound treatments, so they were not done. LPN #5 did not notify the physician on 8/3/2025 that Resident #1's wound treatments were not administered.Interview with the DNS on 8/25/2025 identified on 8/3/2025 LPN #5 should have notified the RN supervisor she was unable to administer Resident #1's wound treatments and notified the on-call provider that Resident #1's wound treatments were not done.Interview with MD #1 on 8/26/2025 at 3:33 P.M. identified on 8/3/2025 when LPN #5 did not administer Resident #1's wound treatments, LPN #5 should have notified the on-call provider. MD #1 identified his expectations are if a wound treatment is not administered for any reason he is notified.Review of facility notification change in condition policy dated 11/30/2025; in part, directed the patient's physician must be immediately notified when there is a need to alter treatment.
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 one (1) of three (3) residen...
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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 one (1) of three (3) residents (Resident #1) reviewed for neglect, the facility failed to protect the resident's right to be free from neglect when wound treatments were not administered as ordered. The findings includeResident #1 had diagnoses that included a right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The Resident Care Plan (RCP) dated 7/23/2025 identified Resident #1 at risk for skin breakdown related to multiple sclerosis, chronic recurrent osteomyelitis, actual skin breakdown to the right ankle lateral aspect, right heel, right calf, and sacrum. Interventions directed to observe skin condition daily with ADL care and report abnormalities, off load/float heels while in bed with a pillow, pat skin when drying, observe for signs of symptoms of skin breakdown, and provide wound treatments as ordered.The physician's order dated 7/30/2025 directed to cleanse back wound with normal saline, followed by calcium alginate, cover with abdominal pad, once daily at 9:00 P.M. and as needed, cleanse the right ankle with generic wound cleanser, followed by xeroform, cover with abdominal pad, wrap with Kerlex (gauze wrap) one time per day on the day shift, and cleanse the right lateral calf wound with normal saline, pat dry, followed by calcium alginate, and wrap with Kerlex one time per day on the day shift.The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with bed mobility, dependent on staff for all ADLs including transfers, was non-ambulatory and dependent on staff for mobility in the wheelchair. The MDS further identified Resident #1 had a stage one pressure injury, a stage three pressure injury, and an infection of the foot.Review of the Treatment Administration Record (TAR) on 8/2/2025 at 9:00 P.M. identified Licensed Practical Nurse (LPN) #9 documented Resident #1 refused the following treatment: cleanse back wound with normal saline, followed by calcium alginate, cover with abdominal pad and it was not done. Review of the Treatment Administration Record (TAR) on 8/3/2025 during the 7:00 A.M. to 3:00 P.M. shift identified the following treatments were not signed off indicating they were not completed: cleanse the right ankle with generic wound cleanser, followed by xeroform, cover with abdominal pad, wrap with Kerlex (gauze wrap) one time per day on the day shift, and cleanse the right lateral calf wound with normal saline, pat dry, followed by calcium alginate, and wrap with Kerlex one time per day on the day shift.Interview with Person #1 on 8/25/2025 at 10:11 A.M. identified on 8/4/2025 h/she checked Resident #1's dressings on the right ankle, right calf, and buttocks. Person #1 indicated the dressings were soiled and dated 8/1/2025. Person #1 indicated Resident #1's wound care was supposed to be done daily. Person #1 indicated on 8/4/2025 when APRN #1 came into see Resident #1 h/she let APRN #1 know that the dressings had not been changed since 8/1/2025.Interview with APRN #1 on 8/25/2025 at 12:56 P.M. identified on 8/4/2025 Resident #1's visitors reported that Resident #1's dressings were soiled and had not been changed since 8/1/2025. APRN #1 identified on 8/4/2025 she observed the dressings on Resident #1's right ankle, right calf, and buttock. APRN #1 identified the dressings were wet, soiled, and dated as 8/1/2025. Interview with Registered Nurse (RN) #2 on 8/25/2025 at 1:15 P.M. identified on 8/4/2025 NA #4 notified him that Resident #1's family members had concerns about Resident #1's dressings. RN #2 identified he and LPN #6 went into to check Resident #1's dressings. RN #2 identified Resident #1's right calf, right ankle, and lower back/buttock dressings were dated as 8/1/2025 with LPN #3's initials. RN #2 identified Resident #1's wound treatments were supposed to be done daily and were not done on 8/2/2025 and 8/3/2025.Interview with LPN #6 on 8/25/2025 at 1:35 P.M. identified on 8/4/2025 RN #2 reported Resident #1's family members had concerns about Resident #1's dressings on h/her wounds. LPN #6 identified she and RN #2 went in to assess Resident #1. LPN #6 identified Resident #1's right calf, right ankle, and lower back/buttock dressings were soiled and dated as 8/1/2025 with LPN #3's initials. LPN #6 identified Resident #1's wound treatments were daily and were not done on 8/2/2025 and on 8/3/2025.Interview with LPN #5 on 8/25/2025 at 2:07 P.M. identified on 8/3/2025 she was aware that she was supposed to administer Resident #1's wound treatments to the right ankle and right lateral calf. LPN #5 identified on 8/3/2025 she did not administer Resident #1's wound treatments. LPN #5 indicated she did not have time to administer Resident #1's wound treatments so they were not done. Interview with the Director of Nurses (DNS) on 8/25/2025 at 2:25 P.M. identified Resident #1's wound treatments should have been completed on 8/2/2025 and 8/3/2025. The DNS was not aware that on 8/2/2025 and 8/3/2025 Resident #1's wound treatments were not administered. The DNS identified she expects wound treatments to be administered per physician's orders and if the nurse signs off on the resident's TAR it indicates the wound treatment was completed. The DNS further identified Resident #1's right ankle, right calf, and lower back/buttocks wound treatments should have been administered on 8/2/2025 and 8/3/2025.Interview with MD #1 (Medical Director) on 8/26/2025 at 3:33 P.M. identified Resident #1's physician's orders directed to complete daily wound treatments for all h/her wounds. MD #1 identified from 8/2/2025 to 8/4/2025 Resident #1's wound treatments should have been completed. MD #1 identified his expectations are resident's wound treatments are administered per the physician's orders.Review of the facility abuse prohibition policy dated 10/24/2022; in part, identified the center prohibits neglect for all patients. Neglect is defined as failure, in difference, or disregard to provide care and services to a patient.
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 one (1) of three (3) residen...
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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 one (1) of three (3) residents (Resident #1) reviewed for abuse, the facility failed to initiate an investigation for an abuse allegation. The findings include: Resident #1 had diagnoses that included right ankle wound, pressure injuries to the sacral spine, right posterior calf, right medial ankle, and left buttocks, recurrent multifocal osteomyelitis of the right foot and ankle, multiple sclerosis, anemia, depression, anxiety, and chronic pain.The admission [NAME] Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicative of intact cognition, was occasionally incontinent of bowel, always incontinent of bladder, required substantial assistance with bed mobility, dependent on staff for all ADLs including transfers, was non-ambulatory and dependent on staff for mobility in the wheelchair.The Resident Care Plan (RCP) dated 8/1/2025 identified Resident #1 requires assistance/is dependent for ADL care related to multiple sclerosis, impaired balance/dizziness, and weakness affecting the lower extremities. Interventions directed to provide extensive assistance for bed mobility, eating, grooming, dressing, toileting, and assistance of 2 for transfers with use of a total mechanical lift.Review of the clinical record and review of facility documentation on 8/25/2025 failed to identify that on 8/4/2025 an investigation was initiated for an allegation that on 8/4/2025 Resident #1's family members found Resident #1 in bed, naked, and crying. Interview with Person #1 on 8/25/2025 at 10:11 A.M. identified on 8/3/2025 while visiting Resident #1 h/she described an incident that occurred earlier that morning. Around 5:00 A.M. a nurse aide entered the room, and abruptly shook Resident #1 awake, stating she was going to change h/her. Resident #1 asked for a moment to collect h/herself, but the aide ignored h/her request and began removing the diaper. Person #1 identified on 8/4/2025 when she entered Resident #1's room, Resident #1 was crying, naked, lying in the bed in the highest position, with the side rails left down, without the call light. Person #1 indicated that Resident #1 told h/her that an aide came h/her then left the room to go get linens and never returned. Person #1 indicated on 8/4/2025 h/she notified the Administrator regarding that incident. Interview with the Administrator on 8/25/2025 at 11:55 A.M. identified on 8/4/2025 Resident #1's family member came down to her office to report that Resident #1 was abused over the weekend. The Administrator indicated she went to speak with Resident #1 who reported on 8/3/2025 at approximately 5:00 A.M. Nurse Aide (NA) #1 entered the room, woke Resident #1 up, Resident #1 asked NA #1 to give h/her some time to wake up, but NA #1 did not give Resident #1 time, NA #1 proceeded to remove the diaper in a rough manner, throwing Resident #1's legs over to the other side of the bed causing soreness to the legs. The Administrator indicated an investigation was initiated into the alleged abuse that occurred on 8/3/2025 at 5:00 A.M. The Administrator indicated on 8/4/2025 Resident #1 nor Resident #1's family alleged that on 8/4/2025 Resident #1's family members found Resident #1 naked, lying in bed when NA #2 left the room to get linens, but never returned. Interview with APRN #1 on 8/25/2025 at 12:56 P.M. identified on 8/4/2025 when she went in to see Resident #1, Resident #1's family members reported when they walked into the room Resident #1 was crying because h/she was left completely naked in bed for at least 20 minutes. APRN #1 identified on 8/4/2025 Resident #1 was lying in bed naked, with just a sheet placed over h/her. Interview with Registered Nurse (RN) #2 on 8/25/2025 at 1:15 P.M. identified on 8/4/2025 NA #2 was notified that Resident #1's family reported Resident #1 was naked in bed and Resident #1's family had concerns regarding Resident #1's wound dressing. RN #2 indicated that before he went to see Resident #1, he spoke to the Administrator, and she reported Resident #1 alleged h/she was abused over the weekend. RN #2 identified when he went up to assess Resident #1, Resident #1's family members reported on 8/4/2025 when they came in to visit Resident #1, Resident #1 was in bed, naked, and crying. RN #2 identified that he did not initiate an investigation nor communicate to the Director of Nurses (DNS) or Administrator that Resident #1's family alleged Resident #1 was left naked in bed by NA #2. RN #2 indicated when he entered Resident #1's room, Resident #1 was not naked. RN #2 identified because Resident #1 was not naked, and an investigation was initiated for the allegation that Resident #1 was abused over the weekend he did think an additional investigation should be initiated. Interview with Licensed Practical Nurse (LPN) #3 (charge nurse) on 8/25/2025 at 1:50 P.M. identified on 8/4/2025 that Resident #1's family told her that Resident #1 was crying because when NA #2 was providing care to Resident #1, she left the room to obtain supplies, and NA #2 left Resident #1 naked and exposed. LPN #3 indicated Resident #1's family members went downstairs to report concerns to the Administrator. LPN #3 identified shortly after Resident #1's family members went downstairs, RN #2 (supervisor) and LPN #6 (unit manager) went into Resident #1's room to obtain further information. LPN #3 indicated that on 8/4/2025 she assumed since RN #2 went into see Resident #1 that RN #2 initiated an investigation for the allegation that on 8/4/2025 Resident #1 was left naked in bed by NA #2. LPN #3 identified on 8/4/2025 she should not have assumed that RN #2 initiated an investigation, and she should have notified the DNS or ADNS. Interview with the DNS on 8/25/2025 at 2:25 P.M. identified she was not aware on 8/4/2025 Resident #1's family members reported to RN #2 that they found Resident #1 crying, lying in bed, naked by NA #2 who had left the room to obtain linens and never returned. The DNS identified on 8/4/2025 that RN #2 should have initiated the investigation and notified her of the allegation. The DNS further identified her expectation for any allegations of mistreatment, abuse, or neglect that an investigation is immediately initiated. Review of the facility abuse prohibition policy dated 10/24/2022; in part, directed immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, initiate an investigation, and the investigation will be thoroughly documented.
Feb 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and interview for the only sample resident (Resident #449) reviewed for dignity, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and interview for the only sample resident (Resident #449) reviewed for dignity, the facility failed to ensure a urinary collecting device was handled in a manner to maintain dignity. The findings include:
Resident #449 's diagnoses included unspecified Obstructive and Reflux Uropathy, unspecified unpacified dementia, moderate, without behavioral disturbance, psychotic disturbance. Mood disturbance and anxiety and Urinary Tract infection (UTI).
The admission Minimum Data Set assessment dated [DATE] identified moderately impaired cognition and the resident requires moderate assistance with toileting hygiene, lower and upper body dressing
The care plan dated 2/20/2025 identified Resident #449 requires indwelling catheter due to obstructive uropathy. Interventions included providing privacy bags, leg bags when appropriate and providing privacy and comfort.
A physician's order dated 2/8/2025 directed to perform indwelling catheter care as needed.
Observation of Resident # 449 at 12:32 PM the survey in the hallway by the nursing station identified the resident with an indwelling catheter without a privacy bag
Interview with RN#4 on 2/18/25 at 12:32 PM identified Resident # 449 should have on a privacy bag and could not explain why the resident did not have a privacy bag. After the surveyor's inquiry the Nurse Aide (NA) was instructed to place a privacy bag over the urinary collecting devices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations of dining, review of facility policy and interview for 1 of 6 dining rooms, the facility failed to ensure staff provided a homelike dining experience for residents. The findings ...
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Based on observations of dining, review of facility policy and interview for 1 of 6 dining rooms, the facility failed to ensure staff provided a homelike dining experience for residents. The findings include:
An observation of 2/18/2025 at 12:48 PM identified the dining room area had six tables; two residents seated at four tables, four residents sitting at one table and three residents at another table. There were also three residents ( Residents #53, #71 and #157) in wheelchairs seated on the left of the dining room facing the residents seated and the dining tables, one other resident ( Resident #96) was seated in a wheelchair without a table, facing residents seated at tables on the right side of the dining room area. At 12:50 PM the meal cart arrived to the unit and two nurse aides (NA) initiated serving the meal trays to resident rooms on the unit and two other nurse aides initiated serving the meal trays in the dining room. Residents seated at the dining room tables were served their meals on trays.
An interview with NA #1 on 12/18/2025 at 1:00 PM identified she/he worked at the facility regularly, floating to other units as needed and further indicated meals are always served to the residents on meal trays.
Continued observation of the meal service in the dining room on the secured unit found two residents (Resident # 135) seated at two different tables without food but the other resident seated at each table was eating. The residents seated in wheelchairs without tables and Resident #135 had not been served any food and were facing the residents who had been served food and were eating.
An interview with the charge nurse LPN #1, in the dining room at the time identified she/he did not know why the residents did not have food and asked NA#1 seated at a table feeding a resident. NA #1 indicated she/he was providing assistance with feeding. RN #8 Independent Nurse Consultant was present at the time of the observations and interviews introduced him/herself and had no comment regarding the current dining experience.
An interview with the Director of Nursing Services (DNS) and the Regional Clinical Director on 2/20/2025 at 2:20 PM identified since the new operators of the Change of Ownership who took over the facility a few months ago, many clinical areas were noted to be in need of improvement and it has taken time coordinate residents to come to the dining room rather than eating in their rooms. The DNS further indicated more work is needed to improve the residents' dining experience. The Regional Clinical Director further indicated in-servicing of staff had begun after surveyor's observation of dining on 2/18/2025, but did not provide the in-services.
A request for the facility policy and procedure for resident dining on the nursing units but one was not provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation, facility policy and interviews for the only sampled resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation, facility policy and interviews for the only sampled resident (Resident #136) reviewed for Physical Restraints, the facility failed to ensure the resident was free from physical restraints. The findings include:
Resident #136's diagnoses included Alzheimer disease, paranoid schizophrenia and hypertension.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 136 as severely impaired and requires maximal assistance with bed mobility, personal hygiene and partial assistance with toilet transfers. The MDS further indicated no restraints utilized.
The care plan dated 12/6/2024 identified Resident #136 demonstrates poor body alignment requiring use of custom wheelchair. Interventions included to report for any signs or symptoms of pain, fatigue, discomfort, poor tolerance while in custom wheelchair and report as indicated.
The physician's orders failed to reflect an order for Resident #136's pelvic positioning belt.
The Occupational Therapy ( OT) notes dated 1/17/2025 identified Resident #136 referral is due for his/ her custom wheelchair program to get a replacement wheelchair cushion, elevating leg rests and to allow for repairs to be made. Occupational Therapy notes had no mention/ recommendation for a pelvic positioning belt.
Observation on 2/18/25 at 10:45AM identified Resident #136 scooting in hallway in his/her wheelchair, Resident #136 was also observed with a pelvic positioning belt on.
An interview with RN #4 ( unit manager ) on 2/18/25 at 10: 46 AM indicated Resident #136 can take off the pelvic positioning belt him/ herself. RN#4 asked Resident # 136 to unbuckle his/her belt, however, Resident #136 was not able to do so.
An interview with OT #1 on 2/20/25 at 10:00 AM identified the belt on the wheelchair was called a pelvic positioning belt. She identified in some cases residents might receive a custom wheelchair. OT#1 also indicated residents who are believed to have issues maintaining an upright position while in a wheelchair are assessed to see if the pelvic positioning belt is appropriate for them. Once determined, then the Residents Care Plan and physician's order would be updated to reflect recommendations. OT#1 identified Resident #136 was recently assessed in January 2025 and it was determined a Pelvic Positioning Belt was not appropriate for Resident #136.
On 2/24/25 at 12:19 PM observation of Resident #136 identifed the resident with pelvic belt on in hallway heading to dining room.
The facility Physical Restraints policy updated in June 2024 identified a physical resistant as physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the resident cannot remove easily and one that prevents the resident from freedom of movement or normal access to his/her body.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #153) revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility policy, and interviews for 1 of 3 residents (Resident #153) reviewed for pain management, the facility failed to follow physician's orders for pain management.
Resident #153's diagnoses included fracture of the left femur, liver disease, and hypertension.
The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #153 had moderate cognitive impairment, was dependent on staff for personal hygiene and dressing, required maximal assistance with rolling left and right in bed, and utilized a manual wheelchair.
The Resident Care Plan (RCP) dated 2/12/25 identified Resident #153 was at risk for alterations in mobility related to a left hip fracture. Interventions included : monitoring for pain and stiffness, medicate as ordered, and report to physician as indicated. The RCP further identified Resident #153 was at risk for substance abuse related to a history of addiction. Interventions included observing for evidence of substance use and providing social service visits for support.
An Advance Practice Registered Nurse (APRN) order dated 2/12/25 for Resident #153 directed that non-pharmacological interventions and effectiveness should be documented every shift in supplementary documentation. If the resident is having pain, follow the provider's direction which may include pain medication.
a. An Advance Practice Registered Nurse (APRN) order dated 2/12/25 for Resident #153 directed non-pharmacological interventions are to be used before (PRN) pain medication.
A record review of Resident #153's pain management identified he/she reported pain on 2/12/25 at 4:18 PM, 2/12/25 at 8:00 PM, 2/13/25 at 12:23 AM, 2/13/25 at 12:17 PM, 2/13/25 at 4:58 PM, 2/14/25 at 11:48 PM, 2/16/25 at 1:03 AM, 2/16/25 at 5:26 PM, 2/16/25 at 8:00 PM, 2/17/25 at 6:00 AM, 2/17/25 at 2:35 PM and 2/17/25 at 5:49 PM. No non-pharmacological interventions for Resident #153 were documented within the electronic health record or on paper for the dates 2/12/25 through 2/17/25.
b. An Advance Practice Registered Nurse (APRN) order dated 2/12/25 and having
an end date of 2/19/25 for Resident #153 directed the administration of 2 tablets of 325 milligrams (mg) of Acetaminophen to be given by mouth every 4 hours as needed for mild pain (defined to be a pain level of 1-3 on a 10 point pain scale). If more than 3 doses within a 48 hour time period were given, the physician should be notified.
A record review of Resident #153's pain medication administration identified on 2/14/25 at 5:33 AM 5mg of Oxycodone was given for a pain level of 0. It was further identified on 2/16/25 at 5:26 PM 5mg of Oxycodone was given for a pain level of 2. No Acetaminophen was administered to Resident #153 on 2/14/25. Tylenol was administered on 2/16/25 at 4:00 PM for a pain level of 3.
c. An Advance Practice Registered Nurse (APRN) order dated 2/17/25 and having an end date of 2/18/25 for Resident #153 directed 5 mg of Oxycodone HCL to be given every 4 hours as needed for left hip fracture.
A Medical Doctor (MD) order dated 2/18/25 and having an end date of 3/4/25 for Resident #153 directed 5 mg of Oxycodone HCL to be given every 4 hours as needed for left hip fracture.
A record review on pain for 2/18/25 at 1:01 PM 5mg of Oxycodone was given for a pain level of 8 at 2:41 PM 5mg of Oxycodone was given for a pain level of 7. The duration between the two Oxycodone administrations was 1 hour and 40 minutes.
An interview with Registered Nurse (RN) #3 identified narcotic pain medications are usually ordered with parameters for administration. RN #3 further identified that over the counter medication is usually administered for pain management before a narcotic would be administered, and if a resident reported no pain then no pain medication should be given. RN #3 failed to identify why on 2/14/25 at 5:33 AM 5mg of Oxycodone was given to Resident #153 for a pain level of 0.
An interview with Advanced Practice Registered Nurse (APRN) #1 on 02/25/25 at 10:49 AM identified her expectation is that the nurses try to reposition a resident before administering any pain medication to Resident #153 and pain medication should not be given if there was a reported pain level of 0.
An interview with the Director of Nursing Services (DNS) on 2/25/25 at 03:28 PM identified the reason no non-pharmacological interventions for pain were documented in the Medication Administration Record (MAR) was that the Electronic Health Record (EHR) was missing the codes for documenting the non-pharmacological interventions for pain. She further identified it was her expectation that nurses document the interventions used within a progress note if the EHR did not allow a type of documentation. The DNS failed to identify any documentation of a non-pharmacological intervention for pain within a progress note for Resident #153.
Review of the Facility's Pain Management policy identified (PRN) medications will have defined parameters for use and documented in the MAR. Patients receiving interventions for pain will have documentation of non-pharmacological interventions and its effectiveness, effectiveness of the PRN medication, and ineffectiveness of routine or PRN medications including notification to the physician/APR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy and interviews for 1 of 6 (Resident #123) reviewed for Pressure U...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy and interviews for 1 of 6 (Resident #123) reviewed for Pressure Ulcer/Injury, the facility failed to prevent the re-occurrence of a pressure injury on a resident identified at risk for pressure ulcers and failed to consistently apply a pressure relieving boot while out of bed and failed to consistently turn and reposition the resident ordered and for 2 of 6 residents ( Residents # 67 and # 143) at risk for pressure ulcer development, the facility failed to consistently conduct wound assessments according to facility practice and policy. The findings included:
1.Resident #123's diagnoses included protein calorie malnutrition, Peripheral Vascular Disease (PVD), left below the knee amputation and dementia.
A Braden Skin Risk Assessment completed on 6/9/2024 upon readmission identified at moderate risk for skin break down (score of 13).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #123's cognitive status was moderately impaired, required maximum assistance of staff for rolling to the right and left side while in bed, noted dependent on staff for transferring in and out of bed to the wheelchair, at risk for developing a pressure ulcer/injury and noted no pressure ulcers at the time the assessment was completed.
The care plan dated 1/6/2025 indicated at risk for skin breakdown. Intervention included: conducting weekly skin checks by a licensed nurse, preventative skin care including lotions, and barrier creams as ordered.
A nursing progress note dated 1/15/2025 at 1:34 PM indicated Resident #123 was observed to have a new dark purple, non-blanchable area on the right ankle with surrounding redness, the physician was notified, and new orders were obtained.
The physician's order dated 1/15/2025 directed to offload the right leg with a pillow while in bed every shift, apply skin prep followed by a foam dressing daily and as needed to the right ankle-Deep Tissue Injury (DTI) for 14 days and to have the wound physician evaluate the DTI during the next scheduled wound round.
Resident #123's care plan indicated at risk for skin breakdown identified additional interventions on 1/15/2025 to offload the right leg with a heel boot or pillow while in bed every shift, and to apply skin prep followed by a foam dressing to the right ankle DTI as ordered.
The wound physician's note dated 1/16/2025 indicated the right ankle wound was a Deep Tissue Pressure Injury with persistent non-blanchable deep red, maroon or purple discoloration measuring 0.9 Centimeter (CM) length x 0.6 CM width with no measurable depth, with an area of 0.54 CM with no drainage. The evaluation further indicated significant contributing factors included but were not limited to being diabetic and vascular complicating factors, impaired mobility, general muscle weakness and inevitable effects of aging. The note also indicated education was provided to the facility staff regarding pressure relief, general offloading and frequent repositioning.
A physician's order dated 1/16/2025 directed to apply a heel Medix boot (pressure relieving boot) to the right ankle even when Resident #123 was out of bed.
A Braden skin risk evaluation dated 2/1/2025 noted a score of 12 which identified Resident #123 at high risk of developing skin breakdown (238 days or 7 months, 24 days after the prior Braden skin risk evaluation was previously completed and 18 days after the DTI was noted).
A physician's order dated 2/7/2025 directed to obtain an occupational therapy evaluation and to treat with eight visits within 30 days for wheelchair management and therapeutic activities.
An observation on 2/18/2025 at 11:45 AM identified Resident #123 seated in a wheelchair with the right foot donned with a sock, turned laterally, resting inside the right wheelchair foot box. At 12:48 PM Resident #123 was noted seated in the wheelchair at a dining table with the right foot noted in the same position.
A physician order dated 2/22/2025 directed to take a picture of the right ankle resolved DTI, every Tuesday and complete the skin and wound evaluation.
In interview and record review on 2/24/2025 at 1:20 PM with LPN # 1 (Skin Integrity /Wound Nurse) identified the wound was identified on 1/15/2025. An investigation was conducted but did not indicate the cause of the unrelieved pressure which led to the development of a deep tissue injury. Review of the clinical record with LPN #1 identified no evidence turning and repositioning was consistently performed on Resident #123 from January 1, 2025, through January 14, 2025, who required maximum assistance to turn in bed and who was dependent on staff for transfers to and from the wheelchair. Additionally, no interventions were identified in Resident #123's plan of care for turn and repositioning to prevent skin pressure. LPN #1 further indicated the wound physician had determined the DTI was healed during the last week visit but to continue the treatment. No documentation in the resident record was found regarding a visit by the wound physician or a visit note indicating the DTI was healed/resolved by the wound physician.
An interview and record review with the Director of Nursing Services (DNS) on 2/25/2025 at 10:16 AM indicated from 12/18/2024 through 1/15/2025 when the DTI was identified (29 days later), no documentation of offloading of the heels or turning and repositioning was found in the clinical record. The DNS indicated the facility policy did not provide detailed measures to be put in place for each risk score. However, preventative measures for Resident #123 with a skin risk score of 12 or 13 should have included turning and repositioning, preventative skin care, pressure relieving boots, weekly skin checks and treatments as ordered by the physician all should have been included in the plan of care.
The DNS further indicated from 12/18/2024 until 1/15/2025 when the DTI was found (29 days later) there was no evidence / documentation of offloading of the heels and the pressure relieving boots were not ordered until 1/29/2025 (14 days after the DTI was found). Further clinical document review identified the skin risk assessments had not been conducted per the facility policy. One Braden assessment was conducted on readmission 6/9/2024 and 2/1/25 (238 days or 7 months, 24 days after the prior Braden skin risk evaluation was previously completed and 18 days after a new DTI was noted). The DNS indicated that the Braden skin risk assessments were manually added to the electronic UDA (user defined assessment) by the MDS/clinical reimbursement nurse for the nursing staff to complete and will need to be realigned to reflect the facility policy. The DNS indicated the facility policy does not indicate detailed measures to be put in place for each category of risk, but preventative measures for a Resident(#123) with a skin risk score of 12(Moderate) or 13(high) should have been frequent turning and repositioning, preventative skin care, the pressure relieving boots and treatment applied as ordered by the physician and weekly skin checks by the licensed nurses
Observation on 2/25/2025 at 10:47 AM with RN #6, the facility nurse educator identified Resident # 123 in the dining room lounge area seated in a wheelchair, the right foot donned with a sock resting laterally inside the footrest box. RN #6 wheeled Resident #123 to his/her room for the right foot dressing change and a pressure relieving boot was observed lying on top of the bedside table. RN #6 indicated the pressure relieving boot was used only while in bed but after the surveyor inquired into the physician's she/he indicated the order also directed apply while out of bed. RN #6 indicated s/he would apply it after completing the treatment. RN #6 further indicated the charge nurse was responsible to apply the pressure relieving boot as it is on the treatment [NAME] to be signed off by the licensed nurse. Further observation identified during the treatment of the right ankle an area of discoloration existed, and RN #6 took a measurement picture of the area. After the treatment RN #6 applied the pressure relieving boot and wheeled Resident #123 back to the dining room. Interview with LPN #1 the regular charge nurse for the unit seated at the nurse's station upon exiting Resident #123's room after the treatment was completed indicated s/he ensured application of the pressure relieving boot while Resident #123 was in bed and did not realize it was to be on while out of bed.
An interview with MD #2, the wound physician, on 2/25/2025 at 11:34 AM indicated s/he had last evaluated Resident #123's DTI on 2/14/2025 determining it was resolved and ordered protective dressings to be changed every 3 days. MD #2 further indicated if the wound re-occurred the DNS could add Resident #123 to the next wound round visit. MD #1 indicated having seen Resident #123's right foot position in the wheelchair foot- rest box when out of bed which can cause pressure on the ankle at the location of the DTI. MD #1 further indicated she/he educated the staff on offloading and the need to turn and reposition Resident #123. MD #1 indicated the DTI could have been prevented with turning and repositioning, offloading and other preventative measures in place and utilized, if the pressure causal factor is not relieved a wound will occur and if not relieved it will not heal.
After surveyor inquiry a physician's order dated 2/25/2025 with no time directed staff to obtain a right lower leg ultrasound and ankle brachial index test to rule out peripheral vascular disease.
On 2/26/2025 (12 days after the visit was conducted) at 8:00 AM subject to surveyor inquiry, the facility provided the wound physician visit report dated 2/14/2025 indicating the right ankle-deep tissue pressure injury was improving with measurements at 0 cm length, 0 cm width, no depth and received an outcome of resolved.
The facility policy labeled Skin Integrity and Wound Management indicated in part to conduct risk evaluations (Braden) on admission/readmission, weekly for a month, quarterly and with a change of condition. The policy further indicated to implement pressure injury prevention for identified, modifiable risks factors, determine the need for heel offloading and implement wound treatments.
2. Resident #67's diagnoses included type 2 diabetes mellitus with Diabetic Autonomic Polyneuropathy, Chronic Kidney Disease, and hypothyroidism.
Resident # 67 was admitted on [DATE]. Braden Scale Assessments were completed on 12/16/24 and 12/17/24 indicated the resident was at risk of skin breakdown. However, no further Pressure Ulcer Risk Assessments were completed.
The admission Minimum Data Set assessment dated [DATE] identified Resident #67 was moderately cognitively impaired and required set up assistance for eating and oral hygiene, and substantial assistance for toileting.
A Wound Care Progress note on 2/21/25 identified the resident was at risk for increased risk of wound incidence and/or impaired wound healing due to vascular complicating factors of multi-variable etiologies, urinary and bowel incontinence, impaired cognition, generalized muscle weakness, decreased mobility, poor overall general health, and inevitable effects of aging.
The Resident Care Plan dated 2/17/25 identified the resident was at risk for skin breakdown with actual skin breakdown. Interventions included observing skin for any signs and symptoms of skin breakdown and to evaluate for localized skin problems.
A physician's order dated 2/22/25 direct to take a picture of the coccyx wound and left heel DTI weekly and to complete the wound and skin evaluation.
In an interview with the DNS on 2/26/25 at 10:50 AM identified Braden Scale Assessments should be completed on admission and weekly for 4 weeks.
In an interview with the Regional Director on 2/26/25 at 1:00 PM the MDS Coordinator should be scheduling the Braden Scale Assessments. The DNS also indicated this process has not been consistently done but will be completed moving forward.
3. Resident #143's diagnoses included Chronic Lymphocytic Leukemia, Congestive Heart Failure (CHF), and chronic kidney disease.
Resident # 143 was admitted on [DATE]. Braden Scale Assessments were completed on 11/29/24, 11/30/24, 12/20/24, 12/23/24, 12/25/24, 1/8/25, 1/9/25, 1/22/25. 1/23/25, 2/1/25, 2/2/25, indicating the resident was at risk for developing pressure ulcers.
