POLARIS HEALTHCARE AND REHABILITATION CENTER
For profit - Limited Liability company
100 Beds
NATIONWIDE HEALTHCARE SERVICES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#41 of 43 in DE
Photo by Polaris
Photo by Polaris
Photo by Polaris
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Polaris Healthcare and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns and a poor overall rating. It ranks #41 out of 43 facilities in Delaware, placing it in the bottom half, and #10 out of 11 in Sussex County, meaning only one local option is better. The facility's performance is worsening, with the number of issues increasing from 19 in 2024 to 41 in 2025. Staffing is below average, with a rating of 2 out of 5 stars and a concerning turnover rate of 67%, significantly higher than the state average of 42%. The facility has incurred $127,199 in fines, which is alarming and suggests repeated compliance problems. While it has average RN coverage that can help catch issues, there have been critical incidents reported, such as a resident not receiving necessary insulin due to delivery delays and another resident suffering from unrelieved pain for over sixty hours due to a lack of medication. Overall, while there are some strengths, the numerous serious deficiencies raise significant concerns for families considering this facility for their loved ones.
- Trust Score
- F
- In Delaware
- #41/43
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 67% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $127,199 in fines. Higher than 91% of Delaware facilities. Major compliance failures.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Delaware. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 89 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 5%
Review needed
19 → 41 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 19 issues
2025: 41 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Delaware average (3.3)
Significant quality concerns identified by CMS
Staff Turnover: 67%
20pts above Delaware avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $127,199
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: NATIONWIDE HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (67%)
19 points above Delaware average of 48%
The Ugly 89 deficiencies on record
1 life-threatening 2 actual harm
Aug 2025
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 F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and other facility documentation, the facility failed to provide sufficient nursing staff to meet the needs of residents for 7 of 20 residents reviewed ...
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Based on observation, interviews, record review and other facility documentation, the facility failed to provide sufficient nursing staff to meet the needs of residents for 7 of 20 residents reviewed for staffing. The facility did not ensure adequate availability of staff to respond to resident care needs in a timely manner. Findings Include:As of December 2024, the facility assessment documented the following: 5 residents were independent with ADL's; 35 to 40 residents required assistance from 1-2 staff members; 50 to 55 residents were dependent on staff for ADL support.Despite this, residents experienced prolonged call bell response times and unmet care needs. At the time, the census on the Riverwalk unit was 58.1. Interview with a resident who wished to remain anonymous:8/6/25 2:51 PM - F1 reported multiple instances of delays when resident A1 called for assistance with toileting. On 7/16/25 7:30 PM A1 rang bell and contacted F1 about no one answering or providing assistances. F1 contacted E18 who contacted a supervisor to find assistance for A1. R3 contacted F1 at 8:30 PM to let her know someone had come to assist her to the bathroom. On 8/1/25 6:45 PM - A1 rang the call bell at 6:45 PM. At 7:55 PM, A1 contacted F1 who contacted the E18 (Former DON) due to lack of response. A1 reported finally being assisted and returned to bed by 8:45 PM.8/11/25 in the morning an interview with E6 (Supervisor) it was confirmed that he did receive calls about A1 waiting for assistance and would need to find someone to assist with toileting.2. Interview with a resident who wished to remain anonymous:8/7/25 10:00 AM to 10:40 AM - An observations of A2's call bell ringing continuously for 40 minutes before staff responded. During this time, A2 reported to the surveyor of needing assistance with changing and noted such delays were common, stating that sometimes staff just shut the light off and do not return promptly.3. R6's review revealed:7/19/25 11:30 PM - A concern form documented that R6 was not placed in bed until 11:30 PM, indicating a significant delay in bedtime assistance.8/6/25 7:00 PM to 8:00 PM - During an observation while on the Riverwalk unit there were two staff bathing a person, two staff in a room providing care and one staff person picking up trays and answering call bells. During this time an interview was conducted with R6, and it was explained that assistance was required by staff to help R6 to bed. R6 further revealed that there are times that we do wait more than 30 minutes or longer for call bell to be answered or to be put to bed.4. R11's review revealed:8/11/25 8:53 AM - During an interview R11and F2, long wait times for assistance were reported when for call bell response. F2 stated F11 was often