The admission Minimum Data Set assessment dated [DATE] identified Resident #143 was cognitively intact and required maximum assistance for toileting, showering, and personal hygiene.
A physician's order dated 12/6/24 directed to check skin every week.
The Resident Care Plan dated 2/21/25 identified the resident had actual skin breakdown. Interventions included evaluation for any localized skin problems and observing skin for signs and symptoms of skin breakdown.
In an interview with the DNS on 2/26/25 at 10:50 AM identified Braden Scale Assessments should be completed on admission and weekly for 4 weeks.
In an interview with the Regional Director on 2/26/25 at 1:00 PM the MDS Coordinator should be scheduling the Braden Scale Assessments. The DNS also indicated this process has not been consistently done but will be completed moving forward.
Review of the Skin Integrity and wound Management policy dated 2/1/23 currently in effect, direct in part, to complete risk evaluation upon admission/readmission and weekly for the first month, quarterly thereafter and with a change in condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, the facility failed to ensure the oxygen room, the eye washing room that contain medical supplies and soiled linen room were locked appropriately to ensure r...
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Based on observations and staff interview, the facility failed to ensure the oxygen room, the eye washing room that contain medical supplies and soiled linen room were locked appropriately to ensure residents on a secured unit had no access to prevent a potential accident The findings include:
a. Observation on 2/18/2025 at 11:46 AM of the secured unit (A/B wing) identified the oxygen room, with 4 oxygen tanks, eye washing room with medical supplies (mask and gloves) and the soiled lining rooms with soiled lining were not locked. Despite the Eye washing room and the Soiled Linen room having coded locks on were not utilized.
Observation on 2/18/2025 at 11:53 AM of staff entering Eye washing room and soiled linen room without the benefit utilizing codes.
Observation on 2/18/2025 at 12: 15 PM identified residents wandering the hall and holding on the eye washing door to help propel themselves.
Interview with DNS and the Regional Clinical Director on 2/18/2025 at 1:56 PM identified all the storage areas should be locked and not accessible to residents. The DNS further indicated the Maintenance Department is responsible for ensuring the above areas have functioning locks and indicated she/he would bring these concerns to their attention.
After inquiry on 2/18/2025 at 2:45 PM The Regional Clinical Director identified the Maintenance Department has fixed the locks on the lock secure unit (A/B wing) and staff will be doing quality checks on other floors/ units.
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, review of facility documentation, review of policy and staff interviews for 1 of 6 residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of policy and staff interviews for 1 of 6 residents (Resident #105) reviewed for nutrition, the facility failed to ensure a nutritional assessment included the resident's food preferences for a resident at risk for nutrition with a significant weight loss. The findings include:
Resident #105 was admitted on [DATE] with diagnoses that included diabetes mellitus and Adult Failure to Thrive (a syndrome in older adults characterized by progressive decline in physical and mental functioning).
A nutritional assessment dated [DATE] identified Resident # 105's meal preferences were obtained but the information did not indicate any specific resident preferences.
The quarterly MDS assessment dated [DATE] indicated Resident #105 as cognitively intact with adequate hearing and clear speech. The MDS assessment further indicated the resident required set-up or clean us assistance for eating and noted the resident had not experienced a significant weight loss during the look back period of the MDS.
A nutritional assessment dated [DATE] indicated dietary would initiate a selective menu for an expanded meal preferences base.
A review of Resident #105's weights identified the following:: on 10/07/2024 the residents weight was 138.7 Lbs, on 11/03/2024 the resident's weight was 123.8 Lbs (10.7% weight loss in one month).
A dietician's significant weight change note dated 11/11/2024 identified a significant weight loss had occurred and that the etiology of the weight loss was unclear. A twice-a-day dietary supplement was added as an intervention. However, there was no indication that Resident # 105's food preferences had been reevaluated or discussed with the resident when the significant weight loss had been identified.
A dietician's significant weight change note dated 12/06/2024 identified Resident #105 continued to trigger significant weight loss and the weight loss was likely related to poor appetite and varied by mouth intake ( PO) with a PO intake between 25% and 75%. The frequency of the nutritional supplement was increased from twice a day to three times a day as an intervention. There was no indication that the resident's food preferences had been reevaluated or discussed with the resident when PO intake was identified to be variable.
A care plan revised on 12/6/2024 indicated Resident #105 had nutritional risk related to inability to care for themselves. Interventions included honoring food preferences within meal plan and to offer alternate food choices if less than 50% was consumed at mealtime.
A dietician's significant weight change note dated 1/16/2025 identified Resident #105 continued to trigger significant weight loss and the weight loss were likely related to a history of poor appetite and varied PO intake. The dietician's note further indicated the resident's was on Remeron (a medication used to stimulate appetite) had been increased by the provider on 12/11/2024. Fortified cereal for breakfast was initiated as an intervention. There was no indication that the resident's food preferences had been reevaluated or discussed with the resident.
A dietician quarterly/significant weight change note dated 2/12/2025 indicated the dietician met with Resident #105 and the resident visually appeared thin. The note indicated Resident #105 had expressed she/he would not eat if they did not like the food and the resident had requested a peanut butter and jelly sandwich with breakfast, lunch and dinner. The dietician note indicated that the dietician met with the resident to discuss food preferences on 2/12/2024 (three months after the initial significant weight loss had been identified).
On 2/18/2025 at 1:19 PM observation of Resident #105 during dining identified the resident had consumed all of her/his peanut butter and jelly sandwich and had not consumed the main meal.
On 2/24/2025 at 12:38 PM during dining identified Resident #105 had consumed all of her/his peanut butter and jelly sandwich and all of the pasta. The resident indicated that she/he liked peanut butter sandwiches and pasta.
On 2/24/2025 at 10:27 AM an interview with the Food Service Director identified the Food Service Director or Food Service Supervisors would talk to residents about their food preferences on admission and with menu changes. Although requested, the Food Service Director was unable to provide Resident #105's food preferences from admission. Additionally, a review of the facility's dietary manager software with the Food Service Director identified the only food preferences for Resident #105 were food preferences placed on 2/12/2025.
On 2/24/2025 at 2:30 PM, an interview with the dietician indicated that the resident's body mass index (BMI) was 20.3 and that, in general, for the resident's age and weight, the resident's BMI should be 23 or higher; the goal for Resident #105 was a gradual weight gain. The dietician identified Resident #105's weight loss was related to no appetite and the resident did not always like the facility's food. The dietician further indicated for weight loss interventions, the facility takes a food-first approach where regular food is used to help a resident's nutritional status.
The food-first approach included taking the residents' food preferences into account to optimize food intake. The dietician indicated that she thought that food preferences were taken on admission. Additionally, the dietician indicated she did not speak to the resident about their food preferences after the significant weight loss was identified on 11/11/2024 until she met with the resident on 2/12/2025 (three months after the initial significant weight loss had been identified).
The facility policy for Nutrition/Hydration Care and Services last revised on 2/01/2023 identified on admission eating and drinking likes and dislikes are obtained. Additionally, the policy indicated the facility would develop an Interdisciplinary plan of care for enhancing oral intake, promoting adequate nutrition, and identifying individualized goals, preferences, and choices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, facility policy review and staff interview for 4 of 8 medication rooms observed (Unit 2A/B and 3 C/D), the facility failed to ensure stock medications were not expired. The find...
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Based on observations, facility policy review and staff interview for 4 of 8 medication rooms observed (Unit 2A/B and 3 C/D), the facility failed to ensure stock medications were not expired. The findings include:
Observation of medication stock rooms located on Unit 2A/B on 2/26/25 at 10:39 AM with RN#6 identified the following expired medications; 1 bottle of Aspirin 325 mg expired 8/24, Carbamide Peroxide ear drops 65% expired 12/24, and 3 Heparin Flush IV syringes expired 11/24.
Observation of medication stock rooms located on Unit 3 C/D on 2/26/25 at 10:50 AM with RN #6 identified a bottle of Aspirin 325 mg expired 8/24.
In with the Regional Director of Nursing and the Director of Nursing Services on 2/26/25 at 11:00 AM identified the process to ensuring that all medications are not expired consists of the Central Supply Office staff member who stocks the medication rooms look at the expiration dates of the stock. Central Supply Office staff member will move the newest medications to the back and bring the oldest medications to the front to ensure they are used first. However, there is no set process or frequency to review stock medications. In addition, the nurses should be checking the dates of the stock medications before placing them on their medication carts.
Review of the Medication Storage Policy, undated and currently in effect, directs in part, expired, discontinued, and/or contaminated medications will be removed from the storage areas and disposed of in accordance with facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
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 policy and interviews for 1 of 1 resident, (Resident #134) reviewed for dental,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy and interviews for 1 of 1 resident, (Resident #134) reviewed for dental, the facility failed to identify and provide emergency dental services for a resident who dentures were lost. The findings include:
Resident #134's diagnoses included vascular dementia, left sided hemiplegia and hemiparesis, and chronic pain syndrome.
The Resident Care Plan dated 9/1/23 identified Resident #134 exhibited or was at risk for oral health care. Interventions included monitoring for mouth pain and providing oral hygiene/mouth care twice per day and as needed.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #134 had no cognitive impairment, required clean-up assistance with eating, was at risk for malnutrition, and was dependent with rolling left and right.
A provider note dated 12/18/24 identified Resident #134 had no oral or mouth pain and was eating food provided to her/him by the facility. The note further identified the resident had a recent weight gain.
The facility Dental Group Schedule dated 1/2/25 identified Resident #132 was scheduled to see Dental Services on 1/2/25 within the facility in the Occupational Therapy room.
A dental note dated 1/2/25 identified Resident #134 had lost his/her dentures. The note further identified the facility was notified of the missing dentures and staff was instructed to look for them.
The quarterly MDS assessment dated [DATE] further identified Resident #134 was dependent with oral hygiene and had no broken or loosely fitting dentures or mouth pain.
An interview with Resident #134 on 02/19/25 at 11:16 AM identified he/she had lost his/her dentures, informed staff they were missing, and the dentures had not been located.
A review of the facility's grievance log for years 2024 and 2025 on 2/25/25 at 11:15 AM failed to identify and documentation Resident #134's dentures were missing.
An interview with Registered Nurse (RN) #3 on 2/25/25 at 11:41 AM identified nursing was responsible for reviewing completed dental notes, entering missing dentures into the grievance log, and notifying the nurse manager of the missing item.
An interview with RN #5 on 2/25/25 at 11:54 AM identified she was not made aware by nursing Resident #134's dentures were missing.
An interview with the Director of Nursing Services (DNS) on 2/25/25 at 12:24 PM identified the Assistant Director of Nursing Services (ADNS) was responsible for reviewing specialty provider notes after resident appointment. However, there was no ADNS currently employed by the facility. Until a new ADNS was hired, the nurse managers were responsible for reviewing the specialty provider notes after a resident was seen. The nurse managers were directed to review the Dental Group Schedule every day and review the notes for residents seen on that day.
The DNS further identified a resident who loses their dentures should receive a Speech Consultation for a dietary consistency downgrade, have an entry for their missing dentures placed in the grievance log, and receive an appointment with the dentist for new dentures if the dentures cannot be found.
Review of the Facility's Oral Health Policy failed to address the care and maintenance of dentures.
Review of the Facility's Personal Property policy identified any loss of a resident's personal item will be documented on a property loss form and an investigation by the administrator or designee will occur.
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 of the linen storage area and staff interviews, the facility failed to ensure clean linens were stored appropriately. The findings include:
On 2/25/2025 at 11:30 AM during a tou...
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Based on observations of the linen storage area and staff interviews, the facility failed to ensure clean linens were stored appropriately. The findings include:
On 2/25/2025 at 11:30 AM during a tour of the laundry with the Infection Control Nurse (ICN) identified food items in a room containing clean linen for the 11:00 PM to 7:00 AM shift. The linen was stored in open, partially filled linen carts. The food items included an empty can of orange soda, an empty bag of crackers, aluminum foil with yellow residue on it, a can of cashews with cashew crumbs inside, an open single-serve packet of mayonnaise that still contained mayonnaise, an open piece of a red candy cane, two plastic forks with residue, two packets of unopened tea bags, one unopened cough drop, one unopened packet of sugar. The top shelf had two clean incontinence pads and several clean folded towels. On the bottom section of the shelf, there were two clean curtains and a folded, clean fitted sheet. The ICN identified the food items, the medication bottle, and the nail polish should not have been stored there.
An observation and interview with the Director of Laundry/Housekeeping on 2/25/2024 at 11:35 AM indicated the food items should not have been stored there, and he did not know who the items belonged to. The Director of Laundry/Housekeeping indicated that the room was used to store linen for the 11:00 PM to 7:00 AM shift.
The facility policy for linen handling did not indicate whether open food items were allowed in the linen room. However, the facility employee handbook indicated the facility-provided employee lounges and breaks may not be taken in work areas, and food and drinks may only be consumed in designated areas.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of the facility Immunization Program and staff interviews for 2 of 4 residents (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of the facility Immunization Program and staff interviews for 2 of 4 residents (Residents #110 and # 164) reviewed for vaccination, the facility failed to ensure residents received annual education on influenza vaccines and obtain annual informed consent. The findings include:
1. Resident #110 was admitted on [DATE] with diagnoses that included Alzheimer's disease and heart failure. The quarterly MDS assessment dated [DATE] identified Resident #110 had severe cognitive impairment.
A record review and interview with the Infection Control Nurse (ICN) on 2/25/2025 at 11:00 AM failed to identify the administration of an influenza vaccine for the 2024-2025 season and failed to identify a written consent or refusal for the administration of the 2024-2025 influenza vaccine. The ICN was unable to indicate a reason why Resident #110 had not received an influenza vaccine for the 2024-2025 season.
2. Resident #164 was admitted on [DATE] with diagnoses that included dementia and cognitive communication deficit. A review of the facility admission record face sheet indicated Resident #164 had a Conservator of Person ( COP) who was the responsible party. The quarterly MDS assessment dated [DATE] identified Resident #164 was moderately cognitively impaired.
An influenza immunization informed consent form dated 10/31/2022 indicated Resident #164's COP gave verbal consent for annual influenza vaccination.
A review of Resident #164's immunization record identified on 11/01/2022, the resident received an influenza vaccination, and the resident's COP was given a Vaccination Information Sheet (VIS). The immunization record further indicated on 10/20/2023, the resident received an influenza vaccine and was given a VIS. On 10/22/2024, the resident was given an influenza vaccine, but there was no indication the resident or the resident's COP was provided education on the benefits and potential side effects of the influenza vaccine.
A nursing note dated 10/22/2024 indicated Resident #164 received an influenza vaccine but did not indicate if the resident or the resident's COP was provided education on the benefits and potential side effects of the influenza vaccine.
On 2/25/2025 at 11:00 AM an interview with the ICN indicated that if a resident is self responsible the facility would talk with the resident individually, and if the resident is conserved, the facility would contact the COP or responsible party and obtain a signed consent. The ICN indicated that once the consent for annual vaccination is signed the same consent is valid for future influenza vaccinations.
A review of the facility policy for Influenza Immunization indicated the facility would send a Vaccination Information Sheet (VIS) and a letter indicating if a consent was needed or already obtained to the resident or resident representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of policy and interviews for 1 of 7 residents ( Resident #102) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, review of policy and interviews for 1 of 7 residents ( Resident #102) reviewed for Environment, the facility failed to ensure a three-foot clearance was maintained around a resident's bed. The findings include:
Resident #102's diagnosis includes Type 2 diabetes mellitus. The quarterly MDS assessment dated [DATE] indicated in part Resident #102 was moderately cognitively impaired and independent for bed mobility and transfer.
An observation on 2/18/25 at 11:33 AM identified Resident #102 asleep in bed. The left side and foot of the bed was noted up against the wall.
An observation and interview on 2/25/25 at 1:48 PM with the Administrator identified Resident #102 in bed and asleep with a side of the bed against wall . The resident's foot of the bed close to the wall. After exiting the room, the Administrator indicated she/he had possession of some letters requesting waivers dated 2019 from the previous owner and would locate them for view. A discussion regarding the need for three-foot clearance surrounding the sides and foot of the bed and the potential of a bed against the wall might pose a restraint to a resident.
An interview and facility document review on 2/25/25 at 02:35 PM with the Administrator provided a therapy evaluation and the Minimum Data Set to show Resident #102 was independent with bed mobility and transfer. The Administrator also indicated Resident #106 stated to the administrator s/he liked the bed where it was. The Administrator provided a review of the facility documents from 2019 indicating a room similar in size to Resident #102's and a letter to the state agency to request a waiver. She/he also explained one of the beds in the room would need to be against the wall to allow enough room for a resident in a wheelchair to access the bathroom. The Administrator indicated the facility presently had no waivers for three-foot clearance for the two-bed rooms of this size and she/he had plans to convert these smaller rooms to single rooms but since that will take time he/she would apply for a waiver. The Administrator indicated s/he had conducted a room audit, and no other residents' beds were against the wall. A copy of the audit was requested but not provided.
Although a facility policy regarding bed clearance was requested the facility did not have a policy.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to include residents in updating care plans and provide advanced notification of changes to to the resident's care plans. The findings included:
1. Resident #63's diagnoses included End Stage Renal Disease, Dependence on Supplemental Oxygen, and an Acquired Absence of Right Leg Below the Knee.
The Resident Care Plan (RCP) dated 10/26/21 identified Resident #63 was independently capable of pursuing his/her own activities. Interventions included informing the resident of facility happenings and checking in to inquire if he/she needed anything.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact, required supervision with bathing, utilized a manual wheelchair for mobilization, and was independent with chair/bed-to-chair transfers.
A review of social service progress notes for the time period of 6/1/22 through 2/20/25 identified Care Plan meetings were held for the dates 6/3/24 (Attendees: Social Services, Nursing, and Resident #63), and 1/15/25 (Attendees: Unit Manager, Social Services, and Resident #63). The progress notes failed to identify Resident #63 had been invited to an RCP Meeting around the dates the MDS Coordinator identified for RCP scheduling of 7/13/23, 10/9/23, 12/15/23, 3/11/24, and 9/9/24, or had been included in the updating of his/her care plan.
An interview on 2/18/25 at 1:04 PM with Resident #63 identified he/she was informed about plans for his/her care after the fact. Resident #63 further identified he/she was invited to a RCP Meeting on 1/15/25 but he/she had not been invited to participate in a RCP Meeting during the three year time period prior to that meeting.
2. Resident #134's diagnoses included Peripheral Vascular Disease ( PVD), hemiplegia and hemiparesis affecting the left side, and chronic pain syndrome.
The RCP dated 7/15/21 identified Resident #134 had a Court-appointed Conservator. Interventions included involving the conservator in care planning and to involve the resident in his/her care planning discussions.
A review of social service progress notes for the time period 6/1/22 through 2/20/25 identified Care Plan meetings were held for the dates of 9/29/22 (Attendees: Social Work, and Conservator), 12/8/22 (Attendees: Social Work, and Conservator), 3/16/23 (Attendees: Social Work, APRN, and Conservator), 6/15/23 (Attendees: Social Services, APRN, and Conservator), 8/31/23 (Attendees: Dietician, Social Services, APRN, and Conservator), and 10/23/24 (Attendees: Social Services, Nursing, the APRN, Dietician, and Conservator). The Social Service progress notes failed to identify Resident #134 had been provided notification of any of his/her Care Plan meetings or been included in the updating of his/her care plan.
The quarterly MDS assessment dated [DATE] identified Resident #134 had intact cognition, was dependent with personal hygiene, dressing, and rolling left and right, and had been at the facility since March of 2021.
An interview with Resident #134 on 2/18/25 at 1:04 PM identified she/he was invited to his/her RCP Meeting on 10/23/24 but he/she had not been invited to participate in a RCP Meeting during the three year time period prior to that meeting.
3. Resident #153's diagnoses included Fracture of the Left Femur, repeated falls, and Benign Prostatic Hyperplasia (BPH).
The RCP dated 7/14/23 identified Resident #153 had a Court-appointed Conservator. Interventions included involving the Conservator in care planning and involving the resident in choices.
The quarterly MDS assessment dated [DATE] identified Resident #153 was cognitively intact, was dependent with dressing, required set up with eating, and utilized a manual wheelchair.
A review of the MDS Calendar for 8/1/23 through 2/20/25 identified the MDS Coordinator provided Social Services notification Resident #153 was due for a RCP Meeting on or around 10/26/23, 2/2/24, 4/29/24, 7/29/24, 10/17/24, and 1/16/25.
A review of Social Service progress notes for the time period of 7/1/23 through 2/20/25 failed to identify any RCP meetings for Resident #153 were held or that he/she had been included in the updating of his/her care plan.
An interview on 02/20/25 at 11:11 AM with the Director of Social Services identified both the MDS Coordinators and Social Services were responsible for ensuring RCPs were scheduled and residents were invited. He further identified that attempts to contact a representative or their responsible party regarding RCP Meeting dates are documented within a Social Service progress note. The Director of Social Services failed to identify a reason multiple RCPs were not held for Residents #63, #134, and #153 and why no notification was made to Residents #63, #134, and #153 about their RCP Meetings.
An interview with the DNS on 2/20/25 at 01:38 PM identified RCPs should be held upon admission, quarterly, yearly, and upon resident request. The DNS further identified residents should be invited to their RCP, even if there is a conservatorship in place for a resident, and the minutes of those meetings should be documented within Social Service progress notes. The DNS failed to identify why there were no RCP minutes documented for Resident #63, #134, and #153 within Social Service progress notes for multiple dates identified for RCP meetings to be held or why residents had not been invited to RCP Meetings.
An interview with the DNS on 2/24/25 at 9:58 AM identified she failed to locate any additional evidence /documentation that Residents #63, #134, and #153 were invited to or had a RCP meeting occur during the time period of 1/1/21 through 2/24/2025.
Review of the Facility's Person-Centered Care Plan Policy identified residents have the right to participate in the development of their care plan and be informed in advance of changes to their care plan. The policy further identified care plan meetings will be documented in a Care Plan Meeting Note and invitations to residents will be extended in advance of the Care Plan Meeting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review and staff interviews for 4 of 6 residents (Residents # 123) reviewed fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review and staff interviews for 4 of 6 residents (Residents # 123) reviewed for pressure ulcers and Resident # 136 who utilized a gait belt, and (Resident # 164) reviewed for hydration and (Resident #196) reviewed for discharge, the facility failed to ensure a residents care plans were revised to reflect the needs of each resident and for policy for 3 of 5 residents (Resident #63, #134, and #153) reviewed for Care Planning, the facility failed to provide advanced notice to residents of Care Plan Meetings, provide documentation that Care Plan Meetings were held, and ensure revisions to the care plan to reflected involvement of the resident. The findings included :
1. Resident #123's diagnoses included protein calorie malnutrition, peripheral vascular disease, left below the knee amputation and dementia.
A Braden skin risk assessment was completed on 6/9/2024 upon readmission identified at moderate risk for skin break down (score of 13).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #123's cognitive status was moderately impaired, required maximum assistance of staff for rolling to the right and left side while in bed, noted dependent on staff for transferring in and out of bed to the wheelchair, at risk for developing a pressure ulcer/injury and noted no pressure ulcers at the time the assessment was completed.
The care plan dated 1/6/2025 indicated in part, Resident #123 was at risk for skin breakdown Intervention included: to conduct weekly skin checks by a licensed nurse, preventative skin care including lotions, barrier creams as ordered.
A nursing progress note dated 1/15/2025 at 1:34 PM indicated Resident #123 was observed to have a new dark purple, non blanchable area on the right ankle with surrounding redness, the physician was notified and a new orders were obtained.
The physician's orders dated 1/15/2025 directed to offload the right leg with a pillow while in bed every shift, apply skin prep followed by a foam dressing daily and as needed to the right ankle Deep Tissue Injury (DTI) for 14 days and to have the wound physician evaluate the DTI during the next scheduled wound round.
Resident #123's care plan indicated at risk for skin breakdown identified additional interventions on 1/15/2025 to offload the right leg with a heel boot or pillow while in bed every shift, and to apply skin prep followed by a foam dressing to the right ankle DTI as ordered.
The wound physician's note dated 1/16/2025 indicated education was provided to facility staff regarding the need to provide pressure relief, general offloading and frequent repositioning.
A physician's order dated 1/16/2025 directed to apply a heel Medix boot (pressure relieving boot) to the right ankle even when Resident #123 was out of bed.
A Braden skin risk assessment was completed on 2/01/2025 identified Resident #123 to be at high risk for skin break down (score of 12).
An observation on 2/18/2025 at 11:45 AM identified Resident #123 up in an adaptive wheelchair with the right foot donned with a sock, turned laterally, resting inside the right wheelchair foot box.
An observation on 12/18/2025 at 12:48 PM identified Resident #123 noted seated in a wheelchair at a dining table with the right foot noted in the same position.
An interview and record review on 2/24/2025 at 1:20 PM with LPN # 1 ( skin integrity/wound nurse) identified the wound was identified on 1/15/2025, an investigation was conducted but did not indicate the cause factor of the unrelieved pressure which lead to the development of a deep tissue injury. Review of the clinical record with LPN #1 identified no evidence turning and repositioning was consistently performed on Resident #123 who required maximum assistance to turn in bed and was dependent for transfer to and from the wheelchair. Additionally, no interventions were identified in Resident #123's care plan to turn and reposition to prevent skin pressure.
An interview and record review with the Director of Nursing Services (DNS) on 2/25/2025 at 10:16 AM indicated from 12/18/2024 through 1/15/2025 when the DTI was identified (29 days later), no documentation of offloading of the heels or turning and repositioning was found. The DNS indicated the facility policy did not provide detailed measures to be put in place for each risk score. However, preventative measures for Resident #123 with a skin risk score of 12 or 13 should have included turning and repositioning, preventative skin care, pressure relieving boots, weekly skin checks and treatments as ordered by the physician all should have been included in the care plan.
2. Resident #136's diagnoses included Alzheimer disease, paranoid schizophrenia and hypertension.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident # 136 as severely impaired and requires maximal assistance with bed mobility, personal hygiene and partial assistance with toilet transfers. The MDS further indicated no restraints utilized.
The care plan dated 12/6/2024 identified Resident #136 demonstrates poor body alignment requiring use of custom wheelchair. Interventions included to report for any signs or symptoms of pain, fatigue, discomfort, poor tolerance while in custom wheelchair and report as indicated.
The physician's orders failed to reflect an order for Resident #136's pelvic positioning belt.
The Occupational Therapy ( OT) notes dated 1/17/2025 identified Resident #136 referral is due for his/ her custom wheelchair program to get a replacement wheelchair cushion, elevating leg rests and to allow for repairs to be made. Occupational Therapy notes had no mention/ recommendation for a pelvic positioning belt.
An in-person interview with OT #1 on 2/20/25 at 10:00 AM identified the belt on the wheelchair is called a pelvic positioning belt. She reported in some cases residents might receive a custom wheelchair. OT#1 identified residents who are believed to have concerns maintaining an upright position while in a wheelchair are assessed to see if the pelvic positioning belt is appropriate for them. Once determined, then the Residents Care Plan and physician's order would be updated to reflect recommendations. OT#1 further identifed Resident #136 was most recently assessed in January 2025 and it was determined that a Pelvic Positioning Belt was not appropriate for Resident #136.
Subsequent to inquiry, Resident #136 care plan was undated on 2/20/20/2025 to reflect Resident (#136) prefers to have seat belt remain attached to personal wheelchair despite not needing it. The resident does not require a belt at this time.
Observation of Resident #136 on 2/24/25 at 12:19 PM identified the resident with a pelvic belt on in hallway heading to dining room.
However, review of Resident # 136's care on 2/24/25 failed to reflect rationale for the utilization of the pelvic positioning belt.
An in-person interview with RN #4 on 2/24/25 11:42 AM identified staff relays on physician's orders and care plan to let them know if a pelvic positioning belt is required.
An in-person interview with OT#1 on 2/26/25 at 11:56 AM identified care plans should be updated right away once a recommendation is made. She further indicated she was unable to explain why the care plan was updated on 2/202/25. OT # also indicated nursing is responsible for updating care plan.
[NAME] Care Center Person Centered Care Plan (revised on 10/24/22) indicated in part that the care plan is to promote positive communication between patient, patient representative and team to obtain input into the plan of care to ensure effective communication and optimize clinical output.
3. Resident #164's diagnoses include dysphagia, moderate protein calorie malnutrition and dementia.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #164 had moderate cognitive impairment required set up for eating had no swallowing disorders and was on a therapeutic, mechanically altered diet.
A physician's order dated 2/17/2025 directed to infuse Dextrose-NaCL (Sodium chloride) solution intravenously (IV) at 70 cc per hour for two liters.
A physician's order dated 2/18/2025 directed to provide a house supplement with meals for poor oral intake three times daily.
A physician's order dated 2/20/2025 directed to infuse Dextrose-NaCL (Sodium chloride) solution intravenously (IV) at 65 cc per hour for two days.
Interview and clinical record review on 2/25/2025 at 10:00 AM with the DNS and the Regional Clinical Director indicated the care plan for Resident #164 had not been updated to reflect the need for intravenous hydration therapy but should have been.
4. Resident #196's diagnoses included dementia and cerebrovascular disease.
The social service notes dated from 3/11/2024 through 3/19/2024 indicated reaching out to other long term care facilities for transfer of Resident #196.
The annual Minimum Data Set (MDS) assessment dated [DATE] indicated in part no active discharge plan was in process.
The social service notes dated from 4/29/2025 through 4/30/2024 indicated social service was reaching out to other long term care facilities for transfer of Resident #196.
The quarterly MDS assessment dated [DATE] indicated in part, no active discharge plan was in process.
The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #196 was significantly cognitively impaired, the family was participating in the assessment and goal setting, and an active discharge plan was in place.
A nurse's note dated 12/11/2024 at 2:39 PM indicated Resident #196 was transferred to a health care center.
The discharge MDS assessment dated [DATE] indicated Resident #196 had a planned discharge without anticipation of returning to the facility.
An interview and record review on 2/26/2025 at 12:20 PM with the Director of Social Services (Social Worker # 1) indicated although no discharge care plan was initiated for Resident #196 one should have been.
The facility policy labeled Person-Centered Care Plan indicated in part the care plan should be customized to each resident's needs and preferences, be communicated to appropriate staff, be reviewed and revised by the Interdisciplinary Team after the completion of each assessment and as needed to reflect the response to changing needs and goals.
5. Resident #63's diagnoses included below the Knee amputation, Stage Chronic Kidney Disease, and dependence on renal dialysis.
The Resident Care Plan (RCP) dated 10/26/21 identified Resident #63 was independently capable of pursuing his/her own activities. Interventions included informing the resident of facility happenings and checking in to inquire if he/she needed anything.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #63 was cognitively intact, required supervision with bathing, utilized a manual wheelchair for mobilization, and was independent with chair/bed-to-chair transfers
A review of the MDS Calendar for 6/1/23 through 2/20/25 identified the MDS Coordinator provided Social Services notification that Resident #63 was due for a RCP Meeting on or around the dates of 7/13/23, 10/9/23, 12/15/23, 3/11/24, 6/6/24, 9/9/24, and 12/9/24.
Resident #63's RCP Meeting Sign in Sheets identified the resident had been invited to and attended a care plan meeting on 6/3/24 and 1/15/25. The facility failed to provide RCP Meeting Sign in Sheets around the dates of 7/13/23, 10/9/23, 12/15/23, 3/11/24, and 9/9/24.
A review of social service progress notes for the time period of 6/1/22 through 2/20/25 identified RCP meetings were held for the dates 7/3/24 and 1/15/25. The social service progress notes failed to identify a care plan meeting was held around the dates of 7/13/23, 10/9/23, 12/15/23, 3/11/24, and 9/9/24 and that revisions to the RCP reflected involvement of Resident #63.
An interview on 2/18/25 at 01:04 PM with Resident #63 identified he/she is informed about plans for his/her care after the fact. Resident #63 further identified he/she was invited to a RCP Meeting on 1/15/25 but he/she had not been invited to a RCP Meeting during the three year time period prior to that meeting.
An interview with the DNS on 02/24/25 at 09:58 AM identified that she failed to locate any additional documentation that Residents #63, #134, and #153 were invited to or had a RCP meeting occur during the time period of 1/1/21 through 2/24/2025.
6. Resident #134's diagnoses included knee amputation, chronic pain syndrome, and moderate protein calorie malnutrition.
The RCP dated 7/15/21 identified Resident #134 had a Court-appointed Conservator. Interventions included involving the conservator in care planning and to involve the resident in his/her care planning discussions.
A review of the MDS Calendar for 6/1/22 through 2/20/25 identified the MDS Coordinator provided Social Services notification that Resident #134 was due for a RCP Meeting on or around 3/29/23, 6/1/23, 8/31/23, 11/27/23, 3/1/24, 5/24/24, 8/20/24, 11/19/24, and 1/24/25.
A review of social service progress notes for the time period of 6/1/22 through 2/20/25 identified RCP meetings were held for the dates of 9/29/22, 12/8/22, 3/16/23, 6/15/23, 8/31/23, and 10/23/24. The social service progress notes failed to identify a RCP meeting was held around the dates 11/27/23, 3/1/24, 5/24/24, 8/20/24, and 1/24/25 and that revisions to the RCP reflected involvement of the resident.
The Quarterly MDS assessment dated [DATE] identified Resident #134 had intact cognition, was dependent with personal hygiene, dressing, and rolling left and right, and had been at the facility since March of 2021.
An interview with Resident #134 on 02/19/25 at 11:15 AM identified he/she is not invited to RCP Meetings.
An interview on 2/20/25 at 11:11 AM with the Director of Social Services identified both the MDS Coordinators and Social Services were responsible for ensuring RCP's were scheduled. He further identified that attempts to contact a representative or their responsible party regarding RCP Meeting dates are documented within a Social Service progress note. The Director of Social Services failed to identify a reason multiple RCP's were not held for Residents #63, #134, and #153 and why no notification was made to Resident # 134 about his/her RCP Meetings.
7. Resident #153's diagnoses included fracture of the left femur, liver disease, and hypertension.
The RCP dated 7/14/23 identified Resident #153 had a Court-appointed Conservator. Interventions included involving the Conservator in care planning and involving the resident in choices.
The Quarterly MDS assessment dated [DATE] identified Resident #153 was cognitively intact, was dependent with dressing and moving from a sitting lying position, and utilized a manual wheelchair.
RCP Meeting Sign in Sheets for Resident #153 identified he/she had been invited to but declined to attend a RCP meeting on 10/30/24. The facility failed to provide any additional RCP Meeting Sign in Sheets for the dates of July of 2023 through February of 2025.
A review of the MDS Calendar for 7/1/23 through 2/20/25 identified the MDS Coordinator provided Social Services notification that Resident #153 was due for a RCP Meeting on or around 10/26/23, 2/2/24, 4/29/24, 7/29/24, 10/17/24, and 1/16/25.
A review of social service progress notes for the time period of 7/1/23 through 2/20/25 failed to identify any RCP meetings for Resident #153 were held and that revisions to the RCP reflected involvement of the resident.
An interview on 02/20/25 at 11:11 AM with the Director of Social Services identified both the MDS Coordinators and Social Services were responsible for ensuring RCP's were scheduled. He further identified that attempts to contact a representative or their responsible party regarding RCP Meeting dates are documented within a Social Service progress note. The Director of Social Services failed to identify a reason multiple RCP's were not held for Residents #63, #134, and #153 and why no notification was made to Residents #63, #134, and #153 about their RCP Meetings.
A joint interview with MDS Coordinators #1 and #2 on 2/20/25 at 11:20 AM identified that the MDS Coordinators are responsible for creating and emailing a monthly calendar to Social Services as notification RCP's are due for Residents. Staff members the calendar is sent to include Social Services, Medical Providers, Nursing, Recreation, Therapy, Dietary, and the facility Secretary.
An interview with the Director of Nursing Services (DNS) on 02/20/25 at 01:38 PM identified that RCP's should be held upon admission, quarterly, yearly, and upon resident request. The DNS further identified Residents should be invited to their RCP, even if there is a conservatorship in place for a resident, and the minutes of those meetings should be documented within Social Service progress notes. The DNS failed to identify why there were not RCP minutes documented for Resident #153 within Social Service progress notes for multiple dates identified for RCP meetings to be held.
An interview with the DNS on 2/24/25 at 09:58 AM identified that she failed to locate any additional documentation that Resident #134 were invited to or had a RCP meeting occur during the time period of 1/1/21 through 2/24/2025.
Review of the Facility's Person-Centered Care Plan Policy identified that residents have the right to participate in the development of their care plan and be informed in advance of changes to their care plan. The policy further identified care plan meetings will be documented in a Care Plan Meeting Note and invitations to residents will be extended in advance of the Care Plan Meeting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations of the kitchen, review of facility documentation, review of policy and staff interviews, the facility failed to ensure the kitchen was clean and sanitary and kitchen equipment wa...
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Based on observations of the kitchen, review of facility documentation, review of policy and staff interviews, the facility failed to ensure the kitchen was clean and sanitary and kitchen equipment was operating properly. The facility also failed to consistently monitor temperature logs and ensure food items were dated and labeled. The findings included:
1 . a. An observation and interview with the Dietary Manager on 2/18/2025 starting at 10:15 AM and ending at 11:15 AM identified water and food debris on the floor under the prep sink area that had two open drains directly draining dirty water onto the kitchen floor near a floor drain.
The Dietary Manger identified the sink drain strainer help to keep the food debris from going down the drain was missing and needed to be replaced which caused the drains to empty directly onto the floor and the fluid is expected to reach and go down the floor drain. The Dietary Manager pointed out some tiles on the floor in the prep sink area that were missing from the repeated water buildup. S/he further indicated the facility has no basement and the kitchen floor would require excavation and plumbing to be laid to correct the drainage. This had previously been done in the other part of the kitchen to correct drainage issues.
b. The Kitchen Manager provided a demonstration of the coffee maker/serving appliance overflow grate, the fluid drained directly onto the floor then flowed several feet to another floor drain located within a frequently walked area by the staff of the kitchen. The Dietary Manager also indicated they try not to get any fluid into the overflow grate to prevent the flow of water onto the floor.
2. Observation of the walk-in refrigerator thermometer inside identified the device was broken but another thermometer was found in another area of the walk-in. The Dietary Manager indicated having many spare thermometers to replace the broken ones as it occurs often. Observation of a stand-alone refrigerator freezer located near the stove had a broken thermometer inside and no thermometer inside the freezer which contained a solid, clear bag, of frozen vegetables. However, the stand-alone refrigerator/freezer had one temperature list for the month of February 2025 which the Dietary Manager indicated contained refrigerator temperatures that was labeled Freezer temperatures. No temperature log or documented temperatures from 2/1/ 25 through 2/18/25 (17 days) for the freezer were located. The Dietary Manger indicated the wrong temperature log was posted and no freezer temperatures had been taken or logged. After the surveyor inquiry, the Dietary Manager indicated she/he would immediately post the correct temperature logs and place a new thermometer in the freestanding refrigerator and a thermometer in the freezer.
3. On 2/22/2025 starting at 11:30 AM observation of the kitchen staff conducting meal plating and tray line was done. The Dietary Manager and surveyor followed the last meal cart to the 3rd floor at 12:50 PM. At 12:53 PM. Observation and interview with the Dietary Manager of the refrigerator inside the locked kitchenette on the C-D unit found many food items from outside sources/resident food items either not labeled, labeled with only the resident name and room number and no dates. The Dietary Manager indicated the dietary department was responsible for what they place inside each kitchenette refrigerator and at this time it would be one sandwich which was labeled appropriately and indicated items are good for 3 days. An observation and interview with the charge nurse, LPN #7 indicated visitors and residents should be alerting staff if food items are brought into the facility. However, LPN# 7 indicated she/he was not sure who was responsible for labeling and dating the items.
An interview and facility policy review with the Director of Nursing Services (DNS) on 2/22/2025 at 1:50 PM indicated the dietary department was responsible for ensuring that all food items were appropriately dated including food brought in from outside the facility. She/he also indicated the process would need to be reviewed.
The facility policy labeled Food Storage indicated, in part, every refrigerator must be equipped with an internal thermometer and the refrigerators and freezers temperatures should be checked at least twice daily and frozen foods checked for firmness to ensure items are frozen solid.
The facility policy labeled Food Brought in from Outside Sources and Personal Food Storage indicated in part, foods and beverages brought in from outside sources requiring refrigeration or freezing would be labeled with the resident's name, the date, and stored in the refrigerator/freezer apart from facility food.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0570
(Tag F0570)
Minor procedural issue · This affected most or all residents
Based on review of the facility's Personal Funds Account, review of facility documentation, facility policy and interview, the facility failed to ensure necessary coverage through a Surety Bond for th...
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Based on review of the facility's Personal Funds Account, review of facility documentation, facility policy and interview, the facility failed to ensure necessary coverage through a Surety Bond for the Resident Trust Accounts. The findings include:
On 2/26/25 at 10:35 AM, interview and review of the Resident Trust Account (RTA) balances with the Financial Counselor indicated that the RTA balance for the period of 1/1/25 through 1/31/25 ranged from $ 111,410.22 dollars to $127,323.20.
Additionally, the RTA balance for the period of 6/1/24 through 6/30/24 indicated a balance ranging from $0.00 to $188,943.55.
The RTA balance for the period of 7/1/24 through 7/31/24 identified a balance ranging from $3,506.39 to $304,637.38 during that time.
The RTA balance for the period of 8/1/24 to 8/31/24 identified a balance ranging from $108,945.31 to $121,039.58 during that time.
The RTA balance for the period of 9/1/24 through 9/30/24 identified a balance ranging from $100,666.54 to $126,223.64 during that time.
The RTA balance for the period of 10/1/24 through 10/31/24 identified a balance ranging from $103,754.05 to $115,255.42 during that time.
The RTA balance for the period of 11/1/24 through 11/30/24 identified a balance ranging from $109,560.51 to $123.370.77 during that time.
Furthermore, the RTA balance for the period of 12/1/24 through 12/31/24 indicated a balance ranging from $114,755.85 to $124,220.07.
Review of the facility's surety bond identified the Resident Trust Accounts were insured for $100,000 effective June 3, 2024, through June 3, 2025.
An interview with the Administrator on 2/26/25 at 11:57 AM identified the facility does not regularly monitor if the Resident Trust Account $100,000 Surety bond coverage was adequate and indicated she/he was unaware that the Resident Trust Account regularly exceeds the $100,000 coverage limit. After surveyor's inquiry, the Administrator indicated she/he was going to reach out to the Regional Director of Operations to reach out to the Comptroller raise the Surety Bond amount to cover Resident Funds.
Subsequent to surveyor inquiry, on 2/27/25 the facility retroactively increased the amount of their Surety bond to $250,000.00 effective 6/3/24. The $250,000.00 amount of the Surety bond was still not sufficient funds to cover the period of 7/1/24 through 7/31/24 which identified a balance ranging from $3,506.39 to $304,637.38.
Review of the Surety Bond policy dated 3/21 identified a surety bond guarantees compensation for any loss of a resident's funds that the facility holds, accounts for, safeguards, and manages. Further, the policy stated all funds entrusted to the facility are covered by the surety bond.
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
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, facility policy and interviews for one (1) of three (3) samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility by a licensed nurse. The findings include:
Resident #2's diagnoses included paraplegia (immobility of upper or lower extremities),
Depression, chronic pain syndrome,
A physician's order dated 6/26/24 directed to administer Oxycodone 5 milligrams (mg), one (1) tablet every eight (8) hours as needed for pain.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place and time.
The Resident Care Plan dated 8/17/24 identified cirrhosis (liver disease) relating to chronic pain, obesity, and inability to self-turn.
Interventions directed to evaluate for pain, and to encourage the resident to request pain medication before the pain became severe.
The Facility Reported Incident form dated 10/11/24 identified a charge nurse reported she believed a card of controlled medication was missing from the medication cart. The summary report dated 10/18/24 identified on 10/11/24 a 3-11PM charge nurse thought there may be a missing card from the control count despite all counts being accurate. After interviews were conducted, it was determined a card of Oxycodone 5 mg which had nineteen (19) tablets for Resident #2 was no longer in the count and the corresponding disposition sheet was no longer in the record. Upon further check, the shift change log, which counts the cards as well as the disposition sheets for 10/8/24 through day shift 10/10/24, was also missing. The video surveillance footage was reviewed.
Review of the video timeline collected by the Director of Nursing dated 10/10/24 from 11:39 PM through 10/11/24 5:41 AM captured a 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #3, frequenting the medication room, standing at the medication cart, reviewing the controlled substance book, placing papers in her personal bag and in the trash, and frequently went into the restroom. On 10/11/24 at 3:31 AM the video identified LPN # 3 going into her bag putting something in her mouth and at 5:31 AM LPN #3 was viewed leaving the unit.
In an interview with the Director of Nursing (DON) on 11/4/24 at 9:30 AM she identified on 10/11/24 a charge nurse, LPN #1, reported during the medication shift count with the evening charge nurse, LPN #2, a blister pack of Oxycodone and the corresponding disposition sheet were missing. The DON stated she began an investigation, including staff interviews, review of the medication cart and count sheets, alerting the local police, and a review of the video footage. The DON identified after the video review, LPN #3 was identified as the 11PM -7AM nurse on 10/10/24-10/11/24 that had taken Resident #2's Oxycodone, LPN #3 left her shift early, handing the keys to the Nursing Supervisor, and leaving without counting and documenting the controlled medications in the logbook.
In an interview with the 7AM-3PM charge nurse, LPN #1, on 11/4/24 at 10:58 AM identified she reported to the DON on 10/11/24 a missing blister pack of Oxycodone and the correlating count sheet. LPN #1 stated she was very familiar with Resident #2's medications and knew there should have been a blister pack with nineteen (19) Oxycodone in the medication drawer.
In an interview with the 3-11PM charge nurse, LPN #2, on 11/4/24 at 11:04 AM she identified during the first medication pass of the evening she found an empty blister pack belonging to Resident #2 in a different resident's medication drawer and she gave the empty package to the DON.
In an interview with Person #1 on 11/5/24 at 1:11 PM identified LPN #3 confessed to removing the controlled medication from this facility and two (2) other facilities as well.
Review of the Abuse and Neglect Policy directed Misappropriation of Property or Funds:
The deliberate misplacement, exploitation or wrongful temporary or permanent use of a residents' personal belongings or money without the residents' consent.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2) who...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation and interviews for 1 of 3 sampled residents (Resident #2) who were reviewed for the misappropriation of personal property, the facility failed to ensure shift to shift count of the controlled medications was conducted by two (2) licensed nurses when one (1) nurse left before the shift ended and at the change of shift. The findings include:
Resident #2's diagnoses included paraplegia (immobility of upper or lower extremities),
Depression, chronic pain syndrome,
A physician's order dated 6/26/24 directed to administer Oxycodone 5 milligrams (mg), one (1) tablet every eight (8) hours as needed for pain.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place and time.
The Facility Reported Incident form dated 10/11/24 identified a charge nurse reported she believed a card of controlled medication was missing from the medication cart. The summary report dated 10/18/24 identified on 10/11/24 a 3-11PM charge nurse thought there may be a missing card from the control count despite all counts being accurate. After interviews were conducted, it was determined a card of Oxycodone 5 mg which had nineteen (19) tablets for Resident #2 was no longer in the count and the corresponding disposition sheet was no longer in the record. Upon further check, the shift change log, which counts the cards as well as the disposition sheets for 10/8/24 through day shift 10/10/24, was also missing. The video surveillance footage was reviewed.
The Controlled Medication Shift Change Log dated 10/11/24 for the change of shift night, 11PM-7AM to day shift, 7AM-3PM identified the shift-to-shift count by two (2) licensed nurses was not documented as being conducted.
In an interview with the Director of Nursing (DON) on 11/4/24 at 10:20 AM identified LPN #3 left her shift on 10/11/24 at 6:00 AM, handing the keys to the 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #1. The DON stated a shift-to-shift count of the controlled medications was not conducted before LPN #3 left at 6:00 AM with RN #1and RN #1 who left at 7:00 AM failed to count the controlled medications with the oncoming 7AM-3PM nurse charge nurse, LPN #1. The DON identified there should always be a shift-to-shift count of the controlled medications with the nurse going off shift and the oncoming nurse.
In an interview with LPN #1 on 11/4/24 at 10:58 AM identified she went to RN #1's office on 10/11/24 at 7:00 AM to retrieve the keys, and RN #1 left the shift before conducting a shift-to-shift count with her. LPN #1 stated she reported to the DON on 10/11/24 a blister pack of Oxycodone and the correlating disposition sheet were missing when conducting a shift-to-shift count with the 3-11PM charge nurse, LPN #2. LPN #1 identified she was very familiar with the Resident #2's medications and knew there should have been a blister pack with nineteen (19) Oxycodone tablets in Resident #2's medication drawer.
In an interview with LPN #2 on 11/4/24 at 11:04 AM identified during the first medication pass of the evening she found an empty blister pack belonging to Resident #2 in with a different resident's medication drawer and she gave the empty package to the DON.
Although attempted, an interview with RN#1 was not obtained.
Review of the Management of Controlled Medications policy directed a complete count of all Schedule II-IV controlled substances is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses and/or authorized nursing personnel, per state regulations.
May 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
Deficiency F0559
(Tag F0559)
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 policies and interviews for one of three sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #2) who exhibited behavioral symptoms towards others and required transfer to the hospital for treatment, the facility failed to notify and provide a thirty (30) day notice of the resident's room change prior to the resident's re-admission to the facility. The findings include:
Resident #2's diagnoses included dementia with agitation, Parkinson's Disease, and psychotic disorder with hallucinations due to known physiological condition.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall deficits and had not exhibited behavioral symptoms in the past seven (7) days.
The Resident Care Plan dated 4/19/24 identified that Resident #2's thought process was impaired due to dementia and the resident would periodically demonstrate verbal and physical outbursts.
Interventions directed medications as ordered, psychiatric and behavioral health consults as needed, redirection for the resident, and provision of a structured routine.
The psychiatric evaluation note dated 4/29/24 written by the Advanced Practice Registered Nurse (APRN) #1 identified Resident #2 was seen for evaluation due to behavioral escalation and increased agitation after throwing ice cubes onto the roommate's bed while the roommate was in the bed without provocation. The evaluation identified Resident #2 was alert and oriented, restless, and agitated, seemed confused and in no distress, and Resident #2 denied suicidal or homicidal ideation. The note indicated APRN #1 directed to administer Seroquel 25 milligrams (mg) every twelve (12) hours as needed for increased agitation and obtain urine specimens for urinalysis and culture and sensitivity.
The 3-11PM nurse's note dated 4/29/24 written at 11:02 PM identified at 3:30 PM a nurse aide reported to the charge nurse Resident #2 had thrown a pitcher of ice and water at his/her roommate. The note indicated Resident #2's roommate stated Resident #2's behaviors had been escalating all afternoon and he/she was hoping Resident #2's behavior would settle down. The note indicated psych services was in to see Resident #2. The note identified Resident #2 was transferred to the hospital for further evaluation and treatment.
The readmission note dated 5/3/24 written by the Nurse Practitioner (NP) identified Resident #2 was hospitalized from [DATE] to 5/3/24 for acute hypoxic respiratory failure. The note indicated Resident #2 explained he/she was unhappy about being moved from the third to the fourth floor and was requesting to go back to his/her previous room.
Interview with the Director of Nursing (DON) on 5/13/24 at 3:00 PM identified Resident #2's room was changed due to the request of Resident #2's roommate. The DON identified there was an altercation on 4/29/24 which was investigated, and Resident #2 had hit ice off of the bedside table at the roommate. The DON indicated Resident #2's roommate did not feel this was intentional, however requested Resident #2 not return to the same room upon return from the hospital because Resident #2 had been getting more and more agitated. The DON stated the Interdisciplinary Team (IDT) met to discuss this request and the decision was made to move Resident #2 upon return from the hospital. The DON identified although Resident #2's conservator was contacted to get consent for the move Resident #2 was not notified of the room change prior to the move and she was not aware Resident #2 voiced displeasure about the room change to the Nurse Practitioner. The DON indicated she was unable to provide documentation regarding the notification and agreement of the room change.
Interview with the Director of Social Services on 5/13/24 at 3:30 PM identified he was not aware of the room change for Resident #2 on 5/3/24 because he was not working when the IDT made the room change decision. The Director of Social Services stated the process of a room change was to consult with the resident and the conservator and discuss the plan and even if the conservator agrees with the plan the resident has the right to refuse the move. The Director of Social Services identified if the resident refused to move the IDT would meet and try to come up with an alternative solution. The Director of Social Services indicated Resident #2's room should not have been changed while Resident #2 was hospitalized . The Director of Social Services was unable to provide documentation regarding a notice of the room change and the agreement of such move and he was unaware Resident #2 was not happy about having his/her room changed.
Review of the facility policy for Room Changes identified notification of a room change would be provided within the required state regulatory time frame. The policy further identified the resident had a right to refuse transfer to another room. The room change process directed Social Services processed and coordinates all room changes.
Review of the facility policy for Resident Rights directed the facility must promptly notify the resident of a room change. The policy further identified the resident has the right to receive written notice, including the reason for the room change before the resident's room in the facility is changed.
Mar 2024
6 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
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, policy review, and interviews for one of three residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, policy review, and interviews for one of three residents (Resident #1) reviewed for medication errors, the facility failed to ensure medications were administered in accordance with physician orders, resulting in a significant medication error and hospital admission. The failures resulted in a finding of Immediate Jeopardy. The finding includes:
Resident #1's diagnoses included epilepsy, cerebral palsy, and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified Resident #1 had a gastrostomy tube (G-tube for feeding feeding), was alert, responsive, incoherent, able to answer yes/no questions, and the medication list was reviewed with the provider.
Review of the admission orders from APRN #1 dated 2/29/2024, directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Dilantin (used to prevent seizures) 100 milligrams (mg) daily (at 9 AM), Dilantin 150 mg daily (at 9 PM), Clobazam (used to prevent seizures) 15 mg daily (1.5 tabs) every evening (at 8 PM), Lamotrigine (used to prevent seizures) 400 mg twice a day (at 9 AM and 9 PM) and Zonisamide (used to prevent seizures) 50 mg (3 capsules) daily (at 9 AM).
Review of facility documentation dated 2/29/2024 identified that RN#2 activated admission orders which notifies the Pharmacy to deliver the medications to the facility.
Review of the medication administration record (MAR) dated 2/29/2024 identified the 9 PM medications were coded as HD to indicate hold, and to see nursing notes.
Review of the MAR dated 3/1/2024 identified the medications were coded as HD and NN for the 9 AM medications, to indicate see nursing notes for the scheduled medications.
Review of the facility incident report dated 3/1/2024 identified Resident #1 did not receive Dilantin 150 mg, Clobazam 15 mg, and Lamotrigine 400 mg on 2/29/2024 at 9 PM and did not receive Dilantin 100 mg, Lamotrigine 400 mg, and Zonisamide on 3/1/2024 at 9 AM, and Clobazam 15 mg on 3/1/2024 at 9 PM in accordance with physician orders (seven doses of anti-seizure medication were not administered).
Nursing note (authored by RN #4) dated 3/1/2024 at 10:36 AM identified APRN #1 was notified of the missed evening medications (2/29/2024).
Review of APRN #1's note dated 3/1/2024 identified Resident #1 was seen after admission from the hospital and had a history of Epilepsy. Per nursing report, resident missed some medications last night due to the timing of his/her arrival, and all scheduled medications were given in the morning.
A nursing note (authored by LPN #2) dated 3/1/2024 at 10:39 PM identified Clobazam was not received from the pharmacy and the APRN was notified to send another script (prescription).
Record review failed to identify Resident #1 received Clobazam on 2/29/2024 and 3/1/2024 as prescribed.
A nursing note dated 3/2/2024 at 3:01 AM identified the resident had a change in condition with nausea, vomiting, and seizure activity of less than one (1) minute. New orders were obtained for Zofran (treat vomiting).
Review of the physician's order dated 3/2/2024 directed Zofran 4 mg tablet via G-tube every six (6) hours as needed for nausea and vomiting.
A nursing note (authored by RN #5) dated 3/2/2024 at 6:21 AM identified Resident #1 had two (2) seizure occurrences last night, one about midnight and another about 5:45 AM, first less than two (2) minutes, second with vigorous body shaking and tilting head, vomited twice and Zofran was given. Resident #1 sustained a slight cut to the right forehead above the nose, the APRN was notified, and a call was placed to the pharmacy to deliver Clobazam STAT (immediately).
A nursing note (authored by RN #6) dated 3/2/2024 at 8 AM identified at 7:40 AM, Resident #1 was observed on his/her knees on the floor, upper body leaning on the bed, and staff reported a seizure. Resident was noted unresponsive, left eye fixed, bilateral upper extremities elbows bent with arms folded up toward chest and fists clenched. APRN was notified, new order to transfer to hospital, and when the ambulance arrived Resident #1 had another seizure that lasted approximately one (1) minute.
Review of Emergency Medical Services (EMS) run sheet dated 3/2/2024 at 7:52 AM identified Resident #1 was observed on the ground in a fetal position with contractures to the upper extremities and was on oxygen at three (3) liters per minute via a nasal cannula. Staff reported a history of seizure disorder, resident was unresponsive to verbal and painful stimuli, pulse was 121, blood pressure recorded at 104/systolic not recorded, breathing adequately with a blood oxygen level of 97% (normal 90% and above). Skin was warm, sweaty, and Resident #1 was observed to begin having a full tonic clonic seizures (stiffening and jerking movements) that lasted approximately one (1) minute. While enroute to the hospital Resident #1's blood oxygen level decreased to 79%, was placed on a non-rebreather mask at 15 liters oxygen and arrived at the hospital at 8:31 AM.
Review of the Hospital record dated 3/2/2024 identified Resident #1 had a history of aspiration pneumonia, cerebral palsy and seizures, and presented after being found at the facility curled in a fetal position. The resident was unresponsive, intubated and admitted to the ICU. Hospital lab results dated 3/2/2024 identified the resident's Clobazam level collected at 6:37 PM was under 10 nanograms/millilter (ng/ml) (normal 30 to 300). The hospital note dated 3/7/2024 identified Resident #1 was admitted to the hospital for seizures due to missed anti-epilepsy drugs at the facility.
Resident #1 remained in the hospital at the time of this survey.
Review of the facility admission Check list identified the physician orders were completed by the next shift nurse (not the admitting nurse). The form had a space for the admitting nurse to check to identify the orders were reviewed and completed, a space for the next shift nurse to double check the orders, and a clinical meeting review to be checked off. Review of the form identified the only medication review/orders was completed by the next shift nurse; the review was not completed by the admitting nurse or during the clinical meeting review.
Interview, clinical record review and facility documentation review with the DON and Regional RN #3 on 3/7/2024 at 1:04 PM identified Resident #1 did not receive the medications as listed in the incident report (seven doses of anti-seizure medications were omitted) because the medications were ordered from the pharmacy on 2/29/2024 at 9:22 PM for routine delivery (due to be delivered the next day after 2 PM) and they should have been ordered for STAT delivery. The DON and Regional RN #3 stated although the facility did not have a policy that directed new admission medications to be ordered STAT, the facility process was to order all new admission medications as STAT by calling the pharmacy. The DON indicated the Clobazam was additionally delayed because it needed to be reordered in liquid form. The DON identified staff should have completed the medication order review upon admission, completed a second check and then should have completed a third review during the clinical meeting the next day. The DON identified if the second and third checks were completed, the errors could have been identified sooner and the medications could have been ordered for faster delivery.
Interview, clinical record review and facility documentation review with Pharmacist #2 on 3/7/2024 at 2:26 PM identified the medications were ordered as a routine delivery on 2/29/2024 after 9 PM and were scheduled for delivery on 3/1/2024 after 2 PM. Pharmacist #2 indicated the medications were delivered to the facility at 2:27 PM, with the exception of the Clobazam because they were waiting for a script for a liquid medication which was delivered on 3/2/24, following the resident discharge to the hospital.
Interview, clinical record review and facility documentation review with RN #2 on 3/7/2024 at 2:05 PM identified although she activated Resident #1's orders in the electronic record on 2/29/24 to order them from the pharmacy, she did not order the medications STAT. RN #2 indicated new admission orders should be placed STAT, and she was unable to explain why they were not ordered STAT.
Interview, clinical record review and facility documentation review with APRN #1 on 3/7/2024 at 3:10 PM identified he documented in his note dated 3/1/2024 that last antiseizure medications were not administered on 2/29/2024 and was informed the medications were given the morning of 3/1/2024, he subsequently was notified that the medications were never given, and Resident #1 was admitted to the hospital due to seizure activity related to the omitted medications as listed above.
Interview and clinical record review with the Medical Director on 3/11/2024 at 9:26 AM identified he reviewed the clinical record and believed the hospital should have administered the doses that were due on 2/29/2024, however the facility failed to order the medications from the pharmacy for timely receipt. Further, the Medical Director indicated the missed medications could contribute to the cause of the seizures and hospital admission.
Facility documentation review identified staff education was initiated on 3/4/2024 that all new admission medication orders are to be ordered STAT from the pharmacy by placing a call to the pharmacy, and when a medication is not available for administration, the provider must be notified. Audits were initiated on 3/4/2024, and a QAPI meeting was held on 3/4/2024. Based on review of facility documentation, past non-compliance was identified.
Review of facility Medication: Administration: General Policy directed in part, if a medication is not available the nurse will coordinate with the pharmacy to procure the medications as soon as possible and discuss possible substitutions options with the pharmacist, to notify the physician of the unavailability of the medications and discuss substitution options if applicable. The Policy further directed if unable to provide the medication or substitutions within one hour of the prescribed time, refer to Medication Error Policy.
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
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, facility documentation review, facility policy review, and interviews for one of three resident...
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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 residents (Resident #1) reviewed for medication errors, the facility failed to ensure the APRN was notified timely of medication omission. The findings include:
Resident #1's diagnoses included Epilepsy, Cerebral Palsy, gastrostomy status (with tube feeding), and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified that Resident #1 was alert, responsive, incoherent and able to answer yes/no questions, and the medication list was reviewed with the provider.
A physician's order dated 2/29/2024 directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Dilantin (used to prevent seizures) 100 milligrams (mg) daily (at 9 AM, Dilantin (used to prevent seizures) 150 milligrams (mg) daily (at 9 PM) PM, Clobazam (used to prevent seizures) 15 mg daily every evening (at 8 PM), and Lamotrigine (used to prevent seizures) 400 mg twice a day (at 9 AM and 9 PM).
The Resident Care Plan (RCP) dated 3/1/2024 indicated Resident #1 required assistance with ADLs due to Cerebral Palsy and Epilepsy. Interventions directed to provide assistance.
Review of facility incident report dated 3/1/2024 identified Resident #1 did not receive Dilantin 150 mg, Clobazam 15 mg, and Lamotrigine 400 mg on 2/29/2024 at 9 PM, and APRN #1 was notified at 10:59 AM and the Medical Director was notified at 11:02 AM. Additional facility incident report dated 3/1/2024 identified Resident #1 did not receive Dilantin 100 mg and Lamotrigine 400 mg on 3/1/2024 at 9 AM on 3/1/2024, and the Medical Director and APRN #1 were notified at 11:13 AM.
Nursing note dated 3/1/2024 at 10:36 AM identified the APRN was notified of the missed evening medications, APRN saw Resident #1 and no ill effects were identified. New orders were obtained to monitor vital signs for 72 hours and monitor for ill effects.
Clinical record review failed to identify the APRN/physician was notified of the missed medications on 3/1/2024.
Interview, clinical record review and facility documentation review with the DON and Regional RN #3 on 3/7/2024 at 1:04 PM identified the APRN should have been notified of all the omitted medications. Although the APRN was notified of the medications omitted on 2/29/2024, the APRN was not notified of the omitted medications on 3/1/2024, staff should have updated him, and interview failed to identify why the APRN was not updated timely.
Interview and record review with APRN #1 on 3/7/2024 at 1:45 PM identified although he was notified Resident #1 did not receive the Dilantin 150 mg, Clobazam 15 mg, and Lamotrigine 400 mg on 2/29/2024, he was not notified Resident #1 did not receive Dilantin 100 mg and Lamotrigine 400 mg on 3/1/2024 at 9 AM. APRN #1 indicated he would have wanted to be notified, and if he was notified, he would have given additional orders.
Interview with the Medical Director on 3/11/2024 at 9:26 AM identified he was aware of the omitted medications and he was not the attending physician for Resident #1.
Review of facility Medication: Administration: General Policy, directed in part, if a medication is unavailable to notify the physician/Advance Practice Provider.
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 reviews, facility documentation, facility policies and interviews for one of two sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, Resident #3 had the right to be free from sexual abuse by Resident #2. The findings include:
Resident #3's diagnoses included amyotrophic lateral sclerosis, anxiety, depression, psychotic disorder, and abnormal gait and mobility.
The annual Minimum Data Set assessment dated [DATE] identified Resident #3 made reasonable and consistent decision regarding tasks of daily living.
The Resident Care Plan dated 12/12/23 identified Resident #3 had anxiety, depression, psychotic disorder, and difficulty with communication. Interventions directed a consistent routine, emotional support, sufficient time for processing and responding, medications, reorientation to maintain reality, reassurance, and encouraging resident to remain calm.
The nurse's note dated 12/20/23 at 2:50 AM identified on 12/19/23 at 9:40 PM the 3-11PM charge nurse reported to the 3-11PM Nursing Supervisor, Registered Nurse (RN) #7, Resident #3 had made a complaint that Resident #2 pulled down his/her pants and began fondling him/herself in front of Resident #3 and this action made Resident #3 feel uncomfortable. The note indicated Resident #3 identified no physical contact occurred, Resident #3's family, the Advanced Practice Registered Nurse (APRN), and the Police Department were notified.
The psychiatric evaluation dated 12/21/23 identified Resident #3 was seen in follow up to the incident on 12/19/23, Resident #3 identified the event made him/her feel depressed and anxious, Resident #3 declined changing rooms, emotional support was provided, and Resident #3 was reassured that staff would keep him/her safe.
Resident #2's diagnoses included spinal stenosis with fusion, depression, and attention deficit hyperactivity disorder.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable decisions regarding tasks of daily living, required moderate assistance for transfers and utilized a wheelchair for mobility.
The Resident Care Plan dated 12/12/23 identified that Resident #2 had a self-care deficit and required assistance with activities of daily living and Resident #2 was able to self-propel the wheelchair throughout the unit.
The nurse's note dated 12/20/23 at 3:42 AM identified on 12/19/23 that at 9:40 PM the 3-11PM charge nurse reported to the 3-11PM Nursing Supervisor, Registered Nurse (RN) #7, a resident had made a complaint that Resident #2 pulled down his/her pants and began fondling him/herself in front of the resident.
The note indicated the APRN and Police Department were notified, and Resident #2 was placed on one (1) to one (1) observation.
The psychiatric evaluation dated 12/20/23 identified Resident #2 was seen due to exposing self to another resident in that other resident's room. The note identified Resident #2 acknowledged the behavior was inappropriate and claimed it would not occur again. The note indicated the one (1) to one (1) observation was discontinued and every fifteen (15) minute checks were initiated along with Naltrexone 50 milligrams daily for impulsivity.
The social service note dated 12/21/23 at 5:00 PM identified during a visit with Resident #2, Resident #2 pointed to Resident #3's room and asked if Resident #3 was alright.
Interview with the Assistant Director of Nursing (ADON) on 3/7/24 at 2:05 PM identified she assisted in conducting the investigation of the allegation of abuse that involved Residents #2 and #3 on 12/19/23. The ADON indicated she believed the facility discussed moving Resident #2's room further away from Resident #3 as an intervention.
The facility Abuse Prohibition Policy identified that the facility prohibits abuse of all patients, and the policy defines sexual abuse as non-consensual contact of any type with a patient
Although attempted, a call was not returned from RN #7.
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 clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of two sampled residents (Residents #2 and #3) who were reviewed for an allegation of resident-to-resident sexual abuse, the facility failed to implement interventions to prevent Resident #2 from gaining access to Resident #3's room after a prior incident of sexual misconduct by Resident #2 towards Resident #3. The findings include:
Resident #3's diagnoses included amyotrophic lateral sclerosis, anxiety, depression, psychotic disorder, and abnormal gait and mobility.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 made reasonable and consistent decision regarding tasks of daily living.
The current Resident Care Plan initiated on 12/19/23 identified Resident #3 had been a target of inappropriate sexual advancement by another resident. Interventions directed social services to provide emotional support and stop sign placement across Resident #3's entrance door.
The social service note dated 2/13/24 at 9:53 AM identified Resident #3 reported Resident #2 had entered Resident #3's room at approximately 3:00 AM in the morning and Resident #2 touched Resident #3's face. The note indicated Resident #3 became scared and pressed the call button at which time Resident #2 who was in a wheelchair was removed from the room by staff.
The nurse's note dated 2/13/24 at 10:31 AM identified Resident #3 was anxious due to Resident #2 touching his/her face while he/she slept.
The psychiatric evaluation dated 2/13/24 identified that Resident #3 was seen in follow up after identifying Resident #2 had come into his/her room and touched his/her cheek. Resident #3 was tearful, complained of anxiety and depression, and at this time did not want a medication adjustment or room change.
The social service note dated 2/13/24 at 4:28 PM identified Resident #3 had inquired about the location of Resident #2.
Resident #2's diagnoses included spinal stenosis with fusion, depression, and attention deficit hyperactivity disorder.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable decisions regarding tasks of daily living, required moderate assistance for transfers and utilized a wheelchair for mobility.
The Resident Care Plan dated 12/12/23 identified Resident #2 had a self-care deficit and required assistance with activities of daily living and Resident #2 was able to self-propel the wheelchair throughout the unit.
The Resident Care Plan dated 12/12/23 identified that Resident #2 had a self-care deficit, required assistance with activities of daily living, and Resident #2 was able to self-propel the wheelchair throughout the unit.
The revised care plan dated 12/19/23 identified Resident #2 exhibited an inappropriate sexual behavior towards another resident. Interventions directed one (1) to one (1) supervision, psychiatric evaluation, and social services follow up.
The psychiatric evaluation dated 12/20/23 identified Resident #2 was seen due to exposing self to another resident in the other resident's room on 12/19/23, and Resident #2 acknowledged the behavior was inappropriate and claimed it would not occur again.
The nurse's note dated 2/13/24 at 10:40 AM identified the 7AM-3PM charge nurse, Registered Nurse (RN) #3, assessed Resident #2 after a complaint was made Resident #2 had touched Resident #3's face, Resident #2 denied touching or entering Resident #3's room, the APRN was notified and directed to send Resident #2 to the Emergency Department for further evaluation.
The social service note dated 2/13/24 at 1:21 PM identified although Resident #2 denied touching Resident #3's face, Resident #2 did state he/she was in Resident #3's room.
The psychiatric evaluation dated 2/13/24 identified Resident #2 was seen for touching the cheek of Resident #3 and complaints of mood lability and racing thoughts which the resident feels is due to poor control of the attention deficit hyperactivity disorder. Resident #2 denied the allegation. The resident was sent to the Emergency Department for further evaluation and a room change was directed.
Review of the census list dated 3/7/24 identified Resident #3 had resided in room [ROOM NUMBER]. The list identified on 2/9/24 Resident #2 was moved to room [ROOM NUMBER] and then on 2/11/24 was moved to room [ROOM NUMBER].
Review of the facility floor plan identified rooms [ROOM NUMBERS] share the bathroom.
Interview and review of the facility investigation with the Assistant Director of Nursing (ADON) on 3/7/24 at 2:05 PM identified on 2/13/24 Resident #2 entered Resident #3's room through the shared bathroom and was observed by the nurse aide sitting at the end of Resident #3's bed in his/her wheelchair. The ADON identified she believed the facility discussed moving Resident #2's room further away from Resident #3 after Resident #2 admitted to the allegation of abuse on 12/19/23. The ADON identified that it was not appropriate to move Resident #2 into a room that had a shared bathroom with Resident #3 (opposite genders) and does not know how that decision was made.
The facility Abuse Prohibition Policy identified that the purpose of the policy is to ensure staff are doing all that is within their control to prevent occurrents of abuse or mistreatment of patients. This includes identifying, correcting, and intervening in situations in which abuse is more likely to occur and to identify situations which have a potential for risk.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for seven of thirty residents (Resident #1, 10, 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for seven of thirty residents (Resident #1, 10, 11, 12, 13, 16 and 19) reviewed for medication errors, the facility failed to ensure a facility emergency medication supply was maintained, and failed to ensure medications were administered in accordance with physician orders. The findings include:
1.
Resident #1's diagnoses included Epilepsy, Cerebral Palsy, gastrostomy status (G-tube for feeding feeding), and a history of aspiration pneumonia. The admission nursing assessment dated [DATE] identified Resident #1 was alert, responsive, incoherent, able to answer yes/no questions, and the medication list was reviewed with the provider.
Review of the admission orders from APRN #1 dated 2/29/2024, directed nothing by mouth (NPO), and to administer the following medications via gastrostomy tube: Famotidine (for gastric reflux) 20 milligrams (mg) two times a day, Mirtazapine (treat depression) 7.5 mg at bedtime, Refresh Plus Ophthalmic Solution one drop to both eyes two (2) times a day, and Vitamin D3 1000 units daily.
Review of the Medication Administration Record (MAR) for February 2024 identified Resident #1 did not receive the following medications at 9 PM: Famotidine 20 mg, Mirtazapine 7.5 mg, and Refresh Plus Ophthalmic Solution one drop to both eyes. Review of the MAR for March 2024 identified Resident #1 did not receive the following medications at 9 AM: Famotidine 20 mg and Vitamin D3 1000 units daily.
Review of the MAR dated 2/29/2024 identified the Famotidine and Mirtazapine were coded as HD to indicate hold and see nursing notes, and the Refresh Plus Ophthalmic Solution was coded X. further review of the MAR failed to identify a code reference for X. Review of the 3/1/2024 MAR identified the omitted medications were coded as HD to indicate hold and see nursing notes.
Interview, facility documentation review and clinical record review with the DON and Regional RN #3 on 3/7/2024 at 1:04 PM identified Resident #1 did not receive the medications as ordered because when Resident #1 was newly admitted from the hospital on 2/29/2024, the medications were ordered from the pharmacy at 9:22 PM for routine delivery (due to be delivered the next day after 2 PM) and they should have been ordered for STAT delivery. The DON was unable to explain why the medications were not ordered STAT. The DON identified staff also should have completed the medication order review upon admission, completed a second check and then should have completed a third review during the clinical meeting the next day. The DON identified if the second and third checks were completed, the errors could have been identified sooner and the medications could have been ordered for faster delivery. The DON and Regional RN #3 were unable to explain why the reviews were not completed.
2.
Resident #10's diagnoses included chronic kidney disease and history of urinary tract infections. The RCP dated 11/2/2023 identified resident was incontinent of bladder. Interventions directed toileting at scheduled times. The admission MDS assessment dated [DATE] identified that Resident #10 was alert and oriented. A physician's order dated 11/24/2023 directed Ditropan XL (treats overactive bladder) 15 mg by mouth at bedtime.
Review of the MAR for February 2024 identified the Ditropan XL scheduled at 9 PM on 2/10/2024 was marked NN to direct to see nursing notes regarding administration.
Review of facility medication error list identified on 2/10/2024 Resident #10 did not receive his/her 9 PM scheduled dose of Ditropan XL.
3.
Resident #11's diagnoses included pressure ulcer of sacral region, hemiplegia/hemiparesis, and paraplegia. The RCP dated 1/3/2024 identified risk for skin breakdown due to wheelchair position and incontinence. Interventions directed pat skin when drying, apply barrier cream with each cleansing, monitoring for redness and skin breakdown. The quarterly MDS assessment dated [DATE] identified that Resident #11 was alert and oriented. A physician order dated 2/9/2024 directed Lotrisone External Cream (treat infections) 1-0.5% apply to buttock topically two (2) times per day for incontinence dermatitis for 14 days.
Review of facility medication error list identified on 2/10/2024 Resident #11 did not receive his/her 9 AM scheduled dose of Lotrisone cream.
4.
Resident #12's diagnoses included chronic obstructive pulmonary disease (COPD). The RCP dated 2/1/2024 identified a risk for respiratory complications related to COPD. Interventions directed to provide respiratory treatments as ordered. The quarterly MDS assessment dated [DATE] identified Resident #12 as severely cognitively impaired. A physician's order dated 2/9/2024 directed Robitussin Mucus and Chest Congestion (for cough) oral liquid, give 10 milliliters (ml) by mouth every eight (8) hours for congested cough for 7 days.
Review of the MAR for February 2024 identified the 6 AM dose on 2/11/2024 was marked NN to refer to the nursing notes.
Review of facility documentation (medication error list) identified Resident #12 did not receive his/her 6 AM scheduled dose of Robitussin on 2/11/2024.
5.
Resident #13's diagnoses included cerebral infarction. The RCP dated 12/14/2023 identified impaired mobility. Interventions directed monitor for medication side effects. The admission MDS assessment dated [DATE] identified Resident #13 was alert and oriented. A physician order dated 2/15/2024 directed Ritalin oral tablet 5 mg by mouth two (2) times per day for physical debility at 8 AM and 4 PM.
Review of the February 2024 MAR identified the Ritalin scheduled on 2/19/2024 at 6 AM was signed HD to identify the dose was held.
6.
Resident #16's diagnoses included chronic pulmonary obstructive disease. The significant change MDS assessment dated [DATE] identified Resident #16 was cognitively impaired. The RCP dated 2/26/2023 identified Resident #16 was at risk for infections related to respiratory status. A physician order dated 2/16/2024 directed Augmentin Oral Suspension (antibiotic) Reconstituted 250-62.5 mg/5 ml give 10 ml by mouth two (2) times per day for cough and congestion for seven (7) days.
Review of the February 2024 MAR identified the scheduled 2/17/2024, 9 AM dose of Augmentin was the first scheduled dose, and was marked NN to direct to see nursing notes.
Review of facility documentation (facility medication error list) identified Resident #16 did not receive his/her 9 AM scheduled dose of Augmentin on 2/17/2024.
Review of the facility emergency (e-box) supply medication list identified Augmentin was not included in the e-box medications.
7.
Resident #19's diagnoses included infective endocarditis. The quarterly MDS assessment dated [DATE] identified that Resident #19 was alert and oriented. A physician order dated 2/13/2024 directed Fluticasone Propionate HFA Aerosol (treats congestion) one (1) spray in both nostrils at bedtime for runny nose for fourteen (14) days.
Review of the February MAR identified the Fluticasone scheduled on 2/17/2024 at 8 PM was signed NN to direct to the nursing notes.
Review of facility medication error list identified on 2/17/2024 Resident #19 did not receive his/her scheduled evening dose of Fluticasone.
Interview with DNS and Regional Nurse #1 on 3/7/2024 at 10:37 AM, Regional Nurse #1 identified the facility had no emergency supply of medications for residents between 2/7 and 2/16/2024 due to the facility automated medication dispensing unit was not functioning. Interview identified the facility had contacted the Medical Director, and the pharmacy and put a plan into place for an extra runner delivery for required medications; if a medication was needed it would be ordered STAT (for immediate delivery) and the pharmacy would send it on the extra delivery run.
Interview with pharmacist #1 on 3/7/2024 at 12:11 PM identified that the pharmacy was notified on 2/6/2024 that the Omnicell (automated medication dispensing unit) had stopped working. A new unit was installed on 2/28/2024.
Interview with Regional Nurse #1, DNS, Administrator and Regional Clinical Representative on 3/7/2024 at 3:36 PM identified the facility had eight residents with medication errors when the Omnicell was not functioning, and on 2/14/2024 the facility initiated a tackle box system for an emergency medication supply, and a lockbox system for emergency controlled medications to attempt to reduce the number of medication errors. Interview further identified the facility experienced additional medication errors due to the reordering system, and availability of medications. Interview further identified subsequent to the errors, the facility initiated staff education.
Review of facility documentation identified staff education was initiated on 3/4/2024 and included the use of the emergency supply medications, access for emergency supply, ordering medications, facility policy review, and to contact the provider if a medication is not available. Audits and QAPI were initiated on 3/4/2024. Based on review of facility documentation, past non-compliance was identified with a correction date of 3/6/2024.
Review of facility Emergency Medication Supplies (Emergency Kits) Policy dated 12/1/2023 directed in part, item #3 The Emergency Medication Supply (Emergency Kit) should be stored in known, secured location(s) per Facility policy with immediate access only by authorized Facility personnel. Facility should maintain a list of inventory items in Emergency Kit in a location easily retrievable for quick reference. The Policy further directed, the Facility may request an On-Demand Exchange of Emergency Kit as needed by calling the pharmacy and arranging the exchange.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, facility documentation review, facility policy review, and interviews, the facility failed to ensure medications were stored at proper temperature controls and failed to ensure ...
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Based on observations, facility documentation review, facility policy review, and interviews, the facility failed to ensure medications were stored at proper temperature controls and failed to ensure room temperatures were monitored timely. The findings include:
Observation and interview with the DNS #1 and Maintenance Person #1 on 3/7/2024 at 10:04 AM of the medication room identified the room contained two (2) fans which were running, and the room was warm. Maintenance Person #1 verified the room temperature was 84 degrees Fahrenheit. The DNS indicated since the new Pixis was installed, the room temperature had been high, a temperature log was maintained, fans were placed to attempt to cool the room, and that maintenance was installing a portable air conditioner today to reduce the room temperature. The DNS indicated the room temperature was too high.
Review of facility documentation identified the OMNI (pharmacy) Inventory list of medication for Omnicell (Pixis) identified the following medications were stored in the Pixis unit: Alprazolam, Amoxiclav, Amoxicillin, Atorvastatin, Atropine, Azithromycin, Ceftriaxone, Cefuroxime Axetil, Cephalexin, Ciprofloxacin HCL, Dextrose 5%-0.9% Normal Saline Intravenous Solution, Dextrose %5 - ½ Normal Saline Intravenous Solution, Diphenhydramine, Doxycycline, Eliquis, Enoxaparin, Epinephrine, Fentanyl, Furosemide, Glucagon, Heparin, Hydrocodone/Acetaminophen, Levofloxacin, Levothyroxine, Lidocaine, Metformin, Metronidazole, Morphine, Naloxone, Nitrofurantoin, Nitroglycerin, Normal Saline flush, Ondansetron, Oxycodone, Oxycontin, Phenytoin, Phytonadione, Quetiapine Fumarate, Sertraline HCL, Simvastatin, Sodium Polystyrene Sulfate, Sodium Chloride, Solumedrol, Spironolactone, Sulfamethoxazole, Tamsulosin, Tramadol, Trazodone, and Warfarin.
Interview and facility documentation review with Pharmacist #1 on 3/7/2024 at 11:32 AM identified that the facility's automated medication dispensing unit indicates medications should be stored between 68 to 77 degrees Fahrenheit. Pharmacist #1 indicated the temperatures listed above, and the temperature observed today were too warm according to the manufacturer medication storage guidelines. Pharmacist #1 indicated he would follow-up with the facility and review all the medications to identify if medications needed to be replaced due to warm temperatures.
Review of facility documentation titled Omnicell Room Temperature Log directed to keep the room temperature between 68 to 77 degrees Fahrenheit (F). Review of the facility medication room temperature log for February 2024 identified the only temperatures recorded were as follows: 2/28/2024 was 79 degrees F during the 2nd shift, and 2/29/2024 for the 1st was 80 degrees F and 2nd shift was 81 degrees F (55 empty spaces).
Review of the facility medication room temperature log for March 2024 identified temperatures from 3/1 to 3/7/2024 were 80, 81, 77, 79, 79, 82 and 84 degrees on the 7 AM to 3 PM shift and from during the 3 to 11 PM shift temperatures were 79, 82, 81, 80, 81 and 82 degrees (temperatures were above the 77 degrees F recommended by Pharmacisit #1 for the three dates recorded during February and on 12 out of 13 occasions for March).
Interview and facility documentation review with Regional Nurse #3 on 3/7/2024 at 11:20 AM identified although the temperature logs should have been completed, Regional Nurse #3 was unable to provide temperatures of the room where the medication dispensing unit was held for the dates with no temperatures recorded.
Interview and facility documentation review with Regional Nurse #3 and the Administrator on 3/7/2024 at 3:58 PM identified medications should be stored between 68 to 77 degrees F, and the recorded temperatures were too warm. The Administrator indicated the facility attempted to cool the room with the use of two (2) fans and was installing the portable room air conditioner today. Interview failed to identify if the medication storage temperatures were assessed for potential need for replacement.
Subsequent to surveyor inquiry, the facility indicated they would follow up with the pharmacy regarding the room temperatures where the medications were stored.
Review of Manufacturer Instructions directed in part, the recommended cabinet temperatures for the Omnicell XT medications to be stored at 68 to 77 degrees Fahrenheit.
Feb 2024
4 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
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 reviews, facility documentation, facility policies and interviews for one of three sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were reviewed for a change in respiratory condition, the facility failed to notify the physician or Advanced Practice Registered Nurse when the resident required suctioning and the user of an as needed inhaler. The findings include:
Resident #1's diagnoses included emphysema, tracheostomy, acquired absence of larynx, dysphagia, vascular dementia, and history of cerebral infarction.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required extensive assistance of one (1) for turning and repositioning when in bed, and Resident #1 did not receive respiratory therapy, oxygen, or suctioning.
The Resident Care Plan dated 12/6/23 identified Resident #1 was at risk for respiratory complications. Interventions directed to observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress, obtain respiratory therapy consult as indicated and to report to the physician.
Monthly physician orders directed to suction the tracheostomy stoma as needed and instill one (1) to two (2) drops of normal saline in the stoma as needed for dry thick secretions, to administer (a bronchodilator medication that relaxes the muscles around the airways so they open and you can breathe more easily) Albuterol Sulfate two (2) puffs every four (4) hours as needed for wheezing and shortness of breath, oxygen at two (2) liters via nasal cannula to maintain oxygen saturation levels greater than 92% as needed, and a respiratory therapy evaluation as indicated.
Review of the medication and treatment administration records for the months of November and December 2023 and January 2024 identified Resident #1 did not require suctioning or the use of the Albuterol inhaler until 1/22/24.
The nurse's note dated 1/23/24 at 12:38 AM identified a 3-11PM nurse aide informed the charge nurse Resident #1's breathing was loud and different than usual. The note identified that Resident #1's breathing was noted to be labored, loud, with a whistling sound from the stoma, and the 3-11PM Nursing Supervisor was notified. The note indicated Resident #1 was suctioned three (3) times, the as needed Albuterol inhaler was administered, and after the third suction attempt, a small piece of food was noted on the Resident #1's chest, Resident #1's breathing returned to regular and unlabored, however after a few minutes, Resident #1's breathing became labored again, suction was done again due to thick mucus, and once cleared, Resident #1's breathing was normal. The note failed to reflect documentation the physician or Advanced Practice Registered Nurse (APRN) was notified of Resident #1's change in respiratory status requiring suctioning and the administration of the Albuterol.
The nurse's note dated 1/23/24 at 11:43 PM identified Resident #1 was suctioned, the Albuterol inhaler was administered due to labored and loud breathing, and prior to suctioning Resident #1's oxygen saturation was 92 % and after suctioning it was 98 % on room air. The note failed to reflect documentation that the physician or APRN was notified of Resident #1 requiring suctioning and the administration of the Albuterol.
A copy of a telephone screen shot identified that on 1/24/24 at 4:12 PM a nurse notified APRN #1 a chest x-ray should be obtained, and Resident #1's diet downgraded due to Resident #1's oxygen saturation levels dropping after coughing and choking the day before. This documentation was not entered into the clinical record.
The nurse's note dated 1/25/24 at 10:56 PM identified Resident #1 had a change in condition and a communication form was completed by the 3-11PM Nursing Supervisor. The note indicated Resident #1's pulse oximetry was 93%, Resident #1 was short of breath with labored breathing, Resident #1 was in respiratory distress and anxious. The note identified Resident #1 was suctioned three (3) times, an extra-large mucous plug was expelled from the tracheostomy site, and Resident #1 experienced immediate relief after suctioning. The note indicated Resident #1's name was entered in the Advanced Practice Registered Nurse (APRN) book for evaluation the following morning.
The APRN Referral Sheet for the facility identified Resident #1's name was entered on the form on 1/25/24 to be seen by the APRN for increased congestion and labored breathing.
Review of the clinical record failed to reflect documentation Resident #1 was seen by the APRN on 1/26/24 and the clinical record did not identify a referral was made to the Respiratory Therapist.
A nurse's note on 1/30/24 at 1:56 PM identified Resident #1 was sitting in the wheelchair visiting with a family member and the family member reported to the nurse he/she was concerned that Resident #1 was breathing more through the tracheostomy then the mouth or nostrils. The note indicated the APRN was informed, and Resident #1 was suctioned without mucous being obtained.
A nurse's note on 1/30/24 at 8:50 PM identified Resident #1 was found unresponsive in bed with no pulse, no respiration, and no blood pressure, Cardiopulmonary Resuscitation and defibrillator where initiated due to full code status and 911. The note identified upon Emergency Medical Services (EMS) arrival, they took over the resuscitation efforts which were unsuccessful, and Resident #1's death was pronounced by an Emergency Department physician at 8:32 PM.
Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 2/27/24 at 2:20 PM identified on 1/23/24 Resident #1's breathing was very labored which was unusual and with suctioning a nickel sized hardened piece of material with blood around it was suctioned up. LPN #1 indicated at first, she identified this as a food particle but after talking to a couple of the nurses realized the material was a mucous plug. LPN #1 identified she did not relay this information to the APRN the next day but thought the APRN was notified during the week because Resident #1 was requiring more frequent suctioning. LPN #1 identified Resident #1 was using accessory muscles when breathing was labored and that the requirement to be suctioned was new.
Interview with APRN #1 on 2/28/24 at 11:15 AM identified she saw Resident #1 on 1/24/23 for a routine visit and at that time the only concern the nursing staff requested she address was review of the dysphagia diet which she had no concerns about. APRN #1 indicated she was not informed of Resident #1's requirement for the Albuterol inhaler and suctioning due to labored breathing and would have expected the nursing staff to inform her of this. APRN #1 stated that she would have been concerned with this change because Resident #1 was more at risk for respiratory distress due to the laryngectomy but without having seen Resident #1 was unable to determine if she would have recommended any further orders since there were orders for suctioning and inhaler use.
Interview with the Assistant Director of Nursing (ADON) on 2/28/24 at 1:10 PM identified if a resident's name was placed on the APRN referral sheet the expectation was that they would be seen the next day by the APRN. The ADON indicated based on facility policy, if a change in condition was documented, staff were required to contact the physician or APRN either by phone or through the telehealth service immediately and it is not acceptable to just put the resident's name on the APRN referral sheet for follow up. The ADON identified the nurse's notes dated 1/23/24 and 1/25/24 identified a change in condition and the expectation would have been to notify the physician or APRN immediately. The ADON stated it was not acceptable Resident #1 was not evaluated by the physician or APRN for the respiratory change between 1/22/24 and 1/30/24.
Interview with APRN #2 on 2/28/24 at 2:00 PM identified she was the APRN assigned to the facility on 1/26/24, she did not see Resident #1 and does not recall being asked to see Resident #1. APRN #2 indicated although she looks at the APRN referral sheet she relies on the charge nurse to update her on any concerns or residents that require a visit.
Review of the facility policy for Chage in Condition identified that the center must immediately inform the patient's physician when there is a significant change in the patient's physical, status (that is, a deterioration in health, in either life-threatening conditions or clinical complications) and ensure that all pertinent information is available and provided upon request to the physician. The purpose is to provide timely information about changes relevant to the patient's condition.
An attempt to interview RN #2 was unsuccessful.
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 reviews, review of facility policy, review of facility documentation, and interviews for one of three s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policy, review of facility documentation, and interviews for one of three sampled residents (Resident #4) who required staff assistance with personal care and were reviewed for an allegation of neglect, the facility failed to reapproach the resident when the resident refused care and inform the licensed nurse the resident had refused care. The findings include:
Resident #4's diagnoses included vascular dementia with mood disturbance, diabetes mellitus, and generalized muscle weakness.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no problems with short or long-term memory recall, made reasonable decisions regarding tasks of daily living, required extensive two (2) person assistance for turning and repositioning when in bed and toileting, was frequently in continent of urine and always incontinent of bowel.
The Resident Care Plan dated 1/26/24 identified that Resident #4 was at risk for decreased ability to perform Activities of Daily Living. Interventions directed to provide extensive assistance of one (1) for dressing, personal hygiene, and bathing and offer or assist the resident with the urinal or commode as requested or needed. The care plan identified Resident #4 was resistive to care. Interventions directed to approach with a calm, unhurried manner, and reassure as needed, explain all care and the reason for performing the care before initiating the care, and allow time for expression of feelings.
The social service progress note dated as a late entry on 2/5/24 at 2:17 PM, identified Resident #4 informed Social Services about a concern he/she had related to a disagreement of care with a nurse aide and a grievance was submitted for an investigation to management.
The nurse's progress note dated 2/5/24 at 5:26 PM identified Resident #4 reported care not being provided by a nurse aid on the 3-11PM shift on 2/4/24. The note indicated Resident #4 was placed in bed without changing his/her clothes.
The Facility Reported Incident form dated 2/5/24 identified Resident #4 did not receive evening care from a nurse aide, Nurse Aide (NA) #1, during the 3-11PM on 2/4/24 and Resident #4 was left in bed with his/her clothes on for the night shift.
The investigation identified Resident #4 was being assisted by NA #1 when there was a disagreement about transferring Resident #4 into the bed and Resident #4 told NA #1 to get out of the room. The investigation identified that although NA #1 told another nurse aide of the event, she did not inform the 3-11PM charge nurse, reapproach Resident #4, and did not report the incident to the on-coming nurse aide. The investigation indicated evening care was provided on first rounds by the 11PM-7AM shift and concerns were reported to the 11PM-7AM charge nurse and Nursing Supervisor. In an interview with the Assistant Director of Nursing on 2/9/24, NA #1 admitted she did not provide care for Resident #4.
Interview with the Assistant Director of Nursing (ADON) on 2/27/24 at 1:50 PM identified the nurse aide, NA #1, assigned to Resident #4 was responsible for providing care to Resident #4 during the 3-11PM shift and she did not provide evening care for Resident #4 and left Resident #4 in bed with his/her clothes on for 11-7PM shift. The ADON indicated although Resident #4 initially refused care during the 3-11PM, NA #1 did not reapproach Resident #4 and did not notify the charge nurse of the refusal.
Interview and review of incident report with the DON on 2/27/24 at 2:38 PM identified upon completion of the investigation NA #1 was terminated.
Review of the facility Abuse Prohibition policy dated 10/24/22 identified, in part, that neglect was defined as the failure, indifference, or disregard of the facility and its employees or service providers, to provide care and comfort to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Additionally, the failure to implement an effective communication system across all shifts for communication of necessary care and information was included in the definition. The policy directed, in part, that the abuse and neglect of all patients is prohibited.
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 reviews, review of facility policy, review of facility documentation, and staff interviews for one of t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policy, review of facility documentation, and staff interviews for one of three sampled residents (Resident #4) who were reviewed for an allegation of neglect, the facility failed to ensure the allegation of resident neglect was reported to the Administrator or Director of Nursing at the time the event was reported to the Nursing Supervisor. The findings include:
Resident #4's diagnoses included vascular dementia, moderate, with mood disturbance, generalized muscle weakness, and difficulty in walking.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 had no problems with short or long-term memory recall, made reasonable decisions regarding tasks of daily living, required extensive two (2) person assistance for turning and repositioning when in bed and toileting, was frequently in continent of urine and always incontinent of bowel.
The Facility Reported Incident form dated 2/5/24 identified Resident #4 did not receive evening care from a nurse aide, Nurse Aide (NA) #1, during the 3-11PM on 2/4/24 and Resident #4 was left in bed with his/her clothes on for the night shift.
The investigation identified Resident #4 was being assisted by NA #1 when there was a disagreement about transferring Resident #4 into the bed and Resident #4 told NA #1 to get out of the room. The investigation identified that although NA #1 told another nurse aide of the event, she did not inform the 3-11PM charge nurse, reapproach Resident #4, and did not report the incident to the on-coming nurse aide. The investigation indicated evening care was provided on first rounds by the 11PM-7AM shift and concerns were reported to the 11PM-7AM charge nurse and Nursing Supervisor. In an interview with the Assistant Director of Nursing on 2/9/24, NA #1 admitted she did not provide care for Resident #4.
Interview and review of incident report with the Director of Nursing (DON) on 2/27/24 at 2:38 PM identified she was the person responsible for the initial reporting and overall investigation of the allegation of neglect for Resident #4. The DON identified she was informed of the allegation at 9:00 AM on 2/5/24 by facility staff. The DON identified it is the expectation to be notified about any allegation made by residents immediately from nursing supervisors or other facility staff. The DON indicated upon receiving an allegation, she or the ADON will then make the initial report to the state via the portal.
Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #2 on 2/27/24 at 3:40 PM identified she was informed by a nurse aide who had concerns Resident #4 was in bed with his/her clothes on. RN #2 identified she did not report the nurse aide's concerns as an allegation of neglect to the DON. RN#2 identified the policy was to report allegations to the DON or ADON.
Review of facility Abuse Prohibition policy directed for staff to identify events, occurrences, patterns, and trends that may constitute abuse, and that anyone who witnesses an incident of suspected abuse or neglect is to report the incident to his/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or Designee.
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
Respiratory Care
(Tag F0695)
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 policies and interviews for one of three sampled residents (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) reviewed for respiratory care, the facility failed to implement interventions in accordance with the resident care plan. The findings include:
Resident #1's diagnoses included emphysema, tracheostomy, acquired absence of larynx, dysphagia, vascular dementia, and history of cerebral infarction.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required extensive assistance of one (1) for turning and repositioning when in bed, and Resident #1 did not receive respiratory therapy, oxygen, or suctioning.
The Resident Care Plan dated 12/6/23 identified Resident #1 was at risk for respiratory complications. Interventions directed to observe respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress, obtain respiratory therapy consult as indicated and to report to the physician, to suction the tracheostomy as needed and administer medications as ordered.
Monthly physician orders directed to suction the tracheostomy stoma as needed and instill one (1) to two (2) drops of normal saline in the stoma as needed for dry thick secretions, to administer (a bronchodilator medication that relaxes the muscles around the airways so they open and you can breathe more easily) Albuterol Sulfate two (2) puffs every four (4) hours as needed for wheezing and shortness of breath, oxygen at two (2) liters via nasal cannula to maintain oxygen saturation levels greater than 92% as needed, and a respiratory therapy evaluation as indicated.
Review of the medication and treatment administration records for the months of November and December 2023 and January 2024 identified Resident #1 did not require suctioning or the use of the Albuterol inhaler until 1/22/24.
The nurse's note dated 1/23/24 at 12:38 AM identified a 3-11PM nurse aide informed the charge nurse Resident #1's breathing was loud and different than usual. The note identified that Resident #1's breathing was noted to be labored, loud, with a whistling sound from the stoma, and the 3-11PM Nursing Supervisor was notified. The note indicated Resident #1 was suctioned three (3) times, the as needed Albuterol inhaler was administered, and after the third suction attempt, a small piece of food was noted on the Resident #1's chest, Resident #1's breathing returned to regular and unlabored, however after a few minutes, Resident #1's breathing became labored again, suction was done again due to thick mucus, and once cleared, Resident #1's breathing was normal. The note failed to reflect documentation the physician or Advanced Practice Registered Nurse (APRN) was notified of Resident #1's change in respiratory status requiring suctioning and the administration of the Albuterol.
The nurse's note dated 1/23/24 at 11:43 PM identified Resident #1 was suctioned, the Albuterol inhaler was administered due to labored and loud breathing, and prior to suctioning Resident #1's oxygen saturation was 92 % and after suctioning it was 98 % on room air. The note failed to reflect documentation that the physician or APRN was notified of Resident #1 requiring suctioning and the administration of the Albuterol.
Review of the clinical record failed to reflect documentation Resident #1's respiratory status was monitored on 1/24/24.
A copy of a telephone screen shot identified that on 1/24/24 at 4:12 PM a nurse notified APRN #1 that a chest x-ray should be obtained, and Resident #1's diet downgraded due to Resident #1's oxygen saturation levels dropping after coughing and choking the day before. This documentation was not entered into the clinical record.
The nurse's note dated 1/25/24 at 10:56 PM identified Resident #1 had a change in condition and a communication form was completed by the 3-11PM Nursing Supervisor. The note indicated Resident #1's pulse oximetry was 93%, Resident #1 was short of breath with labored breathing, Resident #1 was in respiratory distress and anxious. The note identified Resident #1 was suctioned three (3) times, an extra-large mucous plug was expelled from the tracheostomy site, and Resident #1 experienced immediate relief after suctioning. The note indicated Resident #1's name was entered in the Advanced Practice Registered Nurse (APRN) book for evaluation the following morning.
The APRN Referral Sheet for the facility identified Resident #1's name was entered on the form on 1/25/24 to be seen by the APRN for increased congestion and labored breathing.
Review of the clinical record failed to reflect documentation Resident #1 was seen by the APRN on 1/26/24 and a referral was made to the Respiratory Therapist.
Review of the clinical record failed to reflect documentation Resident #1's respiratory status was monitored on 1/29/24.
Interview with the 3-11PM charge nurse, Licensed Practical Nurse (LPN) #1, on 2/27/24 at 2:20 PM identified on 1/23/24 Resident #1's breathing was very labored which was unusual and with suctioning a nickel sized hardened piece of material with blood around it was suctioned up. LPN #1 indicated at first, she identified this as a food particle but after talking to a couple of the nurses realized the material was a mucous plug. LPN #1 identified she did not relay this information to the APRN the next day but thought the APRN was notified during the week because Resident #1 was requiring more frequent suctioning. LPN #1 identified Resident #1 was using accessory muscles when breathing was labored and that the requirement to be suctioned was new.
Interview with APRN #1 on 2/28/24 at 11:15 AM identified she saw Resident #1 on 1/24/23 for a routine visit and at that time the only concern the nursing staff requested she address was review of the dysphagia diet which she had no concerns about. APRN #1 indicated she was not informed of Resident #1's requirement for the Albuterol inhaler and suctioning due to labored breathing and would have expected the nursing staff to inform her of this. APRN #1 stated that she would have been concerned with this change because Resident #1 was more at risk for respiratory distress due to the laryngectomy but without having seen Resident #1 was unable to determine if she would have recommended any further orders since there were orders for suctioning and inhaler use.
Interview with the Assistant Director of Nursing (ADON) on 2/28/24 at 1:10 PM identified if a resident's name was placed on the APRN referral sheet the expectation was that they would be seen the next day by the APRN. The ADON stated it was not acceptable Resident #1 was not evaluated by the physician or APRN for the respiratory change between 1/22/24 and 1/30/24.
Interview with APRN #2 on 2/28/24 at 2:00 PM identified she was the APRN assigned to the facility on 1/26/24, she did not see Resident #1 and does not recall being asked to see Resident #1. APRN #2 indicated although she looks at the APRN referral sheet she relies on the charge nurse to update her on any concerns or residents that require a visit.
Review of the facility policy for Person Centered Care Plan identified that care plans will be developed to include instructions needed to provide effective and person-centered care that meet professional standards of quality care and reviewed and revised as needed to reflect the response to care and changing needs.
An attempt to interview RN #2 was unsuccessful.
Nov 2023
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility documentation review, and interviews for one of eight residents (Resident #7) reviewed for acci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility documentation review, and interviews for one of eight residents (Resident #7) reviewed for accidents, the facility failed to provide the necessary supervision to a resident who required assistance with toileting resulting in a fall with injury. The finding includes:
a.
Resident #7's diagnoses included vascular dementia, muscle weakness, chronic pain syndrome, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment and required extensive with two staff assistance for transfers, and required one staff assistance for ambulation and toilet use. The Resident Care Plan (RCP) dated 9/30/2023 identified Resident #7 had dementia and required assistance with ADLs. Interventions directed to provide moderate assistance for toileting needs and transfers, and to provide cueing for safety and sequencing to maximize current level of function.
A nursing note dated 10/21/2023 at 10:37 AM identified the resident reported he/she fell during the 3-11 shift on 10/20/2023 and the responsible party was contacted. The responsible party indicated the resident had notified them on 10/20/2023 of the fall and Resident #7 indicated he/she had a bruise. The provider was contacted to obtain an order for a left hip x-ray.
The Physician's order dated 10/21/2023 directed a left hip x-ray.
The nursing note dated 10/22/2023 at 6:29 AM indicated x-ray would be done this morning and as needed Oxycodone was administered for pain with good results.
Review of nursing notes dated 10/22/2023 at 2:54 PM and 3:41 PM identified the resident was transferred to the hospital related to a left hip fracture.
Clinical record review identified after the fall, in addition to the scheduled Oxycodone (15 milligrams 7.5 mg, two times a day, for chronic pain), Resident #7 received Oxycodone 5 mg PRN for complaints of pain on 10/21/2023 at 1:17 AM, 11:45 AM and 4:15 PM. Further, Resident #7 received Oxycodone 5 mg PRN for complaints of pain on 10/22/2023 at 3:45 AM and 2:20 PM, prior to transfer to the hospital on [DATE] (2 days after the fall).
Review of the Hospital Diagnostic Studies radiology report (x-ray report) dated 10/22/2023 identified Resident #7 had a left-sided transcervical femur fracture with slight superior displacement of the proximal femur was visualized. Resident #7 was admitted to the hospital on [DATE] and had a left hip hemiarthroplasty (half of a hip joint replacement) on 10/23/2023.
Interview with NA #7 on 11/6/2023 at 3:40 PM identified on 10/20/2023 she was assigned to Resident #7 and after dinner time NA #6 assisted Resident #7 to the bathroom and notified her that Resident #7 would call when ready. When Resident #7 activated the call light, NA #7 went to assist the resident and upon entry to the room, observed Resident #7 was coming out of the bathroom doorway with his/her walker and was noted to be shaking. NA #7 indicated she immediately attempted to retrieve Resident #7's wheelchair, but before she could get the wheelchair Resident #7 fell to the ground and she immediately notified LPN #2.
Interview with LPN #2 on 11/6/2023 at 11:10 AM identified on 10/20/2023, she was walking by Resident #7's room, and observed the resident on the floor between the edge of the bed and the wall with his/her walker nearby and NA #7 was with the resident. Resident #7 indicated he/she was tired after using the bathroom, and NA #7 indicated Resident #7 had just sat down.
Interview with NA #6 on 11/6/2023 at 3:25 PM identified on 10/20/2023, after dinner time, she assisted Resident #7 to the bathroom and directed Resident #7 to ring the bell when finished. NA #6 indicated she then left the room and continued to provide care for other residents. A few minutes later she went back to check on the resident who stated they needed more time. NA #6 then left the room and notified NA #7 that the resident was in the bathroom. NA #6 indicated that Resident #7 required supervision with transfers and ambulation and she should have stayed with Resident #7 while the resident was in the bathroom to ensure the resident was safely assisted back to bed/chair.
Interview with the Director of Therapy (DOT) on 11/6/2023 at 2:20 PM identified Resident #7 was discharged from physical therapy services on 10/21/2023 and required supervision for ambulation with a walker. The DOT indicated Resident #7 would not be safe to be left alone in the bathroom due to the resident's cognitive status and limited physical ability.
Interview with the DON on 11/6/2023 at 2:30 PM identified during the facility investigation, it was identified NA #6 should have stayed with Resident #7 while in the bathroom for safety.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one resident (Resident #6) reviewed for resident rig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and interviews for one resident (Resident #6) reviewed for resident rights, the facility failed to ensure an alert, oriented, independent resident's rights were honored and failed to ensure the resident was allowed Leave of Absence from the facility. The finding includes:
Resident #6's diagnoses included hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, hypertension, and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was alert and oriented and required supervision with locomotion on/off unit. The Resident Care Plan (RCP) dated 9/8/2023 identified Resident #6 was at risk for substance use (alcohol/drugs) related to a history of cocaine use per hospital records/labs. Interventions directed to observe for signs/symptoms of withdrawal for detox, monitor conditions that may contribute to substance use, evaluate need for psych/behavioral health consult, reinforce the need for a plan for recovery/sobriety as a means of improving judgment and behavioral self-control to reduce the probability of relapse, and Social Service visits to provide support as needed.
Clinical record review identified Resident #6 was responsible for him/herself (had no Power of Attorney or court appointed Conservator that was responsible for him/her) and had a standing physician order for Leave of Absence (LOA) privileges.
A physician order dated 10/29/2023 directed Resident #6 may not have LOA privileges.
Interview with MD #1 on 11/06/2023 at 11:45 AM identified prior to 10/29/2023 Resident #6 had a physician order for LOAs from the facility. MD #1 had multiple discussions with Resident #6 regarding not returning to the facility timely from prior LOAs and behaviors that occurred when on LOA from the facility. MD #1 indicated although Resident #6 was alert, oriented and responsible for him/herself, due to Resident #6's behaviors during LOAs from the facility and refusal to access support services, on 10/29/2023 MD #1 discontinued Resident #6's LOA orders.
Interview with the DON, Administrator, RN #5, and SW #2, on 11/6/2023 at 1:20 PM identified prior to 10/29/2023 Resident #6 had a physician order for LOAs from the facility. Resident #6 was alert, oriented (cognitive assessment score of 15 out of 15), was independent with ADLs, ambulated independently, self-administered medications from a lockbox, and self-responsible for him/herself. Interview identified Resident #6 had refused support services for substance abuse, and when Resident #6 left the facility for LOAs, he/she did not return to the facility timely, several times was absent for days, and had hospital admissions for substance abuse while on LOA. Interview further identified the physician order for LOA privileges was discontinued on 10/29/2023; Resident #6 had no current orders for LOA from the facility, and if Resident #6 left the facility again on an LOA the facility would consider the resident was discharged .
Review of the facility Leave of Absence/Therapeutic Leave Policy dated 11/9/2020 identified a therapeutic leave of absence must be consistent with the patient's goals for care, be assessed by the comprehensive assessment, and incorporated into the comprehensive care plan, and cannot be a means of involuntary discharging the patient.
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 review, facility policy review and interviews for one of five Residents ...
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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 five Residents (Resident #2) reviewed for abuse, the facility failed to ensure adequate supervision to ensure residents were free from mistreatment. The findings include:
1.
Resident #1 was admitted with diagnoses that included dementia, stroke with resultant right sided hemiplegia (lack of muscle movement on one side of the body) and hemiparesis (muscle weakness on one side of the body). A quarterly MDS assessment dated [DATE] identified Resident #1 was alert and oriented and was independent to walk with a cane. The Resident Care Plan (RCP) dated 8/2/2023 identified Resident #1 had impaired thought and cognitive function. Interventions directed to observe and evaluate changes in cognitive status that included confusion, decision making capabilities and impulsivity and to evaluate the need for psych/behavioral consult.
Clinical record review identified Resident #1 was responsible for him/herself.
Review of Resident #1's clinical record identified a nursing note dated 9/12/2023 at 2:02 PM identified Resident #1 had taken a liking to a resident (Resident #2) and was observed directing Resident #2 to his/her room or to go outside. Resident #1 was redirected, became irate, and Social Services was updated.
2.
Resident #2 was admitted with diagnoses that included dementia with behavioral disturbance and depression. A quarterly MDS dated [DATE] identified Resident #2 had severe cognitive impairment, was independent to walk in room/corridor and supervision for dressing and personal hygiene. The RCP dated 6/8/2023 identified Resident #2 was at risk for fluctuating mood and the potential to exhibit physical behaviors with a history of resident-to-resident altercations. The interventions directed to allow time to express feelings, provide empathy, approach the Resident in a clam unhurried manner and remove from environment if necessary.
Clinical record review identified Resident #2 had a court appointed Conservator.
Review of Resident #2's clinical record identified a nursing note dated 9/12/2023 at 2:08 PM written by LPN #3, identified Resident #2 had taken a liking to Resident #1. Staff intervened a few times as Resident #1 tried to take Resident #2 to his/her room and Resident #2 was redirected away and noted to calm down.
A nursing note dated 9/17/2023 at 8:45 PM written by LPN #1, identified Resident #1 was observed kissing Resident #2 with a closed mouth on the lips and staff separated the residents.
Interview and clinical record review with LPN #3 on 10/30/2023 at 10:00 AM identified on 9/12/2023 and she observed Resident #1 loudly tell Resident #2 to go to Resident #1's room, and loudly directed Resident #2 to sit by him/her in the dining room. LPN #3 indicated she separated the residents, and then sent a text message to Social Worker (SW) #1 about the incident. LPN #3 further indicated she did not notify the nursing supervisor about the behaviors; she indicated that she wrote a nursing note and thought if she notified SW #1 then she did not need to notify the nursing supervisor. LPN #3 identified approximately one (1) week later she noticed that there were no new interventions put into place to address the behaviors that she observed on 9/12/2023, and she then contacted the Dementia Program Director (DPD). The DPD indicated to LPN #3 that she would follow up with SW #1. LPN #3 indicated she observed Resident #1 and Resident #2 together when she worked, holding hands and that Resident #1 continued to direct where Resident #2 sat when they were together on the unit, and she did not follow up any further; she did not notify the nursing supervisor.
Interview with SW #1 on 10/30/2023 at 11:30 AM identified she could not recall being notified of Resident #1's behaviors on 9/12/2023 or 9/17/2023. SW #1 identified if nursing had reported the behaviors to her, she would have expected nursing to also notify the nursing supervisor or place the information in the APRN communication book on the unit for follow up. The interview failed to identify that she notified the nursing supervisor or put a new intervention into place.
Interview with the DPD on 10/20/2023 at 11:20 AM identified after she was notified by LPN #8 that LPN #1 had observed Residents #1 and #2 had increased interest in each other, she notified SW #1 via a text message on 9/18/2023. The DPD indicated LPN #8 did not give her specific information, but she had read the nursing notes. The DPD asked SW #1 if there were any plans to move Resident #1 to another unit, and SW #1 indicated that she was working on it. The DPD identified although she believed nursing was working with social services to address the behaviors, she did not indicate that she notified the nursing supervisor or put a new intervention into place.
a.
A nursing note dated 9/27/2023 at 10:22 PM written by LPN #4, identified Resident #1 was observed telling Resident #2 to give him/her a kiss. Staff intervened and prevented the kiss by separating the residents and redirecting Resident #1, and close frequent supervision was provided by staff throughout the shift.
Clinical record review failed to identify new interventions were put into place to reduce the risk of additional incidents, after the staff observed behaviors on 9/12, 9/17 and 9/27/2023.
b.
A facility incident report dated 10/5/2023 at 5:15 PM identified a visitor reported they witnessed Resident #1 and #2 seated in the dining room and Resident #1 grabbed Resident #2's breast. The visitor further reported Resident #1 made a sexual gesture with his/her hand and then asked Resident #2 to go to Resident #1's room. Both residents were separated, and Resident #1 was put on one-to-one supervision pending psychological follow up visits.
Interview with RN #3 on 10/30/2023 at 10:37 AM identified that she was the supervisor on 10/5/2023 and she was called to the unit by the charge nurse who reported a visitor had observed inappropriate behavior between Resident #1 and Resident #2 in the dining room (after residents had finished the evening meal). Upon entering the dining room, RN #3 observed Resident #2 sitting in the dining room and Resident #1 was no longer in the area. The visitor identified he heard Resident #1 ask Resident #2 to go to his/her room while making a suggestive hand motion and pointing to his/her groin area. The visitor then indicated he/she observed Resident #2 stand up and touch Resident #2's breast over her/his clothing. Resident #2 then stood and walked to the other side of the dining room. RN #3 indicated Resident #2 could not recall the event, did not seem upset and had no injuries. Resident #1 was placed on one-to-one (1:1) supervision and was moved to another floor (private room). RN #3 indicated she was unaware of any other behaviors as documented in the medical record on 9/12, 9/17 and 9/27/2023, and identified that those behaviors should have been reported to the supervisor.
Interview and clinical record review with the ADNS on 10/20/2023 at 11:00 AM identified the supervisor should have been notified of the behaviors observed by staff on 9/12/2023, 9/17/2023 and 9/27/2023 with interventions put into place, and she did not know why they were not reported timely. Interview further identified the incident on 10/4/2023 should not have occurred.
Review of the facility Abuse Prohibition Policy, dated 10/24/2022, directed in part, the center prohibits abuse, mistreatment, neglect, and exploitation for all residents. Verbal abuse is identified as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families. Sexual abuse is defined as a non-consensual sexual contact of any type with a resident including sexual harassment, sexual coercion, or sexual assault.
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 F0660
(Tag F0660)
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 resident (Residen...
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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 resident (Resident #6) reviewed for discharge planning, the facility failed to ensure staff conducted adequate discharge planning timely for an independent resident. The finding includes:
Resident #6 was admitted during June 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, hypertension, and adjustment disorder.
Clinical record review identified Resident #6 was responsible for him/herself (had no Power of Attorney or court appointed Conservator that was responsible for him/her).
Review of the social services notes dated 6/12/2023 at 3:35 PM identified Resident #6 was admitted for an expected short-term stay, and a resident/family conference was initiated, with Resident #6, SW #1, and financial advisor present. Resident #6's expectations for length of stay was 31-100 days. The interdisciplinary team (IDT) determination for projected length of stay is 22-30 days. Resident #6 and the IDT were not in agreement upon projected length of stay and further discussion was recommended to reach an agreement.
The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was alert and oriented and required supervision with locomotion on/off unit. The Resident Care Plan (RCP) dated 9/8/2023 identified Resident #6 was at risk for substance use (alcohol/drugs) related to a history of cocaine use per hospital records/labs. Interventions directed to observe for signs/symptoms of withdrawal for detox, monitor conditions that may contribute to substance use, evaluate need for psych/behavioral health consult, reinforce the need for a plan for recovery/sobriety as a means of improving judgment and behavioral self-control to reduce the probability of relapse, and Social Service visits to provide support as needed.
Review of the social services note dated 6/23/2023 at 1:54 PM identified SW #1 met with Resident #6 and the business office to discuss insurance coverage. Resident #6 identified he/she wanted to explore placement in a residential care home (RCH) in a nearby town. The note identified SW #1 will continue to follow-up and provide support.
Review of the social services note dated 7/7/2023 at 1:56 PM identified SW #1 assisted Resident #6 in completing residential care home surveys, and SW #1 sent the completed surveys to the RCH.
Review of the social services note failed to identify any additional documentation addressing discharge planning between 7/7/23 and 11/6/2023.
Interview with SW #2 on 11/02/2023 at 2:20 PM identified initially, Resident #6 was followed by a different social worker and that social worker had made a referral to MFP. SW #2 identified although Resident #6 was independent and did not require long-term care in the facility (was independent with all care needs) and left the facility for extended periods, SW #2 was unable to verbalize a discharge plan for Resident #6.
Interview with the DON, Administrator, RN #5, and SW #2, on 11/6/2023 at 1:20 PM identified Resident #6 was responsible for him/herself, was alert, oriented, ambulated independently, was independent with care, self-administered medications, and was non-compliant with substance abuse interventions. Although interview identified Resident #6 was on a list for potential assistance with discharge through Money Follows the Person (MFP), the interview failed to identify any additional discharge planning or resources were utilized or involved the Ombudsman for possible resources for a discharge plan.
Review of the facilities Discharge Planning Process Policy dated 11/15/2022 identified the facility must develop and implement an effective discharge planning process that focuses on the patient's/resident's discharge goals, preparation of patients to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable re-admissions. Interprofessional Utilization Management (UM) and Discharge Planning meeting will be conducted to continue evaluation of discharge potential.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of eight resident...
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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 eight residents (Resident #7) reviewed for accidents, the facility failed to ensure an RN assessment was performed timely after a witnessed fall. The findings include:
Resident #7's diagnoses included vascular dementia, muscle weakness, chronic pain syndrome, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment and required extensive with two staff assistance for transfers, and required one staff assistance for ambulation and toilet use. The Resident Care Plan (RCP) dated 9/30/2023 identified Resident #7 had dementia and required assistance with ADLs. Interventions directed to provide moderate assistance for toileting needs and transfers, and to provide cueing for safety and sequencing to maximize current level of function.
A facility incident report and investigation dated 10/21/2023 at 10:30 AM identified Resident #7 stated he/she had fallen yesterday evening (10/20/2023) and complained of pain in his/her left hip.
A nursing note dated 10/21/2023 at 10:37 AM identified the resident reported he/she fell during the 3-11 shift on 10/20/2023 and the responsible party was contacted. The responsible party indicated the resident had notified them on 10/20/2023 of the fall and Resident #7 indicated he/she had a bruise. The provider was contacted to obtain an order for a left hip x-ray.
Review of the clinical record failed to identify a resident fall occurred or RN assessment was completed on 10/20/2023.
Review of the nursing note dated 10/21/2023 at 1:21 PM written by RN #2, identified Resident #7 indicated he/she fell on [DATE] at 10:30 AM and was presently unable to move his/her left leg without complaints of pain. RN #2 assessed Resident #7 and identified he/she was able to bend his/her left leg approximately 20 degrees before complaints of pain.
The nursing note dated 10/22/2023 at 6:29 AM indicated x-ray would be done this morning and as needed Oxycodone was administered for pain with good results.
The nursing notes dated 10/22/2023 at 3:41 PM identified the resident was transferred to the hospital related to a left hip fracture.
Review of the Hospital Diagnostic Studies radiology report (x-ray report) dated 10/22/2023 identified Resident #7 had a left-sided transcervical femur fracture with slight superior displacement of the proximal femur was visualized. Resident #7 was admitted to the hospital on [DATE] and had a left hip hemiarthroplasty (half of a hip joint replacement) on 10/23/2023.
Interview with LPN #2 on 11/6/2023 at 11:10 AM identified Resident #7 walked with one assist using a walker prior to 10/21/2023. LPN #2 identified on 10/20/2023, she was walking by Resident #7's room, and observed Resident #7 sitting on the floor between the edge of the bed and the wall with his/her walker nearby and NA #7 was with the resident. Resident #7 indicated he/she was tired after using the bathroom, and NA #7 indicated Resident #7 had just sat down. LPN #2 identified she assessed Resident #7 and obtained a Hoyer lift to assist to transfer Resident #7 into bed. LPN #2 further indicated she did not notify the nursing supervisor because it wasn't a situation such as abuse or neglect and didn't think it was necessary, and the following day Resident #7 reported the fall. LPN #2 identified she should have notified the supervisor.
Interview with NA #7 on 11/6/2023 at 3:40 PM identified on 10/20/2023 she was assigned to Resident #7 and after dinner time NA #6 assisted Resident #7 to the bathroom and notified her that Resident #7 would call ready. When Resident #7 used the call light, NA #7 went to assist Resident #7 and upon entering the room Resident #7 was coming out of the bathroom doorway with his/her walker and was noted to be shaking. NA #7 indicated she immediately attempted to retrieve Resident #7's wheelchair, but before she could get the wheelchair Resident #7 fell to the ground and she immediately notified LPN #2. NA #7 indicated she instructed LPN #2 to call the RN Supervisor, but LPN #2 told her to hold on and left the room. LPN #2 came back to Resident #7's room with a Hoyer lift and NA #6. NA #7 identified an RN assessment was not completed prior to transferring Resident #7 into bed.
Interview with the DON on 11/6/2023 at 2:30 PM identified LPN #2 should have reported the incident to the RN Supervisor at the time of the fall and an RN assessment should have been completed at the time of the fall.
Review of the facility Falls Management Policy dated 8/7/2023 directed in part, for post-fall management, to first evaluate the patient for injury.
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
Medical Records
(Tag F0842)
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 five Residents...
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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 five Residents, (Resident #3), reviewed for abuse, the facility failed to ensure the clinical record was complete and accurate to include an RN assessment after an allegation of abuse, and for three of eight residents (Resident #6, #7 and #8) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include document when a resident leaves and returns from a leave of absence, the facility failed to ensure a resident fall was documented timely, and the facility failed to ensure attendance/rescheduling of medical appointments were documented in the clinical record timely and failed to ensure a resident's scheduled medical appointments were documented in the clinical record and white out was not used on facility documentation for medical appointment scheduling. The findings include:
a. Resident #3 was admitted with diagnoses that included agoraphobia (fear of open spaces), chronic pain, insomnia, and depression. An admission MDS assessment dated [DATE] identified Resident #3 had moderate cognitive impairment and required extensive assistance for bed mobility, personal hygiene and was unable to walk in their room or on unit. The Resident Care Plan (RCP) dated 9/21/2023 identified Resident #3 was at risk for distressed/fluctuating mood due to anxiety, depression, and agoraphobia. Interventions directed to observe for signs and symptoms of worsening sadness, fear, or agitation and to provide a calm, quiet environment.
A facility incident report dated 9/28/2023 identified an unwitnessed allegation of resident-to-resident abuse was reported by Resident #3 at 12:30PM. Resident #3 alleged that earlier that morning at approximately 2:00 AM, a tall person (with description provided) wearing glasses put his/her hand over Resident #3's mouth. Resident #3 responded and screamed what do you want and alleged the person stood looking at Resident #3 until staff removed him/her from the room.
Interview and clinical record review with the DNS on 11/1/2023 at 1:30 PM identified although an RN assessment should have been documented, the DNS indicated the medical record lacked documentation of a RN assessment of Resident #3 after the allegation of abuse on 9/28/2023. She identified that an RN assessment is needed after an allegation of abuse, and she did not know why it was not documented.
Interview with RN #2 on 11/1/2023 at 1:45 PM identified that she was the supervisor on 9/28/2023 and that she evaluated Resident #3 after the allegation of abuse. RN #2 indicated she assessed the resident but did not document her assessment. RN #2 indicated she should have documented her assessment and she could not recall why she did not document the assessment.
No assessment policy was provided for surveyor review during survey.
b. Resident #6's diagnoses included hemiplegia and hemiparesis following cerebral infarct, diabetes mellitus, hypertension, and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 was alert and oriented and required supervision with locomotion on/off unit. The Resident Care Plan (RCP) dated 9/8/2023 identified Resident #6 was at risk for substance use (alcohol/drugs) related to a history of cocaine use per hospital records/labs and went on Leave Of Absence (LOA) without medications. Interventions directed to encourage to give ample notice of pending LOA so that medications can be ordered and delivered from pharmacy if staying out of facility for an extended period, and to explain risk versus benefits of taking/omitting prescribed medication.
Clinical record review identified Resident #6 was responsible for him/herself (had no Power of Attorney or court appointed Conservator that was responsible for him/her) and had a standing physician order for Leave of Absence (LOA) privileges.
Review of the clinical record and facility documentation identified the following:
i. On 6/30/2023 at 1:29 PM, Resident #6 signed out at the nurse's station for LOA and Resident #6 left on his/her own accord. Review failed to identify when Resident #6 would return and when Resident #6 did return from the LOA.
ii. A nursing note dated 7/2/2023 at 6:31 PM identified Resident #6 reported a fall when in [NAME] on 7/1/2023 when on LOA from the facility. Further review failed to identify when Resident #6 left the facility for the LOA and failed to identify when Resident #6 returned to the facility.
iii. Review identified on 9/26/2023 Resident #6 was on an LOA from the facility. Further review failed to identify when Resident #6 left the facility for the LOA and failed to identify when Resident #6 returned to the facility.
iv. A nursing note dated 9/27/2023 at 8:14 AM identified a call was placed to the resident and a message was left. A nursing note dated 9/27/2023 at 1:57 PM identified the DON notified the local police department to report that Resident #6 who had left on an LOA on 9/25/2023, had not returned to the facility. Further review failed to identify a nursing note that indicated when Resident #6 left the faciity on LOA. A nursing note dated 10/1/2023 at 4:00 PM identified Resident #6 returned to the facility from a six (6) day LOA.
Interview with DON on 11/2/2023 at 3:00 PM the DON indicated there should be a nursing note written when a resident leaves or returns from an LOA and she was unable to explain why they were not written.
Review of the facility Leave of Absence/Therapeutic Leave Policy dated 11/9/2020 identified the purpose of the policy is to document a resident's leave from and return to the center.
c.
Resident #7's diagnoses included vascular dementia, muscle weakness, chronic pain syndrome, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had moderate cognitive impairment and required extensive with two staff assistance for transfers, required one staff assistance for ambulation and toilet use. The Resident Care Plan (RCP) dated 9/30/2023 identified Resident #7 had dementia and required assistance with ADLs. Interventions directed to provide moderate assistance for toileting needs and transfers, and to provide cueing for safety and sequencing to maximize current level of function.
A facility incident report and investigation dated 10/21/2023 at 10:30 AM identified Resident #7 stated he/she had fallen the evening prior, on 10/20/2023 and complained of pain in his/her left hip. The APRN was notified and ordered to obtain an x-ray of the hip.
clinical record review failed to identify a resident fall occurred or an RN assessment was completed on 10/20/2023.
Interview with LPN #2 on 11/6/2023 at 11:10 AM identified Resident #7 walked with one assist using a walker prior to 10/21/2023. LPN #2 identified on 10/20/2023, she was walking by Resident #7's room, and observed Resident #7 sitting on the floor between the edge of the bed and the wall with his/her walker nearby and NA #7 was with the resident. Resident #7 indicated he/she was tired after using the bathroom, and NA #7 indicated Resident #7 had just sat down. LPN #2 identified she assessed Resident #7 and obtained a Hoyer lift to assist to transfer Resident #7 into bed. Further, although LPN #2 indicated she should have written a nursing note about the incident, she was unable to explain why she did not write a note.
Interview with the DON on 11/6/2023 at 2:30 PM identified LPN #2 should have written a nursing note reflecting the incident.
Although requested, the facility did not provide a policy related to documentation for surveyor review.
d.
Resident #8's diagnoses included malignant neoplasm of uterus and endometrium, dementia, and adjustment disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was alert and oriented and required extensive with two staff assistance for transfers and bed mobility, and one staff assistance for locomotion. The Resident Care Plan (RCP) dated 7/29/2023 identified Resident #8 may go out on a LOA with responsible party. Interventions directed to assist Resident #8 with signing the LOA book when leaving and returning to the unit and to ensure accompanied by a responsible party.
Review of the Hospital Discharge summary dated [DATE] identified Resident #8's scheduled future appointments included an appointment on 9/5/2023, for a CT scan at the hospital's outpatient center.
Review of the nursing notes failed to identify a note related to Resident #8's appointment on 9/5/2023; notes failed to identify if Resident #8 went to the appointment or if the appointment was rescheduled.
Interview with Medical Records Management (MRM) #1 on 11/6/2023 at 10:30 AM identified it was the nursing staff's responsibility to ensure they notify our department to coordinate and schedule all future appointments for a resident upon return from the hospital or other related services. MRM #1 identified Resident #8 was scheduled to attend his/her appointment on 9/5/2023 but was unable to confirm if Resident #8 went to the appointment. MRM indicated nursing was responsible to report to medical records if a resident refused or was unable to go to an appointment, and the appointment would be rescheduled. MRM #1 further indicated Resident #8 had a second appointment on 10/23/2023 for a CT scan.
Review of the Resident Appointment Requests Out of the Facility Sheet with MRM #1 on 11/6/23 at 10:40 AM identified Resident #8's appointment for a CT scan dated 10/13/2023 at 11:20 AM. The date and time of the appointment was identified to have been whited out with another date and time written over the whited out section. MRM #1 identified she does not know why or who used white out over the date and time. MRM #1 further indicated white out should not be used on the records, and indicated a new sheet should have been utilized for the appointment. MRM #1 was unable to verify if Resident #8 went out to any of his/her appointments, and indicated it was nursing's responsibility to notify the MRM if re-scheduling was needed, and medical records did not keep track of refusal/missed appointments.
Interview with RN #5 on 11/6/2023 at 3:30 PM identified the facility staff should not utilize white out on resident's clinical records. RN #5 indicated errors should be initialed and a new form or note should be documented/initiated. Further RN #5 indicated nursing notes should have indicated if Resident #8 went to appointments or if they were rescheduled.
Review of the facility Leave of Absence/Therapeutic Leave Policy dated 11/09/2020 identified the purpose of the policy is to document a resident's leave from and return to the center.
Although requested, the facility did not provide a policy related to documentation for surveyor review.
Aug 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, facility policies and interviews for one sampled resident (Resident #1)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of sexual abuse reported to the facility by hospital personnel, the facility failed to report the allegation to the State Agency at the time the allegation of abuse was reported. The findings include:
Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required extensive assistance with getting in and out of the bed and chair, turning and repositioning when in bed, dressing, toilet use, personal hygiene, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) on both sides, and was always incontinent of bowel and bladder.
The Facility Reported Incident form dated 8/7/23 at 12:45 PM identified Resident #1 was observed with swelling to left groin, hip, and thigh. Resident #1 was sent to the hospital for further evaluation related to immediate x-rays ordered would take five (5) to six (6) hours to be obtained at the facility.
The nurse's note dated 8/7/23 at 4:22 PM identified Resident #1 was observed with swelling to the left groin, hip, and thigh, Resident #1 was guarded with attempts to palpate the area, there was no bruising or discoloration to left leg noted and Resident #1 was sent to the hospital for further evaluation.
Review of the hospital documentation identified a social worker's note dated 8/10/23 at 7:02 PM identified the Social Worker was re-consulted for suspected sexual abuse based on injuries, elder abuse was reported to the State on admission to the hospital. The note indicated the Social Worker collaborated with the Attending Physician and Assistant Nurse Manager who reported concern regarding bruising pattern to Resident #1's upper inner thigh, and suspected sexual abuse based on injuries while at his/her facility and per the team Resident #1's skin noted to have bruising on bilateral lower extremities, right eye, right forehead, left groin, upper left thigh, and edema to the left upper thigh. The note identified the Social Worker called and spoke with the facility's Nursing Supervisor to discuss the above concerns.
Interview with the Director of Nursing (DON) on 8/16/23 at 2:25 PM identified she was informed on 8/10/23 by the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, regarding the allegation of sexual abuse via group text. The DON indicated she did not direct RN #1 to investigate the allegation, however the Administrator was aware of the allegation of sexual abuse.
Interview with the 3-11PM Nursing Supervisor, RN #1, on 8/16/23 at 2:50 PM identified she received a phone call from the hospital social worker regarding Resident #1's ecchymotic wound in the groin area which was symptomatic according to them with sexual assault. RN #1 indicated she immediately notified the Administrator and the Director of Nursing via text and relayed the message. RN #1 identified she did not receive any directions from the DON or the Administrator.
Interview with the Administrator on 8/16/23 at 3:00PM identified on 8/10/23 he received a text message from RN #1 regarding Resident #1, indicating the hospital social worker called the facility staff to report concerns regarding bruising in the upper inner thigh, questionable sexual assault. The Administrator indicated Resident #1's injuries had been reported as a fracture to the State Agency and the hospital social worked stated she will be reporting the allegation of sexual abuse, so he did not report it because it would be double reporting.
Review of the Abuse Prohibition policy directed immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee well report allegations to the appropriate state and local authorities. Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in the material facts originally reported.
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 clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of sexual abuse reported to the facility by hospital personnel, the facility failed to initiate an investigation of the allegation of sexual abuse at the time the allegation of abuse was reported. The findings include:
Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required extensive assistance with getting in and out of the bed and chair, turning and repositioning when in bed, dressing, toilet use, personal hygiene, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) on both sides, and was always incontinent of bowel and bladder.
The nurse's note dated 8/7/23 at 4:22 PM identified Resident #1 was observed with swelling to the left groin, hip, and thigh, Resident #1 was guarded with attempts to palpate the area, there was no bruising or discoloration to left leg noted and Resident #1 was sent to the hospital for further evaluation related to the immediate x-rays ordered would take five (5) to six (6) hours to be obtained at the facility.
Review of hospital documentation dated 8/7/23 identified Resident #1 was diagnosed with a closed displaced oblique fracture of the shaft of the left femur, a closed displaced fracture of acromial process, the left shoulder, and the hospital suspected elder abuse.
Review of the hospital documentation identified a social worker's note dated 8/10/23 at 7:02 PM identified the Social Worker was re-consulted for suspected sexual abuse based on injuries, elder abuse was reported to the State on admission to the hospital. The note indicated the Social Worker collaborated with the Attending Physician and Assistant Nurse Manager who reported concern regarding bruising pattern to Resident #1's upper inner thigh, and suspected sexual abuse based on injuries while at his/her facility and per the team Resident #1's skin noted to have bruising on bilateral lower extremities, right eye, right forehead, left groin, upper left thigh, and edema to the left upper thigh. The note identified the Social Worker called and spoke with the facility's Nursing Supervisor to discuss the above concerns.
Review of the facility's investigation identified the investigation of sexual assault was initiated on 8/17/23, seven (7) days after the facility was informed by the hospital social worker.
Interview with the Director of Nursing (DON) on 8/16/23 at 2:25 PM identified she was informed on 8/10/23 by the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, regarding the allegation of sexual abuse via group text. The DON indicated she did not direct RN #1 to investigate because she was not at the facility, however the Administrator was aware of the allegation of sexual abuse. The DON identified she returned to work on 8/14/23 and although she was aware of the allegation of sexual abuse, she did not investigate the allegation of sexual abuse on 8/14/23.
Interview with the 3-11PM Nursing Supervisor, RN #1, on 8/16/23 at 2:50 PM identified she received a phone call from the hospital social worker regarding Resident #1's ecchymotic wound in groin area which was symptomatic according to them with sexual assault. RN #1 indicated she immediately notified the Administrator and the Director of Nursing via text and relayed the message. RN #1 identified she did not receive any directions from the DON or the Administrator.
Interview with the Administrator on 8/16/23 at 3:00 PM identified on 8/10/23 he received a text message from RN #1 regarding Resident #1, indicating the hospital social worker called the facility staff to report concerns regarding bruising in the upper inner thigh, questionable sexual assault. The Administrator indicated Resident #1's incident had been reported to the State Agency regarding the fractures and it was the same incident, so he would not expect the facility staff to conduct an investigation regarding the allegation of sexual abuse.
Review of the Abuse Prohibition policy directed to initiate an investigation within 24 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent, clinical examination for signs of injury if indicated, causative factors, and interventions to prevent further injury. The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews was included.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for one sampled resident (Resi dent #1) who was dependen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, and interviews for one sampled resident (Resi dent #1) who was dependent on staff for activities of daily living, the facility failed to ensure a resident did not sustain injuries of unknown origin. The findings include:
Resident #1's diagnoses included Alzheimer's disease, dementia, contracture right and left knee, contracture right and left hand.
The Resident Care Plan dated 7/14/23 identified Resident #1 was at risk for falls due to moderate intellectual disability and lack of safety awareness. Interventions directed when in bed, leave bed in a lower position and place the call light within reach while in bed or close proximity to bed.
The Resident Care Plan dated 7/14/23 identified Resident #1 required assistance with Activities of Daily Living care in bathing, grooming, personal hygiene, dressing, eating, turning, and repositioning when in bed, getting in and out of the bed and chair, movement on the unit, and toileting. Interventions directed total assistance of one (1) person for toileting needs secondary to incontinence of bowel and bladder, provide total assistance of two (2) persons with getting in and out of the bed and chair using a mechanical lift, and provide Resident #1 with extensive assistance of one (1) person for personal hygiene, dressing, and bathing.
The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required extensive assistance with getting in and out of the bed and chair, turning and repositioning when in bed, dressing, toilet use, personal hygiene, had functional limitation in range of motion to the upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) on both sides, and was always incontinent of bowel and bladder.
The Facility Reported Incident form dated 8/7/23 at 12:45 PM identified Resident #1 was observed with swelling to the left groin, hip, and thigh, Resident #1 was sent to the hospital for further evaluation related to the immediate x-rays ordered would take five (5) to six (6) hours to be obtained. The report indicated the facility received a call that Resident #1 had a fracture of the left femur and Resident #1 had no recent falls noted.
The nurse's note dated 8/7/23 at 4:22 PM identified Resident #1 was observed with swelling to the left groin, hip, and thigh, Resident #1 was guarded with attempts to palpate the area, there was no bruising or discoloration to left leg noted and Resident #1 was sent to the hospital for further evaluation.
Review of hospital documentation dated 8/7/23 identified Resident #1 was diagnosed with a closed displaced oblique fracture of the shaft of the left femur, a closed displaced fracture of acromial process (the outer end of the shoulder blade that forms the highest part of the shoulder), the left shoulder, and the hospital suspected elder abuse.
The facility's Summary Report dated 8/14/23 identified Resident #1 was observed with swelling to the left upper thigh without discoloration on 8/7/23 and after an assessment Resident #1 was transferred to the hospital for further evaluation. The report indicated during Resident #1's hospitalization, the hospital x-rays showed displaced angulated fracture of the left femoral shaft likely extending into the intertrochanteric region. There was also left shoulder dislocation with left upper chest wall protrusion and surrounding heterotopic ossification suggest chronic process. The report identified the conservator had decided Resident #1 was not a candidate for surgery and had been on Hospice care twice while a resident at the facility. In conclusion, after a comprehensive investigation that included interviews, observations, and the record reviews, the facility had determined that the fractures may have been caused by a diagnosis of osteoporosis, the chronic contractures, and impulsive movements Resident #1 exhibited.
Interview with the Director of Nursing (DON) on 8/16/23 at 11:55 AM identified during her extensive investigation she found out Resident #1 had repetitive movements, moving his/her right and left arm back and forth to his/her face especially while Resident #1 was being fed by the staff, scissored his/her legs, crossed his/her legs while in bed and had no recent falls.
Subsequent interview with the Director of Nursing (DON) on 8/16/23 at 2:25 PM identified Resident #1 required a Hoyer lift for transfers with assistance of 2 staff, had contractures to upper and lower extremities. The DON indicated the staff used pillows to position Resident #1 on the left side because Resident #1's left leg was flaccid, and the staff would find his/her leg dangling off the bed and they would put the leg back on the bed.
Interview with the Radiologist, MD #3 on 8/21/23 at 2:15 PM identified the cause of the displaced angulated fracture of the left femoral shaft likely extending into the intertrochanteric region was an injury typically sustained from a fall, not typically self-inflicted injury. MD #3 indicated this type of injury required high impact trauma like a fall and was unlikely caused by Resident #1's movement in bed, i.e. scissoring, crossing, dangling his/her left leg off the bed. MD #3 identified he did not see any indications of a pathologic fracture.
May 2023
4 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three resident...
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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 residents (Resident #4), reviewed for wandering, the facility failed to ensure staff verified that the wander guard bracelet was functioning and that the generator room door was secured, and as a result the resident eloped from the facility, was located 0.3 miles away, and staff were unaware he/she was not in the facility from 4:15 AM until notified by a caller from the apartment complex at approximately 6:50 AM (2 hours and 33 minutes). The failures resulted in a finding of Immediate Jeopardy, past non-compliance. The finding includes:
Resident #4 was admitted with diagnoses that included dementia with psychotic disturbance, orthostatic hypotension, and hallucinations.
A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on unit and dressing. Review of the Resident Care Plan (RCP) dated 3/11/2023 identified Resident #4 was at risk for elopement related to cognitive loss and a family member requested placement of the wander guard device. Interventions directed use of wander guard security bracelet, redirect Resident #4 if near exits or doorways, ambulate with rolling walker and one (1) staff assistance.
A physician's order dated 2/25/2023 directed to check function of wander guard every night shift.
Review of the Treatment Administration Record (TAR) for April 2023, identified the wander guard function was initialed to identify the function was checked nightly on 4/23, 4/24 and 4/25/2023. The TAR failed to identify that staff verified wander guard placement every shift.
A facility reportable event form dated 4/25/2023 at 7:30 AM identified Resident #4 had wandered away from the facility to the building across the street and stated he/she was going to church. Resident #4 was returned to the facility by police and a wander guard bracelet was placed on his/her right ankle. Resident #4 had no complaints of pain, and no injuries were identified.
A nursing note dated 4/25/2023 at 7:30 AM identified Resident #4 returned to the facility, a body assessment was performed, and Resident #4 had no injuries.
A review of the Emergency Medical Service (EMS) report dated 4/25/2023 at 6:56 AM identified EMS was called at 6:50 AM and evaluated Resident #4 at 6:56 AM. RN #1/supervisor arrived on scene and indicated to EMS Resident #4 had dementia and must have gotten out of the facility somehow.
Observations identified the apartment building where Resident #4 was found, was located across a State road (route) with three (3) lanes of traffic in one direction and two (2) lanes of traffic in the opposite direction, 0.3 miles from the facility.
Interview and observations with the Maintenance Supervisor on 5/10/2023 at 1:11 PM identified the elevators on Resident #4's unit had wander guard alarms, and required a code to be entered to de-activate the alarm for use of the elevator if a wander guard bracelet was nearby. Further, Resident #4's room was located near the nurse's station and close to the elevators. The Maintenance Supervisor indicated he reviewed the facility video surveillance tape which was recorded on 4/25/2023, and the tape revealed Resident #4 had accessed the wander guard alarmed dietary elevator on the second floor and was recorded exiting that elevator on the first floor at 4:15 AM. The next video recorded Resident #4 walking to a door to the generator room/main water supply room. Resident #4 was able to open the door (the door was unsecured) and was viewed to then exit the facility through an unsecured door to the outside at 4:17 AM. The Maintenance Supervisor indicated the generator room door should always be secured (locked) and indicated the type of lock on the door did not always lock securely. The Maintenance Supervisor further identified, subsequent to Resident #4's elopement on 4/25/2023, the door lock style was changed to a lock that required a key to unlock the door.
Interview with Person #1 on 5/10/2023 at 10:20 AM identified on 4/23/2023 as he/she was exiting the facility with Resident #4's laundry and the wander guard alarm sounded at the elevator. Person #1 notified the charge nurse (LPN #2) the wander guard bracelet may be in the laundry, and staff verified Resident #4 did not have the wander guard bracelet on.
Interview with LPN #2 on 5/10/2023 at 11:16 AM identified that on 4/23/2023 Person #1 notified her that the wander guard bracelet may be in the laundry as the alarm had sounded when entering the elevator. LPN #2 verified Resident #4 did not have a wander guard bracelet on, and she did not replace the bracelet because she did not see an order to check the wander guard bracelet placement every shift. Further, LPN #2 indicated because she did not see a physician's order and there was no unit list/resource of residents at risk for wandering for staff reference, she did not notify the nursing supervisor.
Interview with RN #1 on 5/10/2023 at 2:30 PM identified that she was the evening nurse on 4/23/2023 (took over after LPN #4 left at the start of the shift) and was not aware Resident #4 required a wander guard bracelet to be applied. Further, RN #1 indicated the TAR did not direct her to check placement of a wander guard device for Resident #4; there was no physician order that directed her to verify placement of the wander guard bracelet during her shift. RN #1 indicated that if there was an order, it would have shown up on the TAR, and then she would have reapplied the bracelet.
Interview with LPN #1 on 5/10/20203 at 10:30 AM identified that she was Resident #4's nurse during the 11 PM to 7 AM shifts on 4/24 and 4/25/2023. LPN #1 indicated although she had documented that she had checked the wander guard function during both shifts, LPN #1 indicated she had only checked the placement. LPN #1 indicated the wander guard bracelet was on during both shifts, but she did not verify the function of the device. LPN #1 indicated she received re-education to ensure she verifies the placement and the function of the device.
Interview with RN #3/supervisor on 5/12/2023 at 8:30 AM identified on 4/25/2023 at approximately 6:40 AM she received a call from someone at the apartment complex across the street asking her if they were missing a resident, and she replied no. The person informed her that Resident #4 was in the lobby. RN #3 went to the apartment complex and observed Resident #4 with the police and EMS. RN #3 indicated Resident #4 must have left the facility without staff knowledge while staff were busy. RN #3 indicated when Resident #4 returned to the facility, he/she was not wearing a wander guard bracelet, and a bracelet was reapplied.
Interview with the DNS on 5/10/2023 at 10:48 AM identified Resident #4 should not have been able to exit the facility without staff knowledge. The DNS indicated staff are expected to check residents at least four (4) times a shift and the staff should have identified that Resident #4 was not on the unit prior to receiving notification from the police at approximately 6:58 AM. She identified there should have been physician orders that directed staff to check placement of the wander guard device and it should have been replaced when it was identified as missing on 4/23/2023, and the generator room door should have been locked.
The facility policy, Patient Security Bracelet, dated 11/30/2020 directed in part, a Resident/Patient security bracelet (e.g., Wander guard) will be at a minimum of every shift for placement and daily for function to ensure patient's safety.
The facility policy, Elopement of Patient, dated 10/24/2022, directed in part, that the process for managing patients at risk of elopement would include a elopement risk identification form and to place the form in a binder accessible to staff.
Subsequent to the 4/25/2023 incident, the facility implemented an immediate plan of correction that included immediate staff education regarding accurately entering wander guard orders into the clinical record, checking placement of wander guard bracelets every shift and replacing timely, checking function of wander guard bracelets daily, performing rounds to monitor resident's whereabouts, and to lock the generator room door. Audits were conducted and are ongoing, and results reviewed in quality assurance meetings. This plan was verified as fully implemented on 4/29/2023, resulting in Immediate Jeopardy past non-compliance.
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 F0553
(Tag F0553)
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 resident...
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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 residents (Resident #4), reviewed for wandering, the facility failed ensure quarterly care plan meetings were held to include the resident and/or the resident's responsible party. The findings include:
Resident #1 was admitted with diagnoses that included dementia with psychotic disturbance, orthostatic hypotension, and hallucinations. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on unit and dressing. Review of the Resident Care Plan (RCP) dated 3/11/2023 identified Resident #4 was at risk for elopement related to cognitive loss and a family member requested placement of the wander guard device. Interventions directed use of wander guard security bracelet, redirect Resident #4 if near exits or doorways, ambulate with rolling walker and one (1) staff assistance.
A review of Resident #4's medical record identified that the last Resident Care Conference was held on 10/11/2022 (seven months ago).
Interview with Social Worker #1 (SW#1) on 5/12/2023 at 1:30 PM identified she was responsible to coordinate Resident Care Conference meetings/invite residents and their responsible parties. SW #1 indicated although meetings should be held at least every three (3) months, the last resident care conference meeting for Resident #4 was held on 10/11/2022 (seven months ago). SW #1 indicated meetings should have been held and the resident and family should have been invited.
Review of facility Person Centered Care Plan Policy dated 10/24/22, directed in part, the care plan is reviewed and revised after each assessment known as the Minimum Data Set (MDS) and that the interdisciplinary team in conjunction with the patient and/or patient representative as appropriate with review the effectiveness of the care plan.
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 review, facility documentation review, facility policy review, and interviews for one of three resident...
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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 residents (Resident #4), reviewed for wandering, the facility failed ensure the care plan was reviewed and revised by the interdisciplinary team timely. The findings include:
Resident #1 was admitted with diagnoses that included dementia with psychotic disturbance, orthostatic hypotension, and hallucinations. A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on unit and dressing. Review of the Resident Care Plan (RCP) dated 3/11/2023 identified Resident #4 was at risk for elopement related to cognitive loss and a family member requested placement of the wander guard device. Interventions directed use of wander guard security bracelet, redirect Resident #4 if near exits or doorways, ambulate with rolling walker and one (1) staff assistance.
A review of Resident #4's medical record identified Resident MDS assessments were completed on the following dates: 10/11/2022 quarterly assessment; 12/8/2022 PPS 5-day assessment; 1/9/2023 quarterly assessment; 3/1/2023 PPS 5-day assessment; 3/28/2023 annual assessment; and 4/19/2023 PPS discharge assessment. Further review identified the last Resident Care Conference was held on 10/11/2022 (seven months ago); 5 MDS assessments were completed without a resident care conference meeting held.
Interview with Social Worker #1 (SW#1) on 5/12/2023 at 1:30 PM identified she was responsible to coordinate Resident Care Conference meetings. SW #1 indicated although meetings should be held at least every three (3) months or after an MDS assessment, the last resident care conference meeting for Resident #4 was held on 10/11/2022 (seven months ago). SW #1 indicated Resident #4 moved from one floor to another in the facility and although the MDS assessments were conducted, Resident #4's name was not included on the care conference schedule on the new floor. SW #1 was unable to explain why five (5) MDS assessments were completed without a Resident Care Conference held to review Resident #4's care plan.
Subsequent to surveyor's inquiry, interview with the Director of Social Services on 5/12/2023 at 2:30 PM identified staff were provided with re-education to hold resident care conference meetings.
Review of facility Person Centered Care Plan Policy dated 10/24/22, directed in part, the care plan is reviewed and revised after each assessment known as the Minimum Data Set (MDS) and that the interdisciplinary team in conjunction.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three resident...
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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 residents (Resident #4), reviewed for wandering, the facility failed to ensure the resident's wander guard placement was checked every shift and the function was checked daily, and the facility failed to ensure the wander guard device was replaced timely, and the facility failed to ensure elopement risk assessments were completed timely. The findings include:
Resident #4 was admitted with diagnoses that included dementia with psychotic disturbance, orthostatic hypotension, and hallucinations.
A Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had moderately impaired cognition, had no wandering behavior in the prior seven (7) days, and required extensive assistance with one (1) staff for locomotion on unit and dressing. Review of the Resident Care Plan (RCP) dated 3/11/2023 identified Resident #4 was at risk for elopement related to cognitive loss and a family member requested placement of the wander guard device. Interventions directed use of wander guard security bracelet, redirect Resident #4 if near exits or doorways, ambulate with rolling walker and one (1) staff assistance.
A physician's order dated 2/25/2023 directed to check function of wander guard every night shift.
Interview with Person #1 on 5/10/2023 at 10:20 AM identified on 4/23/2023 as he/she was exiting the unit with Resident #4's laundry and the wander guard alarm sounded at the elevator. Person #1 notified the charge nurse/LPN #2 the wander guard bracelet may be in the laundry, and staff verified Resident #4 was not wearing a wander guard bracelet/device.
Interview with LPN #2 on 5/10/2023 at 11:16 AM identified that on 4/23/2023 Person #1 notified her that the wander guard bracelet may be in the laundry as the alarm had sounded when entering the elevator. LPN #2 verified Resident #4 did not have a wander guard bracelet on, and she did not replace the bracelet because she did not see an order to check the wander guard bracelet placement every shift. Further, LPN #2 indicated because she did not see a physician's order and there was no unit list/resource of residents at risk for wandering for staff reference, she did not notify the nursing supervisor.
Interview with RN #1 on 5/10/2023 at 2:30 PM identified that she was the evening nurse on 4/23/2023 (took over after LPN #4 left at the start of the shift) and was not aware Resident #4 required a wander guard bracelet to be applied. Further, RN #1 indicated the TAR did not direct her to check placement of a wander guard device for Resident #4; there was no physician order that directed her to verify placement of the wander guard bracelet during her shift. RN #1 indicated that if there was an order, it would have shown up on the TAR, and then she would have reapplied the bracelet.
Interview with LPN #1 on 5/10/20203 at 10:30 AM identified that she was Resident #4's nurse during the 11 PM to 7 AM shifts on 4/24 and 4/25/2023. LPN #1 indicated although she had documented that she had checked the wander guard function during both shifts, LPN #1 indicated she had only checked the placement. LPN #1 indicated the wander guard bracelet was on during both shifts, but she did not verify the function of the device. LPN #1 indicated she received re-education to ensure she verifies the placement and the function of the device.
Interview with RN #4 (unit manager) on 5/10/2023 at 11:40 AM that she was unaware that Resident #4's order for check wander guard placement was not active after the Resident returned to the facility on 2/23/2023. She identified that during the readmit process the orders would be either newly entered or reactivated by the supervisor or RN as part of the admission process but was unsure how only the one order for check function was currently active in the system.
Interview with the DNS on 5/10/2023 at 10:48 AM identified staff should have replaced the wander guard bracelet/device on 4/23/2023 when they verify Resident #4 was not wearing a device. The DNS further indicated, on 4/23/2023 when LPN #2 verified Resident #4 was not wearing a wander guard device, she would expect LPN #2 to check the actual physician's orders and to notify the supervisor for further direction. The DNS further indicated Resident #4 was transferred to the hospital on 2/22/2023 and upon readmission on [DATE], the order for wander guard placement checks every shift should have been reactivated (only the order to check function of the wander guard daily on the night shift was reactivated). The DNS was unable to explain why the order was not entered correctly and she would have expected the admitting nurse to enter the orders.
Review of the facility Patient Security Bracelet Policy, dated 11/30/2020 directed in part, a resident security bracelet (e.g., Wander guard) will be inspected at a minimum of every shift for placement and daily for function to ensure patient's safety.
Review of the facility Elopement of Patient Policy, dated 10/24/2022, directed in part, the process for managing patients at risk of elopement included quarterly elopement risk assessments, an elopement risk identification form, and to place a from in a binder accessible to staff.
Although requested, a wander guard list or communication form for residents at risk for elopement was not provided.
a. Review of the clinical record identified the most recent wander risk assessment was completed on 6/1/2021. Further review identified although Resident #4 was noted to have diagnoses of dementia and hallucinations, ambulated independently and walked the halls and looked out the window, Resident #4 was identified as a low risk for elopement.
Interview with RN #4 (unit manager) on 5/10/2023 at 11:40 AM identified Resident #4 was an elopement risk due to wandering behavior and a dementia diagnosis and ambulated independently in the hallway with a walker.
Interview with the DNS on 5/11/2023 at 2:13 PM identified that the nursing elopement risk assessment should be completed on admission, readmission, an elopement, or significant change and if wander guard gets removed for instance for a procedure or out to hospital, and was unable to explain last elopement assessment was completed on 6/1/2021. The DNS indicated the nursing risk assessment should be completed at least annually, and was unable to explain why a resident with dementia, hallucinations and independent ambulation was identified as low risk on 6/1/2021.
Additional clinical record review identified Resident #4 was readmitted to the facility after hospitalizations on the following dates: readmitted on [DATE]; readmitted on [DATE]; readmitted on [DATE]: readmitted on [DATE]; and readmitted on [DATE] (five readmissions since the wander risk assessment was completed on 6/1/2021).
Review of the facility Elopement of Patient Policy dated 10/24/2022, directed in part, Patients/Residents (hereinafter patient) will be evaluated upon admission, readmission, quarterly or with a change in condition as part of the clinical assessment process.
Although requested, the facility did not provide an elopement risk assessment policy.
Jun 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 2 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 2 residents (Resident #175) reviewed for dignity, the facility failed to ensure a urinary device was covered for privacy. The findings include:
Resident #175 was admitted to the facility with diagnoses that included cervical mass with lymphadenopathy with invasion to right ureter and right hydro nephrosis.
A physician's order dated 5/1/22 directed right nephrostomy tube to gravity drainage every shift for urinary drainage, empty drainage bag every 8 hours and document output. Additionally, change dressing to urostomy insertion site every shift, cleanse with wound cleanser apply dressing every 11:00 PM – 7:00 AM shift.
The admission MDS dated [DATE] identified Resident #175 had intact cognition, required extensive assistance for toileting, personal hygiene, and dressing and 2-person assistance with transfers.
The care plan dated 5/25/22 identified Resident #175 had a nephrostomy tube related to malignancy of ureter. Interventions included to monitor for signs and symptoms of infection and irrigate for blockage as ordered.
Observation on 5/31/22 at 10:50 AM identified Resident #175 was self-propelling in the hallway, and his/her urinary device was visible with yellow urine in it (appeared as a leg bag). The device was resting on the right side of the resident's right hip/thigh in the wheelchair on top of the cushion. Resident #175 whet down the hallway from nurses station to end of the hallway and back, and then around nurses station and was heard asking for a staff member to empty the urinary device.
Interview with Resident #175 on 5/31/22 at 11:00 AM indicated he/she had a urine tube coming out of his/her right lower back and he/she urinates into the urinary bag that was lying next to him/her in the wheelchair full of yellow urine. Resident #175 indicated the bag usually hangs off the front of the wheelchair with Velcro, but when it gets full the bag gets too heavy so he/she takes the urine bag and lays it next to his/her leg in the wheelchair so people can't see it until staff empties it. Resident #175 indicated since he/she came to the facility, they have not given him/her anything to cover the urinary bag and was not aware there was something made to cover the urinary bag. Resident #175 indicated he/she would like something to cover it up, because he/she would prefer people did not see it. Resident #175 indicated he/she was embarrassed to have people see the urine in the bag, especially when urine is in it.
Interview with LPN #1 on 5/31/22 11:10 AM indicated Resident #175 has been self-propelling in the wheelchair in the hallways at least for the last 2 days. LPN #1 indicated she did notice the urinary bag was laying in the wheelchair next to Resident #175 the last couple of days. LPN #1 noted she did not provide Resident #175 with a privacy bag because she did not know if the facility had a privacy bag for the nephrostomy urinary bags. LPN #1 indicated the foley catheter bags the facility use have a privacy flap attached to them. LPN #1 indicated she would call central supply to see if they had a privacy bag for the nephrostomy bag to provide to Resident #175.
Interview with the Unit Manager (RN #1) on 5/31/22 at 11:45 AM indicated Resident #175 does self-propel in the hallway in the wheelchair with the urinary bag lying in the wheelchair next to his/her leg. RN #1 indicated she does not know how Resident #175 transfers to and from the bed to the wheelchair. RN #1 indicated the urinary bag should be covered for privacy, but she was afraid to provide one to Resident #175 because the nephrostomy tube would be pulled out because she felt they come out easily. RN #1 indicated she would get a privacy bag for Resident #175.
Interview with the DNS on 6/1/22 at 1:10 PM indicated Resident #175's urinary device should have been covered for privacy. The DNS indicated after survey inquiry, nursing got a cover for the urinary device and provided it to Resident #175.
Interview with Resident #175 on 6/1/22 at 1:20 PM indicated he/she was pleased to have the privacy bag for the urinary device.
Review of facility Considerate and Respectful Treatment Policy identified dignity means that in their interactions with patients, any staff, carry out activities that assist the patient to maintain and enhance his/her self-esteem and self-worth and incorporate the patient ' s needs, preferences, and choices. Additionally, staff will refrain from practices that are demeaning to patients such as: keeping urinary catheter bags uncovered.
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, and interviews for 1 of 4 residents (Resident #143) reviewed for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for 1 of 4 residents (Resident #143) reviewed for positioning, the facility failed to complete an RN assessment after a change in skin condition. The findings include:
Resident #143 was admitted with diagnoses that include hemiplegia/hemiparesis of the left side, diabetes and dementia.
A significant change MDS dated [DATE] identified that Resident #143 had severely impaired cognition, required extensive 2-person assistance for bed mobility and personal hygiene and was at risk for developing pressure ulcers.
The care plan dated 5/13/22 identified Resident #143 required bilateral leg splints due to contractures, with interventions that included the resident to wear bilateral knee splints morning to evening, caregiver to check skin prior to donning. Additionally, the care plan identified that Resident #143 was at risk for skin breakdown due to bilateral leg splints, impaired sensation, and limited mobility.
A nursing progress note dated 5/19/22 at 11:14 AM identified that a skin check was performed with abrasion identified on the right breast, left knee, left inner thigh, and a DTI (deep tissue injury) on the left toe (tip). External device removed and site inspected: skin intact.
Interview and observation with LPN #3 on 6/2/22 AT 11:30 AM identified that she had seen as per her note a bruised area on the top of the residents left big toe and had reported the bruise to the Unit Manager. LPN #3 indicated the Unit Manager had assessed the area but was not sure if she needed to write a note as the resident is hospice and stated that hospice would do the weekly assessments. LPN #3 indicated she thought it was due to the socks the resident ' s family member had put on the resident as they were very tight, and she had asked the family member to stop putting them on.
Observation with LPN #3 identified a flat. approximately 1.5 cm linear blue/purple area at the tip of the left big toe, unchanged per LPN #3 from her previous note on 5/19/22. LPN #3 indicated that she works with Resident #143 routinely.
An APRN order dated 6/3/22 at 1:17 PM directed diabetic foot care and to check feet/toes daily, and to note any alterations in skin integrity.
Interview with RN #1 (Nurse Manager) on 6/6/22 at 12:00 PM identified that she could not recall being told that Resident #143 had an area on the left toe but had reviewed the 5/17/22 note that the LPN had written and evaluated Resident #143 ' s toe on 6/2/22. RN #1 indicated she would expect the nurses to tell her about any new area on the skin and she then would assess it and document the evaluation in the resident's medical record. RN #1 identified by her assessment on 6/2/22, she wasn't sure it was a DTI, it was more like a blood blister and indicated she did not document the assessment in the medical record and that she planned to add a late entry as she did not document anything at on 6/2/22.
Interview with the DNS on 6/6/22 at 12:15 PM identified that she would expect the LPN to tell the RN if she saw anything on the skin, and the RN should assess and document the assessment. The DNS indicated she would expect both to document their findings in the medical record. The DNS indicated ongoing weekly assessments should be completed and documented. Further, the DNS indicated she was aware that RN #1 saw the area on Thursday and did not document her assessment and indicated that she had directed RN #1 to do an addendum.
A nursing progress note dated 6/6/22 at 4:12PM (late entry for 6/2/22) identified that Resident #143 ' s left great toe was evaluated with tip of toe with purplish discoloration; appears as intact blood blister measuring 1.5 cm wide by 0.5 cm long without drainage or signs of infection.
The Nursing assessment policy directs that a LPN may assist the RN to collect data for the assessment, assessments will be reviewed and certified as complete within 24 hours.
The facility failed to ensure an RN assessment was completed after the LPN identified a 1.5 cm linear blue/purple area at the tip of Resident #143 ' s left big toe, on 5/19/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #1...
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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 2 of 4 residents (Resident #115 and 201) reviewed for pressure ulcers, for Resident #115 the facility failed to have an RN conduct an initial wound assessment when the new wound was identified, and for Resident #201, the facility failed to identify a new pressure ulcer and provide treatments in accordance with professional standards. The findings include:
1.
Resident #115's diagnoses included Alzheimer's disease, dementia, anemia, peripheral vascular disease, hypertension and contractures.
The care plan dated 4/4/21 identified Resident #115 was at risk for skin breakdown related to actual skin impairment, abnormal posture, weight loss and contractures. Interventions included staff to complete weekly skin assessments to include measurements and stage of wound and provide wound treatment as ordered.
The annual MDS dated [DATE] identified Resident #115 had severely impaired cognition, required extensive assistance with bed mobility, dressing and personal hygiene, total dependence with transfer and locomotion on unit. Further review identified the resident was at risk of developing pressures/injuries.
A change in condition evaluation form, created by LPN #1, and dated 5/24/22, identified Resident #115 with open area on coccyx noted by staff during morning care. No complaints of pain, discomfort or distress noted. The physician and family were updated, and new treatment order was obtained to cleanse open area on coccyx with wound cleanser and to apply dry clean dressing daily. The nursing evaluation note failed to reflect documentation that a comprehensive skin assessment to include the characteristics of the open area on coccyx had been completed.
The wound evaluation consult by MD #1 dated 5/25/22 (one day after open area noted) identified Resident #115 with a stage II pressure wound to sacrum for at least 3 days duration that measured 1.2 cm by 1.1 cm by 0.1 cm with no exudate. Treatment plan included gauze island with boarder apply once daily for 30 days. MD #1 recommended to limit sitting to 60 minutes, off load wound, reposition per facility protocol, turn side to side and front to back in bed every 1-2 hours if able, gel cushion to chair and group 2 mattress and nutritional consult.
The wound evaluation consult by MD #1 dated 6/1/22 identified Resident #115 with a stage II pressure wound to sacrum that measured 0.9 cm by 0.3 cm by 0.1 cm with no exudate and wound progress improved.
Interview and review of the clinical record with the DNS on 6/1/22 at 12:00 PM failed to reflect why the resident's clinical record lacked documentation pertaining to a pressure ulcer assessment on 5/24/22 when the resident was identified with the open area. The DNS indicated that an initial wound assessment should have been conducted by an RN at the time the wound was identified. The DNS further identified that Wound Evaluation Report was completed on 5/25/22 (one day after open area noted).
Interview with LPN #2 on 6/1/22 at 1:00 PM identified that the residents open wound was assessed by the unit manager, RN #2, when identified on 5/24/22 (this is in conflict with RN #2 ' s interview). LPN #2 further identified that she thought that she documented the measurements and wound description on the change in condition evaluation form that she completed on that day. Additionally, LPN #2 identified that she can complete a late entry describing the open wound.
Interview with RN #2 on 6/1/22 at 3:35 PM identified that although he was the unit manager on 5/24/22, he was not notified of the residents new open wound. RN #2 further identified the pressure ulcer should had been assessed when identified and the assessment was to include measurements, stage, drainage and description of wound bed. Additionally, RN #2 identified if notified, he would have assessed the open wound, determined the stage and documented in nursing progress notes.
Interview with MD #1 on 6/2/22 at 9:38 AM identified that the expectation was to assess wounds when identified to determine proper treatment.
Review of the facility policy on Skin Integrity Management identified the purpose to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The policy directed to perform wound observations and measurements and complete skin integrity report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.
2.
Resident #201's diagnoses included diabetes and chronic kidney disease.
The hospital Discharge summary dated [DATE] identified Resident #201 had an incision to the left upper chest. The summary failed to reflect any other wounds or breakdown of Resident #201's skin.
The admission MDS dated [DATE] identified Resident #201 had moderately impaired cognition, required extensive assistance with bed mobility, transfers, walk in room, dressing, eating, toilet use and personal hygiene. The MDS further identified that Resident #201 was at risk of developing pressure ulcers/injuries but had no pressure ulcer/ injury.
A physician's order dated 5/12/22 directed to perform daily diabetic foot check every- day shift.
The nurse admission note dated 5/12/22 at 6:23 PM identified that the skin was reviewed, the note did not indicate a check mark where it questioned Foot evaluation- for any redness, maceration or breakdown and record if present.
The care plan dated 5/13/22 identified Resident #201was at risk for skin breakdown related to advanced age and decreased activity. Interventions included to provide preventative skin care, observe skin condition daily with care and report changes noted, and weekly skin check by licensed nurse
Observation on 5/31/22 at 10:56 AM identified both of Resident #201's lower legs were swollen, the left leg and foot was lying on bed and right leg was elevated on standard pillow. Resident #201 complained that the right heel felt sore and was hurting. Observation of the right heel, with staff present, identified an open dime size area that was red, with no drainage noted, dermis exposed. The resident identified that the heel was painful at times and that was why he/she knew it was there. A dry padded bandage was noted in the resident ' s sock.
Interview with RN #4, the Infection Preventionist, (IP) on 5/31/22 at 2:45 PM identified license nurses or nurse aides are expected to provide update to her regarding any skin changes observed on residents. RN #4 further identified that she was not made aware that Resident #201 had any skin issues and indicated that Resident #201 was not on the wound list.
After surveyor's inquiry, Resident #201 was placed on the wound evaluation list and evaluated by wound MD on 6/1/22.
Review of MD #1 (wound doctor's) note dated 6/1/22 identified that Resident #201 had a right heel stage 2 fluid filled blister that had reabsorbed. Recommendations included to apply skin prep and off-load with off-loading boots.
Interview with LPN #5 on 6/2/22 at 11:25 AM identified that on 5/30/22 the nurse aide updated her that Resident #201's right heel was red. LPN #5 identified that she went to observe and noted the right foot was resting on the bed and a check of the heel identified that it was red. LPN #5 indicated she repositioned the leg on a pillow to ensure the heel was not resting on the bed and placed a padded bandage under heel held in place by the sock to prevent further damage to the skin. LPN #5 indicated she did not make a note or tell anyone because she didn't think anything of it because the heel was just red.
Observation of Resident #201 accompanied by RN #4 on 6/2/22 at 1:35 PM identified that Resident #201 was in bed in semi-upright position with the left heel resting on bed, and the right on a standard pillow, the right heel was covered by sock. When asked if Resident #201 ' s left foot should be resting on the bed, RN # 4 identified that nothing was wrong with the residents left foot. The right foot sock was removed by RN #4 to inspect the wound on the heel. Observation identified that when RN #4 touched the resident's right heel, the resident instantly pulled his/her foot from RN #4's hand and complained of pain. Subsequently, LPN #6 applied off-loading boots to both Resident #201's feet.
Review of the facility's skin integrity management policy directed that a comprehensive skin inspection should be performed on the resident and should be completed on admission/readmission and weekly. Findings should be documented in the residents' clinical record. The skin integrity status and need for prevention, intervention, or treatment would be determined from assessment information. Implement pressure ulcer prevention for identified risk factors, determine the need for heel protectors and heel lift devices and utilize per manufacturer's guidelines. Notify physician, dietitian, and rehab to obtain orders and/or services as required and notify resident or resident's responsible party of plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #1...
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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 #16) reviewed for accidents, the facility failed to ensure the resident was assessed by a Registered Nurse after the resident fell out of bed and prior to an LPN moving the resident off the floor. The findings include:
Resident #16 was admitted on [DATE] with diagnoses that included dementia and diabetes.
The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition, required 2-person extensive assistance for transfer, was non-ambulatory and dependent for dressing, toileting, hygiene and eating.
The corresponding care plan dated identified Resident #16 was at risk for falls related to dementia, cognitive loss, history of frequent falls and lack of safety awareness. Interventions included to always place call light within reach, when in bed - place all necessary personal items within reach and staff to check if resident had blanket and provide her blanket if needed on first safety round on 11:00 PM – 7:00 AM shift.
The reportable event form dated 2/3/22 at 3:15 AM identified Resident #16 had rolled out of bed.
The care plan dated 2/3/22, revised after the fall included the intervention of bed in low position.
A reportable event form dated 2/15/22 at 8:25 PM identified Resident #16 had another unwitnessed fall and was found lying on his/her right side on the floor next to the bed.
The nurse's note dated 2/15/22 at 8:54 PM identified a 5.5 cm by 0.5cm by 0.2 cm laceration was noted on the resident ' s forehead after the fall. In addition, Resident #16's nose was noted with swelling, was purple in color and with moderate amount of bleeding. Resident #16 was transferred to the hospital at 8:45 PM via ambulance.
The hospital Discharge summary dated on 2/16/22 identified Resident #16 had a c-spine fracture, bilateral comminuted nasal bone fractures, questionable rib fracture, and forehead laceration.
Interview with LPN #4 on 6/3/22 at 12:00 PM identified that the nurse aide called her because Resident #16 was on the floor. When she came into the resident ' s room, she saw Resident #16 lying on the floor with blood on the floor. LPN #4 observed Resident #16 was coughing on her own blood related to bleeding from the forehead and nose. LPN #4 further indicated that the bed was at the low position and she transferred Resident #16 back to bed herself to attend to his/her injury. In addition, LPN #4 identified that she was aware that an RN needed to assess the resident for injury after the fall; however, she was not aware of the facility policy of no lift policy.
Attempt to interview RN #3 was unsuccessful.
Interview with the DNS on 6/6/22 at 2:10 PM identified that an RN was responsible for assessing the resident after the fall and that LPN #4 should have waited for an RN to assess Resident #16 for major injury prior to transferring the resident from the floor. The DNS also indicated that LPN #4 should not have picked up Resident #16 off the floor herself. LPN #4 is no longer employed in the facility.
The Fall Management policy identified to response to a patient fall to evaluate and monitor patient for 72 hours after a fall, investigate the fall circumstances, implement immediate interventions after the fall, notify the physician/responsible party and update care plan with new interventions as appropriate.
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 observation, review of the clinical record, facility documentation and interviews for 1 of 2 residents (Resident #205) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation and interviews for 1 of 2 residents (Resident #205) who were reviewed for nutrition, the facility failed to follow physician's order to monitor the resident ' s weight. The findings include:
Resident #205's diagnoses included hypertension, diabetes, anemia, gastritis, and post feeding tube placement 4/12/22.
The admission MDS dated [DATE] identified Resident #205 required extensive assistance with bed mobility, dressing toilet use and personal hygiene and required total assistance with eating.
The MDS further identified that the resident had a swallowing disorder that included coughing or choking during meals or when swallowing medications.
The care plan dated 5/18/22 identified Resident #205 had a feeding tube to meet nutritional needs because of swallowing difficulties related to brain injury. Interventions included to maintain nothing by mouth to eat, weigh and alert dietitian and physician to any significant loss or gain in weight
A physician's order dated 5/10/22 directed Resident #205 to have NPO diet (nothing by mouth) and continuous tube feeding every shift at 85ml/per hour.
A physician's order dated 5/18/22 directed to weigh Resident #205 every evening shift on Monday, Wednesday, and Friday.
Review of the weight chart dated 5/10/22 identified Resident #205 weighed 136 lbs.
The nutritional assessment note dated 5/18/22 identified Resident #205 had a nutrition problem, had a feeding tube surgically placed and should have NPO diet (nothing to eat or drink through the mouth) and a weighed 136lbs. on 5/10/22. BMI (body max index) was 17.9 (underweight). The note further identified interventions that included maintain NPO diet and weigh Resident #205 as ordered.
Review of the weight chart dated 5/27/22 identified Resident #205 weighed 123.7 lbs., a 12.3 lbs. loss.
Observation on 5/31/22 at 11:25 AM identified Resident #205 lying in semi- upright position in bed asleep was not arousable with greeting, tube feeding in progress.
Review of the weight chart dated 6/2/22 identified Resident #205 weighed 124.1 lbs. Review of the weight chart 5/10/22 to 6/2/22 failed to reflect any other weights.
Interview with the Dietitian on 6/7/22 at 3:14 PM identified that the order for weights was requested by the physician to monitor fluid intake. The Dietitian further identified that it was her responsibility to monitor Resident #205's weights and identified that when she realized the weights were not being obtained as ordered, she emailed the APRN, Physician, and ADNS to notify them that the weights were not being obtained. This email was first sent on 5/18/22 then again on the 19th, 20th, and 25th. On 5/31/22 she included the DNS on email because the weights were still not being obtained. She added that she did not realize that Resident #205 had a weight loss until the 31st of May after nursing did a weight on the 27th which was the Friday before the Holiday weekend. When she saw how much weight the resident had lost, she emailed and included the DNS.
Interview with MD #2 on 6/7/22 at 9:45 AM identified that Resident #205's weight check was ordered for three days a week Monday, Wednesday, and Friday to monitor fluids. MD #2 identified that she received the email from Dietitian and thought the issue was being addressed. MD #2 further identified that she was not notified of Resident #205's weight loss until a week prior to Resident #205 being sent out to hospital, and it was not enough time to evaluate what could have contributed to resident's significant weight loss.
An interview and clinical record review with LPN #6 on 6/7/22 at 10:38 AM identified that an order for weights is usually a nurse's responsibility and is placed on the residents' medication administration record, it is the responsibility of the nurse to direct nurse aide to perform weights as ordered. She reviewed the MAR and identified that the clinical record did not to reflect documentation of Resident #205's weight every Monday, Wednesday and Friday as ordered by physician.
Interview with DNS on 6/7/22 at 11:25 AM identified that she attended morning meetings that are conducted daily with department heads including ADNS and she was never told about Resident #205 ' s weights that were not being obtained as ordered. She further identified that it was the Dietitian that provided an update via email on 5/31/22 which was two days prior to Resident #205 being sent out to hospital.
Review of the facility's weight policy directed that the licensed nurse would perform weight checks as per order and notify the physician/ APRN and dietitian of significant weight changes. The weight will be entered in the resident's clinical record on that shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Res...
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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 #99) reviewed for food and nutrition services, the facility failed to ensure the resident was not served foods the resident had an allergy to and caused an allergic reaction. The findings include:
Resident #99 was admitted to the facility with diagnoses that included fibromyalgia, epilepsy, narcolepsy, and irritable bowel syndrome.
The Nutrition assessment dated [DATE] at 11:49 AM by the Dietitian noted liberalized diet in place, multiple food allergies.
The quarterly MDS dated [DATE] identified Resident #99 had intact cognition and required supervision for eating.
The care plan dated 4/12/22 identified Resident #99 requires assistance for ADL's (activities of daily living). Interventions included to provide the resident with set up for eating.
A physician's order dated 4/25/22 directed to provide a regular liberalized diet. The orders indicated the resident had allergies to banana, egg, milk, onion, pepper, and wheat. Additionally, the order directed to administer the EpiPen solution 0.3mg/0.3ml inject 1 application subcutaneously as needed for anaphylaxis protocol.
The nurse's note dated 5/22/22 identified that Resident #99 reported that he/she was served a salad for dinner that contained onions of which he/she was allergic to. Resident #99 did not eat the onion but being in contact with the salad caused him/her to have a reaction. Resident #99 was observed scratching his/her right arm repeatedly. Call placed to physician and order obtained for Benadryl and first dose given.
The SBAR summary note dated 5/22/22 at 6:57 PM identified that nursing observation, evaluation, and recommendations noted Resident #99 was served salad with onions which he/she was allergic to and caused itchy skin. Subsequent to physician notification, a new order for Benadryl liquid 50 mg now and then Benadryl 25 mg every 6 hours as needed was obtained.
The APRN progress note dated 5/24/22 at 11:40 PM indicated Resident #99 was seen as a follow up on complaints of hives after being served salad with onions that the resident has communicated, he/she was severely allergic to onions. Resident #99 noted he/she did not eat the onions, but they were on the salad. On examination the rash has resolved. Resident #99 with mild hives status post exposure to allergen. Resident #99 denies eating allergen but was in close contact causing bilateral arms to itch. Symptoms resolving upon examination, allergy list checked with resident and verified onion allergy was on list. Patient has EpiPen order as needed.
Interview with Resident #99 on 5/31/22 at 10:47 AM indicated he/she has food allergies to onions, eggs, peppers, bananas, and wheat bread. Resident #99 indicated on Sunday 5/22/22 he/she asked for a salad and the salad had onions on it and he/she didn't notice them at first and did not eat any but was highly allergic to onions and had a reaction. Resident #99 indicated the kitchen last Monday had open face sandwiches on wheat bread and served the sandwich with the wheat bread to him/her despite the allergy to wheat bread. Resident #99 indicated the kitchen also sends him/her bananas and he/she can't eat them. Resident #99 indicated he/she wishes the kitchen would get it right. Resident #99 noted the kitchen also sends foods with pepper in it. Resident #99 indicated a few days ago the kitchen sent chicken leg quarter and the chicken isn't fully cooked every time he/she receives it and has told the kitchen he/she no longer wanted the chicken leg quarters, but still receives them.
Observation of Resident #99's lunch tray on 5/31/22 at 12:55 PM noted a plate with a baked chicken leg quarter, a 4-ounce bowl of salad, red potatoes, and sliced carrots. Meal ticket on the tray indicated no chicken leg quarters and a list of allergies.
Interview with Resident #99 on 5/31/22 at 12:58 PM indicated he/she did not want the chicken leg, so he/she asked for a salad. Resident #99 indicated when the girl from the kitchen brought the first salad it came up with a hardboiled egg on it and she is allergic to eggs, and it is on her ticket to not give eggs. Resident #99 indicated she told the dietary person to take that salad back and to get another salad with no eggs, no onions, and no tomatoes. Resident #99 noted the second salad came up correctly.
Interview with Dietary Supervisor #1 on 5/31/22 at 2:10 PM indicated the nurse called her in the kitchen and noted Resident #99 did not want the chicken leg quarters so Resident #99 wanted a chef salad without onions and tomatoes. Dietary Supervisor #1 noted the chef salad normally comes with a hard-boiled egg cut in half, so the nurse said no onions and no tomatoes so that was what she brought. Dietary Supervisor #1 indicated she just went by what the nurse told her and did not look at the meal ticket at all to look for Resident #99's allergies. Dietary Supervisor #1 indicated when she brought the first salad with the eggs on it to Resident #99, Resident #99 informed her, he/she was allergic to eggs and could not have that salad. Dietary Supervisor #1 indicated she would make a new salad. Dietary Supervisor #1 noted she went to the kitchen and looked in meal tracker for Resident #99's diet and allergies before she made the second salad with no eggs, onions, and tomatoes. Dietary Supervisor #1 indicated it was her fault because she did not look at the meal ticket prior to bringing the first salad up to Resident #99 and went by what the nurse said. Dietary Supervisor #1 noted she should have looked at the meal ticket before bring food to any resident and not just go by what the nurse asks for.
The meal ticket for lunch on 5/31/22 for Resident #99 indicated on the bottom, allergies: egg (whole), onion, milk to drink, chili pepper, banana, green and red peppers, milk and milk products, whole wheat products (can have enriched white bread products). Additionally, listed no chicken quarters.
The facility menu for week 2 Tuesday lunch on 5/31/22 listed honey glazed chicken, creamed red potatoes, kale garnish, and sliced carrots.
Interview with the DNS on 6/1/22 at 2:45 PM indicated her expectation was that Resident #99 would not receive food items he/she was allergic to. The DNS indicated the allergies were on the meal tickets and the dietary staff should be reading the meal ticket prior to delivering food to Resident #99. The DNS indicated she was not aware of Resident #99 receiving or having an allergic reaction to any food in the last 6 months. The DNS indicated if Resident #99 had a reaction her expectation would be for the nurse to do an assessment and fill out the SBAR change of condition form and notify the physician. The DNS indicated if the residents tongue began to swell to send the resident to the emergency room. The DNS indicated there was not an accident and incident report done for any allergic reactions and there was not any for Resident #99 for having an allergic reaction from food dated 5/22/22. The DNS indicated her expectation was the allergies would be care planned. The DNS after clinical record review indicated the dietitian did not have it in the care plan.
Interview with the Dietitian on 6/1/22 at 3:05 PM indicate the dietary staff were fully aware that Resident #99 had multiple food allergies and her expectation was the resident would not receive food she was allergic to. The Dietitian indicated she was not aware Resident #99 had received any food he/she was allergic to in the last couple of weeks. The Dietitian indicated she did not have the allergies in the care plan because she had put it in her assessment. The Dietitian indicated she would put it in the care plan now.
Interview with the Dietary Service Manager on 6/2/22 at 11:30 AM indicated on 5/31/22 the nurse called down and asked for a salad with no onions and no tomatoes so when the cook prepared the chef salad it comes with carrots, turkey, ham, and eggs. The Dietary Manager indicated that Dietary Supervisor #1 did not look at the list of Resident Allergies Report next to the phone in the kitchen to check and make sure there was not anything in the salad that Resident #99 would have an allergy to. The Dietary Manager indicated the Dietary Supervisor #1 was responsible to check that list before bringing the food up to Resident #99. The Dietary Manager indicated she suspended Dietary Supervisor #1 for this incident and will do education when she returns to work. The Dietary Manager indicated the meal ticket for Resident #99 did indicate no chicken leg quarters and indicated Resident #99 only likes the chicken breast but sometimes there is no breast so the cook will give Resident #99 the chicken leg quarter and should not have given that and should have given the alternate. The Dietary Manager indicated sometimes when the food shipment comes in there is only chicken breast and sometimes only chicken leg quarters.
Interview with the DNS on 6/2/22 at 12:10 PM indicated the risk management for Resident #99 the last entry was in March and there was nothing listed in April 2022. The DNS indicated there was not an reportable event form done for the 5/22/22 incident when Resident #99 had a reaction to food.
Review of the facility Resident Allergies Report noted Resident #99 had multiple allergies Banana, chili pepper, egg (whole), green/red pepper, milk to drink, onions, whole wheat products (can have enriched white bread products).
Review of the Anaphylaxis Reaction Policy and Procedure identified evaluate for clinical signs and symptoms of anaphylaxis for skin generalized hives, widespread redness, itching, conjunctivitis, or swelling of eyes, lips, tongue, mouth, face, or extremities. If resident exhibits signs and symptoms of anaphylaxis obtain emergency medications epinephrine and/or Benadryl. Administer Benadryl 50 mg IM. Enter the accident and incident report into the Risk Management Portal. Report event as required by state and local regulations. Event including date and time, interventions, vital signs, patients' condition and response, notifications of physician and response, medication administered.
Review of the Allergic and Adverse Reactions identified the facility will establish a system to identify and communicate patients' allergies and/or any adverse reactions. Allergies and or adverse reactions pose a risk to patient safety and therefore must be determined as soon as possible. Observe patient for signs and symptoms of allergies/adverse reaction and report to physician and pharmacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation interviews and review of the facility policy, the facility failed to store food in sanitary conditions. These findings include:
Observation with the Dietary Services Manager on 5/...
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Based on observation interviews and review of the facility policy, the facility failed to store food in sanitary conditions. These findings include:
Observation with the Dietary Services Manager on 5/31/22 at 11:00 AM identified that two of the two refrigerators had four (4) opened 32 ounce containers of liquid whole egg gallon without the benefit of a date on the containers. Each container was 1/2 to 3/4s full.
Interview with the Dietary Services Manager at the time of the observation identified that all food items should be labeled and dated when opened. She further identified that the food service worker who opens or stores the item, is responsible to label the items.
Review of the Facility Policy and Procedure, Food and Nutrition Services use by dating guidelines identified that eggs that are stored in the refrigerator should be dated so a used by date could be established with the day of preparation or opening is considered Day 1 in the use by date.
Subsequent to the surveyor's inquiry, the Dietary Services Manager disposed of all unlabeled items on 5/31/22.
Oct 2019
9 deficiencies
CONCERN
(D)
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 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 #39) reviewed for abuse, the facility failed to report allegation of abuse to the State agency. The findings include:
Resident #39 was admitted to the facility on [DATE] with diagnoses that included thoracic spine injury, quadriplegia and chronic pain.
The care plan dated 2/18/19 identified Resident #39 was grieving the loss of independence. Interventions included to allow time for expression of feelings, provide empathy, encouragement, and reassurance. Additionally, provide social services visits and support, as needed.
A physician's order dated 5/3/19 directed Resident #39 may go on leave of absence (LOA) with non-narcotic medications.
The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required extensive assistance of 2 staff for bed mobility and transfers. Additionally, Resident #39 required extensive assist of 1 staff member for personal hygiene and dressing and was totally dependent for toilet use. Resident #39 was always incontinent of bowel and bladder. Resident #39 has limited range of motion to both upper and lower extremities.
Review of a police report dated 6/2/19 identified police were dispatched to the facility on 6/2/19 at 11:42 PM on a resident report of a threatening complaint against a staff member. The resident stated a verbal disagreement occurred because he/she did not like NA #1 and told her to leave. Resident #39 reported that NA #1 replied with (let me tell you something [explicative], there isn't anything you can do about it) referencing that she was in his/her room when he/she had requested her to leave a couple of times. Resident #39 reported feeling threatened.
A nurse's note dated 6/2/19 at 12:48 AM identified that after receiving care, Resident #39 came to the nurse's station to request the supervisor. At 1:43 AM, Resident #39 was in a power wheelchair at nurse's station waiting for the police. At 1:48 AM a police officer spoke with Resident #39 and the resident agreed to go to bed.
A social service note dated 6/5/19 at 6:57 PM identified that she was made aware Resident #39 wanted to file a complaint. The Social Worker spoke with Resident #39 detailing the events that took place on Saturday night during the 11:00 PM - 7:00 AM shift. Resident #39 knows a report was filed and he/she was waiting for staff to get back to him/her on a resolution. The Social Worker informed Resident #39 that the facility needs time to interview staff and do an investigation and indicated that someone would get back to him/her regarding complaint.
Interview on 10/21/19 at 11:25 AM with Resident #39 identified about 4 months ago he/she was threatened by NA #1 and there was another nurse aide present in the room (NA #2). NA #1 told Resident #39 (look here [explicative], you know where I come from there isn't anything you can do) with her finger in the residents face almost touching his/her nose. Resident #39 indicated once NA #1 and NA #2 left the room, the resident called the police and told the supervisor he/she felt threatened by NA #1. The supervisor did not send NA #1 home because the facility was already short staffed, and the other nurse aides threatened to go home if they sent NA #1 home. Resident #39 indicated he/she spoke to the DNS about what happened however, as of today, no one has told him/her the conclusion of the investigation.
Interview with Administrator on 10/21/19 at 12:15 PM identified he was aware of the incident and the DNS had a report and investigation on the incident.
Interview with the DNS on 10/23/19 at 9:50 AM identified Resident #39 has a history of making accusations against staff and indicated Resident #39 doesn't like NA #1. The DNS identified he had a copy of the police report for that incident, which occurred on 6/2/19 and indicated NA #1 was not suspended.
Interview with the Supervisor, (RN #2) on 10/23/19 at 10:15 AM indicated she was aware Resident #39 called the police as she unlocked the doors and rode the elevator up to the unit with the police officer to see Resident #39, who was waiting at the nurses' station as they came off the elevator. RN #2 indicated she does not remember if Resident #39 told her he/she was threatened. After the officer left Resident #39 agreed to care.
Interview with Records Clerk #1 on 10/23/19 at 10:30 AM indicated that the police report was complete on 6/24/19 and someone had requested a copy. The areas on the copy are redacted because the victim did not pick the copy up him/herself.
Interview with NA #1 on 10/23/19 at 11:25 AM indicated she knocked on Resident #39's door to help NA #2 provide care and the resident was sitting in the electric wheelchair and told NA #1 to get out. NA #1 indicated Resident #39 then drove at her and she backed out of the doorway and the resident passed by her in the wheelchair. NA #1 identified the supervisor told her to she had to go home because Resident #39 reported that she had threatened him/her. NA #1 indicated she went with the supervisor and a union delegate to the first floor and called the DNS to discuss the incident. NA #1 indicated the DNS told her that she was to switch residents and stay away from Resident #39, and write a statement. NA #1 indicated the police were called and the officer spoke with her and informed her that Resident #39 reported that she had threatened him/her. NA #1 gave her statement to the supervisor that evening.
Interview with Social Worker #1 on 10/23/19 at 12:30 PM indicated she was aware and spoke with Resident #39 on 6/5/19 and the resident reported that NA #1 pointed her finger in his/her face and threatened him/her so he/she called the police. Resident #39 informed Social Worker #1 that he/she was verbally threatened. Social Worker #1 indicated nursing staff were aware and were following up with the investigation into the incident.
Interview with the DNS on 10/23/19 at 2:00 PM indicated he went to the police department and picked up the police report but doesn't remember what day. Additionally, the DNS indicated he did read the complete report and he feels that it was never about the resident being abused or threatened, it was because Resident #39 just doesn't like that nurse aide. The DNS indicated he did speak with the supervisor and the staff the night of the incident but doesn't recall anyone stating that the resident felt threatened. The DNS stated he felt the resident just didn't want NA #1 in his/her room.
Although requested, a reportable event on the allegation that Resident #39 was threatened by NA #1 was not provided.
Although attempted, an interview with NA #2 was not obtained.
Review of the Abuse Policy identified abuse is prohibited. Employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. Reporting a suspicion of a crime to an immediate supervisor does not meet the obligation to report. An example of verbal abuse is threats of harm, and saying frightening things to a resident. When staff receive information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report the allegation involving verbal abuse no later than 2 hours after the allegation is made by a resident. Only an investigation can rule out abuse, neglect or mistreatment. Initiate an investigation within 24 hours of an allegation of abuse. The investigation will be thoroughly documented. The facility will protect residents from further harm during the investigation. The facility will assign a social worker or designee to monitor the resident's feeling concerning the incident, as well as the residents' involvement in the investigation. The administrator or designee will report the findings of all completed investigations within 5 working days to the Department of Public Health.
Although staff were aware of the allegation on 6/2/19 that Resident #39 felt threatened by NA #1, the facility failed to report the incident to the State agency within mandated timeframes.
CONCERN
(D)
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 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 #39) reviewed for abuse, the facility failed to complete a thorough investigation, and failed to take measures to protect the resident while the investigation was in progress. The findings include:
Resident #39 was admitted to the facility on [DATE] with diagnoses that included thoracic spine injury, quadriplegia and chronic pain.
The care plan dated 2/18/19 identified Resident #39 was grieving the loss of independence. Interventions included to allow time for expression of feelings, provide empathy, encouragement, and reassurance. Additionally, provide social services visits and support, as needed.
A physician's order dated 5/3/19 directed Resident #39 may go on leave of absence (LOA) with non-narcotic medications.
The quarterly MDS dated [DATE] identified Resident #39 had intact cognition, required extensive assistance of 2 staff for bed mobility and transfers. Additionally, Resident #39 required extensive assist of 1 staff member for personal hygiene and dressing and was totally dependent for toilet use. Resident #39 was always incontinent of bowel and bladder. Resident #39 had limited range of motion to both upper and lower extremities.
Review of a police report dated 6/2/19 identified police were dispatched to the facility on 6/2/19 at 11:42 PM on a resident report of a threatening complaint against a staff member. The resident stated a verbal disagreement occurred because he/she did not like NA #1 and told her to leave. Resident #39 reported that NA #1 replied with (let me tell you something [explicative], there isn't anything you can do about it) referencing that she was in his/her room when he/she had requested her to leave a couple of times. Resident #39 reported feeling threatened.
A nurse's note dated 6/2/19 at 12:48 AM identified that after receiving care, Resident #39 came to nurse's station to request the supervisor. At 1:43 AM, Resident #39 was in a power wheelchair at nurse's station waiting for the police. At 1:48 AM a police officer spoke with Resident #39 and the resident agreed to go to bed.
A social service note dated 6/5/19 at 6:57 PM identified that she was made aware Resident #39 wanted to file a complaint. The Social Worker spoke with Resident #39 detailing the events that took place on Saturday night during the 11:00 PM - 7:00 AM shift. Resident #39 knows a report was filed and he/she was waiting for staff to get back to him/her on a resolution. The Social Worker informed Resident #39 that the facility needs time to interview staff and do an investigation and indicated that someone would get back to him/her regarding complaint.
Interview on 10/21/19 at 11:25 AM with Resident #39 identified about 4 months ago he/she was threatened by NA #1 and there was another nurse aide present in there room (NA #2). NA #1 told Resident #39 (look here [explicative], you know where I come from there isn't anything you can do), with her finger in the residents face almost touching his/her nose. Resident #39 indicated once NA #1 and NA #2 left the room the resident called the police and told the supervisor he/she felt threatened by NA #1. The supervisor did not send NA #1 home because the facility was already short staffed, and the other nurse aides threatened to go home if they sent NA #1 home. Resident #39 indicated he/she spoke to the DNS about what happened however, as of today, no one has told him/her the conclusion of the investigation.
Interview with Administrator on 10/21/19 at 12:15 PM identified he was aware of the incident and the DNS had a report and investigation on the incident.
Interview with the DNS on 10/23/19 at 9:50 AM identified Resident #39 has a history of making accusations against staff and indicated Resident #39 doesn't like NA #1. The DNS identified he had a copy of the police report for that incident, which occurred on 6/2/19 and indicated NA #1 was not suspended.
Interview with the Supervisor, (RN #2) on 10/23/19 at 10:15 AM indicated she was aware Resident #39 called the police as she unlocked the doors and rode the elevator up to the unit with the police officer to see Resident #39, who was waiting at the nurses' station as they came off the elevator. RN #2 indicated she does not remember if Resident #39 told her he/she was threatened. After the officer left, Resident #39 agreed to care.
Interview with Records Clerk #1 on 10/23/19 at 10:30 AM indicated that the police report was complete on 6/24/19 and someone had requested a copy. The areas on the copy are redacted because the victim did not pick the copy up him/herself.
Interview with NA #1 on 10/23/19 at 11:25 AM indicated she knocked on Resident #39's door to help NA #2 provide care and the resident was sitting in the electric wheelchair and told NA #1 to get out. NA #1 indicated Resident #39 then drove at her and she backed out of the doorway and the resident passed by her in the wheelchair. NA #1 identified the supervisor told her to she had to go home because Resident #39 reported that she had threatened him/her. NA #1 indicated she went with the supervisor and a union delegate to the first floor and called the DNS to discuss the incident. NA #1 indicated the DNS told her that she was to switch residents and stay away from Resident #39, and write a statement. NA #1 indicated the police were called and the officer spoke with her and informed her that Resident #39 reported that she had threatened him/her. NA #1 gave her statement to the supervisor that evening.
Interview with Social Worker #1 on 10/23/19 at 12:30 PM indicated she was aware and spoke with Resident #39 on 6/5/19 and the resident reported that NA #1 pointed her finger in his/her face and threatened him/her so he/she called the police. Resident #39 informed Social Worker #1 that he/she was verbally threatened. Social Worker #1 indicated nursing staff were aware and were following up with the investigation into the incident.
Interview with the DNS on 10/23/19 at 2:00 PM indicated he went to the police department and picked up the police report but doesn't remember what day. Additionally, the DNS indicated he did read the complete report and he feels that it was never about the resident being abused or threatened, it was because Resident #39 just doesn't like that nurse aide. The DNS indicated he did speak with the supervisor and the staff the night of the incident but doesn't recall anyone stating that the resident felt threatened. The DNS stated he felt the resident just didn't want NA #1 in his/her room.
Although requested, a reportable event on the allegation that Resident #39 was threatened by NA #1 was not provided.
Although attempted, an interview with NA #2 was not obtained.
Review of the Abuse Policy identified abuse is prohibited. Employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. Reporting a suspicion of a crime to an immediate supervisor does not meet the obligation to report. An example of verbal abuse is threats of harm, and saying frightening things to a resident. When staff receive information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will report the allegation involving verbal abuse no later than 2 hours after the allegation is made by a resident. Only an investigation can rule out abuse, neglect or mistreatment. Initiate an investigation within 24 hours of an allegation of abuse. The investigation will be thoroughly documented. The facility will protect residents from further harm during the investigation. The facility will assign a social worker or designee to monitor the resident's feeling concerning the incident, as well as the residents' involvement in the investigation. The administrator or designee will report the findings of all completed investigations within 5 working days to the Department of Public Health.
Although staff were aware of the allegation on 6/2/19 that Resident #39 felt threatened by NA #1, the facility failed to complete a thorough investigation, and failed to take measures to protect the resident while the investigation was in progress.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752), reviewed for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752), reviewed for activities of daily living, the facility failed to ensure the resident was offered and provided with a shower according to the care plan and facility policy. The findings include:
Resident #752 was admitted to the facility on [DATE] with diagnoses that included pneumonia, hypertension, chronic kidney disease, and heart failure.
An initial nursing assessment dated [DATE] indicated Resident #752 was alert and oriented, able to independently move up and down in bed, and able to independently transfer to and from the bed. Skin breakdown or lower extremity edema was not noted.
The care plan dated 7/3/19 identified Resident #752 had a problem related to risk for decreased ability to perform care in bathing. Interventions included to provide extensive assistance of 1 for bathing. An intervention dated 7/5/19 indicated choosing a tub bath, shower, or bed bath, or sponge bath was important to the resident.
Review of facility documentation identified Resident #752 was discharged from the facility, return not-anticipated, on 7/11/19.
Review of an ADL record dated 7/3/19 through 7/11/19, 9 days, indicated Resident #752 required assistance with bathing, and did not receive a shower.
Interview with Resident #752 on 10/21/19 at 11:43 AM identified that while a resident at the facility, he/she was not offered or provided showers.
A review of the clinical record and interview on 10/24/19 at 10:48 AM with the ADNS indicated facility policy is to offer and provide each resident with a shower once weekly. The ADNS indicated that during Resident #752's time in the facility, he/she would have been scheduled for a shower on 7/3/19 and 7/10/19. The ADNS was unable to provide documentation that the resident was offered or provided a shower on those scheduled days.
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, and staff interview for 1 resident (Resident #752) reviewed for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and staff interview for 1 resident (Resident #752) reviewed for nutrition, the facility failed to ensure daily weights were monitored according to hospital transfer recommendations and physician's orders. The findings include:
Resident #752 was admitted to the facility on [DATE] with diagnoses that included pneumonia, hypertension, chronic kidney disease, and heart failure.
Review of an Inter-Agency Referral Report dated 7/2/19 identified discharge instructions to obtain daily weights. Additionally, if the resident gains 2 lbs. in 2 consecutive days, start Lasix.
A physician's order dated 7/2/19 directed to obtain a weekly weight for 4 weeks, then weigh monthly.
An initial nursing assessment dated [DATE] indicated Resident #752 was alert and oriented, able to independently move up and down in bed, and able to independently transfer to and from the bed. Skin breakdown and lower extremity edema was not noted.
Review of a weight record dated 7/2/19 identified Resident #752 weighed 183 lbs.
A physician's order dated 7/8/19 directed to obtain a weight today, obtain daily weights, and record results in physician communication book daily due to CHF.
The care plan dated 7/8/19 identified Resident #752 had a problem with cardiovascular symptoms related to hypertension, and ASHD. Interventions included to monitor weight as ordered.
Review of a weight record dated 7/9/19 identified Resident #752 weighed 170.6 lbs., a 12.4 lbs. weight loss.
Interview on 10/24/19 at 10:48 AM with the ADNS indicated although she would expect the Inter-Agency Referral Report to be reviewed with the physician on admission for admission orders, she was unable to provide documentation that daily weights were ordered on admission. Additionally, the ADNS identified she was unable to provide the documentation of daily weights directed by MD #1 on 7/8/19 and indicated if the weights were done it is possible they were discarded because documentation placed in the physician communication book was not maintained and discarded.
Interview with MD #1 on 10/24/19 at 11:20 AM indicated he would have expected discharge instructions and physician's orders documented on the Inter-Agency Referral Report to be communicated to the physician approving the admission orders. MD #1 thought he had ordered daily weights on 7/5/19, however, the physician's order for daily weights was on 7/8/19. MD #1 indicated he does not recall an issue with Resident #752's weights, however, the daily weights should have been obtained and documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy and staff interview for 1 resident (Resident #68) observ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy and staff interview for 1 resident (Resident #68) observed during dining, the facility failed to provide food per resident special request. The findings include:
Resident #68's diagnoses included dementia with behavioral disturbances, failure to thrive, dysphagia, anemia, and gastro-esophageal reflux.
A significant change MDS dated [DATE] identified Resident #68 had severely impaired cognition, required total assistance with care, and had a weight loss of 5% or more in the last month, or loss of 10% or more in last 6 months.
The care plan dated 10/3/19 identified Resident #68 was at nutritional risk related to fluctuating intakes, weight loss, dysphagia and advancing dementia. Interventions included to honor food preferences within meal plan, and to provide diet as ordered.
Observation on 10/21/19 at 1:00 PM identified RN #1 was seated at Resident #68's bedside feeding the resident. The lunch tray provided to Resident #68 contained carrots and string beans which the resident was observed to spit out. Resident #68 accepted some apple sauce, a few bites of chocolate cake and refused cranberry juice. RN #1 obtained 2 cups of milk from a cart in the hallway which the resident drank using a straw. Review of the meal ticket at that time identified that Resident #68 was vegetarian and special requests included to provide smooth yogurt, apple sauce and cottage cheese. The meal ticket further identified the nurse aide can mix applesauce with cottage cheese if desired by the resident.
Interview with RN #1 on 10/21/19 at 2:35 PM identified that if food is listed on the meal ticket under special requests, the resident should get that food on their meal tray, and indicated that she did not check the meal ticket for the resident's food preference.
Interview with Dietician #1 on 10/22/19 at 2:30 PM identified that Resident #68's food intake fluctuates and he/she had been losing weight. Dietician #1 further identified that in order for the resident to receive a well-balanced diet he/she needs to receive what is identified on her/his meal ticket as a special request.
Interview with the DNS on 10/22/19 at 2:40 PM identified that Resident #68's diet plan should be followed and the dietary department should have sent the food that was identified on the meal ticket and nursing staff is responsible to check the tray for accuracy before serving the resident.
The facility failed to provide smooth yogurt and cottage cheese as per diet slip special requests.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings include:
1.
Observations on the 2 AB unit on 10/21/19 at 11:00 AM, on 10/23/19 at 1:00 PM and on 10/24/19 at 12:00 PM with the Director of Maintenance and the Maintenance Supervisor identified the following:
In the shower stall; a shower head with continuous dripping water.
In room [ROOM NUMBER]; a ceiling tile with holes in 2 areas, and a ceiling tile with a large brown stain.
In a shared bathroom; a large linear hole in the sheet rock located below and behind the sink.
Interview with the Maintenance Supervisor on 10/24/19 at 11:45 PM identified that the maintenance department does not do rounds on each room to inspect the environment because there are so many other repairs to do. The Maintenance Supervisor indicated they rely on staff to inform them of concerns with the environment which is done either verbally or through the electronic maintenance work order.
Interview with the Director of Maintenance on 10/24/19 at 12:00 PM identified that he was unaware of the dripping shower head until it was brought to his attention during the building fire and safety inspection, and that when staff identify any concerns with the environment it should be communicated to maintenance so it can be addressed.
2.
Observations on the 4 AB Solana unit on 10/21/19 at 12:30 PM through 1:20 PM, and on 10/22/19 at 2:35 PM with the Maintenance Supervisor, and on 10/22/19 at 2:40 PM with the Account Manager, and on 10/24/19 at 9:10 AM with the Assistant Manager identified the following issues:
a. Damaged, chipped and/or marred bedroom/bathroom walls in rooms 401, 403, 411, 413 and 419.
b. Damaged, chipped and/or marred door in the bathroom in room [ROOM NUMBER] and damaged and/or chipped base board in the bedroom in room [ROOM NUMBER].
c. Damaged, stains and/or bulging ceiling tiles in the bathrooms on 4 AB Solana unit in rooms 402, 404, 407, 409, 410, 411 and 419.
d. Damaged and/or stains on the ceiling tile in room [ROOM NUMBER].
e. Damaged, marred and/or stain bedroom wall protector in rooms 402, 403, 405, 406, 410, 411 and 418.
f. Damaged, broken, missing, peeling and/or dirty cove base in bedroom in rooms [ROOM NUMBERS].
g. Stains, dirt, debris, and/or wax build up on floors crevices, along baseboard/floor and corners in rooms 401, 402, 403, 405, 406, 410 and 412.
h. Stains, dirt, debris, and/or wax build up on floors crevices, and corners in the bathroom in rooms 402, 403, 404, 406, 407, 410, 412 and 413.
i. Damaged, chipped and/or scarred closet door and/or missing closet door knob in room [ROOM NUMBER].
j. Damaged, chipped and/or marred door frame in the bathroom in room [ROOM NUMBER] and/or stain, dirt and/or debris on the wall in the bathroom in rooms 406, 407 and 419.
k. Damaged, broken and/or chipped dresser drawer in bedroom in rooms 401, 403, 404, 405, 406, 407, 409, 410, 416 and 419.
l. Damaged and/or broken window blind and/or missing dresser drawer knob in room [ROOM NUMBER].
m. Damaged and/or missing room number for room [ROOM NUMBER] and/or damaged, chipped and/or marred bedroom door in room [ROOM NUMBER].
n. Damaged and/or missing ceiling light bulb and/or damaged, chipped and/or marred bathroom door in room [ROOM NUMBER].
o. 4 AB Solana unit dining room: Damaged, chipped and/or marred walls, broken window blinds, stains and/or debris on walls.
p. 4 AB Solana unit lounge: Damaged, chipped and/or marred walls, damaged, torn, and/or peeling wall paper, damaged, chipped and/or stain window sill. Damaged and/or stain ceiling tiles. Stains, dirt, debris, and/or wax build up on floors crevices, and corners.
q. 4 AB Solana unit hallway: Damaged and/or stain on ceiling tiles. Stains, dirt, debris, and/or wax build up on floors crevices, and corners. Stains and/or debris on walls. Damaged, marred, and/or peeling walls.
r. 4 AB Solana unit shower tub room: Damaged, chipped, and/or marred door and door frame. Stain, dirt, and/or debris on bathroom wall tiles and on bathroom walls. Stains, dirt, debris, and/or wax build up on floors crevices, and corners. Damaged, broken, and/or missing floor tiles. Black and/or orange stains on ceiling vents. Tub room: Damaged, broken, and/or missing wall tiles. Damaged, torn, and/or peeling wall papers. Stains, dirt, debris, and/or wax build up on floor crevices, and corners.
s. Damaged, ripped and/or torn clean linen cart cover.
t. The physical therapy hallway: Damaged and/or stain on ceiling tiles. Damaged, broken, and/or missing floor tiles. Stains, dirt, debris, and/or wax build up on floor crevices, and corners.
u. Recreation room on first floor: Damaged, chipped, stains and/or marred walls. Damaged and/or peeling cove base. Damaged and/or stained ceiling tiles. Stain and/or debris on garbage container top and side. Damaged, broken, and/or missing floor tiles.
v. 4 AB nursing station: Stains, dirt, and/or debris on wood panel, and/or wax build up on floor crevices and corners. Stains and/or debris on garbage container.
w. Elevator 1: Damaged, broken, and/or missing floor tiles.
Review of the Account Manager monthly report dated 10/7/19 regarding the month of September, 2019 identified project work completed: 4 AB dining room, 4 AB nurse station. Power scrubbed the ground floor back hallway.
Interview with the Account Manager on 10/22/19 at 2:50 PM indicated he has been contracted by the facility for 5 months. The Account Manager indicated he was aware of the issues identified on 4 AB Solana unit and indicated the housekeeping department has been working upstairs in the last few months.
Interview with the Maintenance Supervisor on 10/22/19 at 3:01 PM identified he was aware of the issues identified on 4 AB Solana unit and indicated that maintenance of the facility is ongoing. The Maintenance Supervisor indicated the maintenance department was in the process of working on some of those areas and that there is an electronic maintenance work order that any staff members have access to and document what needs to be fixed and/or repaired which is checked several times daily. The Maintenance Supervisor indicated there was a dedicated voice mail line for the shop that was used for an emergency or safety related concern and identified any life safety issues are discussed with the Administrator.
Interview with the Assistant Manager of Housekeeping on 10/24/19 at 9:15 AM indicated he oversees the housekeeping department and identified he was not aware of the issues.
A review of facility housekeeping in-service identified the 5-step daily patient room cleaning policy identified to show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in a healthcare facility. Dust mop: All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corner, problem occur. Damp mop: The most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily. As with dust mopping, start in the far corner of the room, move all furniture necessary, and run the mop along the edges first. Never push the mop into a corner. That will only lead to build up.
The Maintenance Staff Job Description identified the maintenance helper provides a variety of standard and unskilled tasks in the maintenance and repair of center grounds and facilities. Maintain building and grounds in a clean, safe and orderly condition. Maintains and repairs basic functions of the center as determined by the maintenance director/supervisor.
The Maintenance Supervisor Job Description identified the maintenance supervisor is responsible for the maintenance operation of the center, and he/she is responsible for performing repairs and maintenance on equipment.
Review of the Routine Maintenance Policy identified requests for routine maintenance on the physical plant, fixtures, and equipment will require a work order. Once the work is completed, the maintenance supervisor or designee will write the action taken on a work order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Res...
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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 #11) reviewed for range of motion, the facility failed to provide care and services in accordance with professional standards in the assessment and treatment of contractures. The findings include:
Resident #11 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia and hemiparesis.
A physician's order dated 6/5/18 (and current in October 2019) directed to apply a left elbow extension splint in the morning, and remove at bedtime.
Review of an Occupational Therapy Initial Evaluation dated 1/29/19 identified Resident #11 had a right lower extremity knee flexion contracture.
The quarterly MDS dated [DATE] identified Resident #11 had severely impaired cognition, was incontinent of bowel and bladder and required total assistance with bed mobility, dressing, and had impairment of range of motion on one side of the upper and lower extremities.
The care plan dated 7/24/19 identified Resident #11 utilized left elbow and hand splints to prevent contractures. Interventions included the application of a left elbow splint from morning to night as tolerated.
A physician's order dated 8/23/19 directed to obtain an Occupational Therapy evaluation followed by treatment 5 times a week for 3 weeks for therapeutic exercise and orthotic management.
Review of an OT Initial Evaluation dated 8/23/19 identified Resident #11 had right and left knee contractures, and was referred to therapy for splint/contracture management.
Review of an OT Discharge summary dated [DATE] identified Resident #11 was discharge from PT with a splinting and passive range of motion schedule for the management of bilateral knee contractures.
Physician's order dated 9/20/19 directed to provide passive range of motion to both legs then apply bilateral leg splints daily with morning care and remove with evening care.
Observation of Resident #11 on 10/21/19 at 12:30 PM identified the resident lying in bed with the left arm flexed without the benefit of a splint. A blue splint was noted on top of the bedside table.
Interview with NA #3 on 10/23/19 at 1:24 PM identified she was assigned to care for Resident #11 and had performed gentle range of motion to the resident's joints when the resident was washed up earlier during the shift. NA #3 identified it was nursing's responsibility to apply the splints to Resident #11's left arm and both knees.
Interview and review of the October 2019 TAR with LPN #1 on 10/23/19 at 1:27 PM identified she had been assigned to care for Resident #11 and indicated that Resident #11 required a splint for the left hand at night. LPN #1 identified she removed the splint earlier that day and identified Resident #11 had a contracture of the left elbow and of the legs and required passive range of motion and application of splints with morning care. LPN #1 identified she should have performed range of motion and applied the left elbow and bilateral knee splints to help prevent further contractures but did not. LPN #1 identified that although it was 1:27 PM, she had not performed passive range of motion on Resident #11's elbows or knees nor applied the splints because it requires 2 nurses. LPN #1 identified she had not asked other nursing staff to assist her nor had she notified her supervisor that she had not applied Resident #11's splints as directed. Additionally, LPN #1 identified that Resident #11's family frequently visited during the day and sometimes would ask to have the resident's splints removed so as to be able to apply lotion to Resident #11's skin. LPN #1 identified NA #3 and Resident #11's family did not ask her to remove the resident's splints as she had not put them on the resident during the day shift.
Interview and observation of Resident #11 with the supervisor, (RN #5) on 10/23/19 at 1:39 PM identified she retrieved Resident #11's splints from the closet and bedside table drawers and assisted LPN #1 with passive range of motion and application of the splints. RN #1 identified that physician's orders directed passive range of motion with morning care and identified that it was no longer morning. RN #1 identified that the purpose of the splints was to prevent further contractures and indicated that staff should follow physician orders.
Interview and review of the clinical record review with OT #1 on 10/23/19 at 3:00 PM identified that Resident #11 required an evaluation on 8/23/19 for splint and contracture management and was noted to have right and left upper extremity impairment, a severe right lower extremity knee flexion contracture, and a minor left lower extremity knee contracture. OT #1 identified that Resident #11 was provided with bilateral lower extremity splints, orthotic management, training and therapeutic exercises. OT #1 identified that nursing staff was trained in passive range of motion to Resident #11's legs and application of Resident #11's splints with morning care by 9/16/19. OT #1 identified that application of the resident's splints was to ensure the contractures did not worsen, and he expected that the resident would have had the splints in place as directed by the physician order. Although OT #1 could not explain why Resident #11 had developed contractures of the lower extremities, he identified they could develop quickly and the splints and passive range of motion were to help prevent further contractures and skin breakdown.
Interview and review of the clinical record with the Rehabilitation Supervisor (PT #1) on 10/24/19 at 10:50 AM identified that OT #1 worked with Resident #11 from 8/23/19 - 9/17/19 related to bilateral knee contractures. PT #1 identified OT #1 recommended Resident #11 wear bilateral knee splints in the morning to nighttime daily and a physician order was obtained for the treatment. PT #1 identified that it would be expected that nursing staff would apply Resident #11's splints as ordered to prevent further contractures and or skin breakdown.
Interview and review of the clinical record with OT #1 on 10/23/19 at 3:00 PM identified that Resident #11 had left sided weakness because of a stroke and indicated that he treated Resident #11 in January of 2019 to reassess the left elbow. OT #1 indicated although the Initial OT Evaluation dated 1/29/19 identified a right lower extremity knee flexion contracture, Resident #11's care at that time had been focused on the elbow, and he did not measure the knee contracture or make a referral to physical therapy for further treatment. OT #1 identified on 8/23/19 Resident #11 was referred for an evaluation for splint and contracture management and was noted to have impaired right and left upper extremity impairment, a severe right lower extremity knee flexion contracture and a minor left lower extremity knee contracture. OT #1 identified that Resident #11 was provided with bilateral lower extremity splints, orthotic management, training and therapeutic exercises. OT #1 identified that nursing staff was trained in passive range of motion to Resident #11's legs and application of splints with morning care by 9/16/19. OT #1 identified that application of the resident's splints was to ensure the contractions did not worsen. OT #1 indicated he would expect that the resident would have had the splints in place as directed by the physician's order. Although OT #1 could not explain why Resident #11 had developed contractures of the lower extremities, he identified they could develop quickly and the splints and passive range of motion would help prevent further contractures. Review of the clinical record with OT #1 failed to reflect measurements of Resident #11's lower extremity contractures during occupational treatment 1/29/19. OT #1 identified that he would not have taken measurements of Resident #11's lower extremity knee contractures if they were not significant.
Interview and review of the clinical record with PT #1 on 10/24/19 at 10:50 AM identified that PT and OT screenings were to determine if a resident would benefit from further services from the rehabilitation team. PT #1 identified that if OT #1 identified a new knee contracture, she would expect a referral be made to PT for screening and evaluation of the resident. PT #1 identified that Resident #11 had been treated by the rehabilitation department multiple times during his/her admission. PT #1 identified that according to a Physical Therapy Discharge summary dated [DATE] - 3/8/18, Resident #11 was treated related to an alteration in left ankle range of motion. Additionally, although an initial OT Evaluation 1/29/19 identified that Resident #11 had impaired range of motion of the right lower knee due to a flexion contracture, review of the clinical record failed to reflect any measurements of the contracture, referrals to physical therapy for evaluation of the knee contracture, or treatment recommendations. PT #1 identified she would have expected OT #1 to have assessed the severity of the contracture and documented the assessment in the record. Additionally, PT #1 would have expected that OT #1 made a referral to PT for further evaluation, measurement and treatment recommendations related to the right knee contracture. PT #1 identified that OT #1 worked with Resident #11 from 8/23/19 - 9/17/19 related to bilateral knee contractures, but because no documentation of the severity of the knee contracture was documented in the record prior to that time, it was not possible to assess the change in the contracture.
Although requested, a policy on splinting and or positioning of residents was not obtained.
Review of facility policy for Activities of Daily Living identified the facility must ensure that a patient is given the appropriate treatment and services to maintain or improve his/her ability to carry out ADL's.
Review of the Rehabilitation Services Policy on charting identified clinical evaluation is to be consistent with professional standards of practice.
The facility failed to follow up on a new right knee flexion contracture between 1/29/19 - 8/23/19, 7 months. Subsequently, on 8/23/19, Resident #11 was picked up for OT due to right and left knee contractures and discharged on 9/17/19 with recommendations for bilateral knee splinting and a range of motion schedule. Additionally, the facility failed to apply splints to the bilateral knees and left arm as per the therapy recommendations and physician's orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations, review of facility policy, and interviews, the facility failed to serve meals in a timely manner to ensure palatable temperatures. The findings include:
Interview with the Direc...
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Based on observations, review of facility policy, and interviews, the facility failed to serve meals in a timely manner to ensure palatable temperatures. The findings include:
Interview with the Director of Dietary on 10/24/19 at 9:40 AM identified her expectations for appropriate holding temperatures for meal service range between 125 - 140 degrees Fahrenheit (F).
Observation on 10/24/19 on Unit 2C identified the meal truck arrived on the unit at 11:38 AM. A test tray was stored in the meal truck for a total of 47 minutes from time the truck arrived on the unit at 11:38 AM until the last resident was served his/her meal at 12:25 PM. A temperature check of the food on the test tray with the DNS on 10/24/19 at 12:25 PM identified the following food temperatures:
a. Pork 114 degrees F.
b. Hash brown potatoes 116 degrees F.
c. String beans 116 degrees F.
Interview with the DNS on 10/24/19 at that time identified she would expect that the residents receive their food within 5 to 10 minutes upon arrival of the food trays on the unit.
Review of the food preparation policy identified all foods will be held at appropriate temperatures, greater than 135 degree Fahrenheit (or as state regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure food service in accordance with professional standards. The findings include:
1. ...
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Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure food service in accordance with professional standards. The findings include:
1.
Observation on 10/21/19 at 10:00 AM with the Director of Dietary identified Dietary Aide #2 preparing to cook frozen chicken was without the benefit of a hair net. Dietary Aide #2 had approximately 0.5 to 1 inch length hair. Additionally, Dietary Aide #1 was observed washing dishes without the benefit of a beard restraint. Dietary aide #1 had approximately 1 - 2 inch length facial hair.
Interview on 10/21/19 at 10:05 AM with the Director of Dietary identified that kitchen staff should utilize hair nets for hair, and beard nets for facial hair while serving/preparing food.
Review of the Food and Nutrition Services Policy identified dietary employees will wear hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. Facial hair coverings are used to cover all facial hair.
2.
Observation on 10/23/2019 at 12:15 PM during the noon tray line with the Director of Dietary identified numerous meal trays had damaged, delaminated, exposed and/or sharp edges located on the corner of the trays.
Interview with the Director of Dietary on 10/23/19 at 12:15 PM identified that if any equipment is noted to be damaged, unsanitary or sharp, the equipment in question should be immediately removed from circulation.
Observation on 10/23/19 at 2:30 PM with the Director of Dietary identified a total of 157 damaged delaminating meal trays were noted to be utilized in the provision of the noon meal.
Review of an in-voice with the Director of Dietary on 10/23/19 at 3:00 PM identified a purchase of 168 new trays at a cost of $2,245.60. The Director of Dietary identified the estimated delivery of the trays was expected by 10/24/19.
Interview with Director of Dietary on 10/23/19 at 12:15 PM identified the facility policy directed for equipment to be maintained, in good physical condition and working order. The policy's purpose is to ensure the environment and equipment are in good working condition in order to store, prepare, and serve food in a safe and sanitary manner.
3.
Observation on 10/21/19 at 9:45 AM in the kitchen identified a cell phone and cell phone charger was on a tray mixed in with multiple kitchen utensils and equipment. On 10/21/19 at 9:50 AM car keys on a kitchen counter near cooking equipment were observed.
Interview with the Director of Dietary on 10/21/19 at 10:00 AM identified that employees should store their personal belongings in the staff locker room.
Observation during the noon tray line on 10/23/19 at 12:15 PM identified a blue tooth headphone device being charged in an outlet next to a cooking/prepping station.
Interview with the Director of Dietary on 10/23/19 at 12:20 PM identified that employees should store all personal belongings in the staff locker room.
Review of the Food and Nutrition Services Policy identified that pagers and/or cellular telephones are not carried while working. Headphones are not used while working.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), 1 harm violation(s), $110,546 in fines. Review inspection reports carefully.
- • 61 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $110,546 in fines. Extremely high, among the most fined facilities in Connecticut. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Arden's CMS Rating?
CMS assigns ARDEN 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 Arden Staffed?
CMS rates ARDEN CARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Arden?
State health inspectors documented 61 deficiencies at ARDEN CARE CENTER during 2019 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 57 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 Arden?
ARDEN 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 HIGHBRIDGE HEALTHCARE, a chain that manages multiple nursing homes. With 271 certified beds and approximately 204 residents (about 75% occupancy), it is a large facility located in HAMDEN, Connecticut.
How Does Arden Compare to Other Connecticut Nursing Homes?
Compared to the 100 nursing homes in Connecticut, ARDEN CARE CENTER's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Arden?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Arden Safe?
Based on CMS inspection data, ARDEN CARE CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (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 Arden Stick Around?
ARDEN CARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Arden Ever Fined?
ARDEN CARE CENTER has been fined $110,546 across 4 penalty actions. This is 3.2x the Connecticut average of $34,184. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Arden on Any Federal Watch List?
ARDEN 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.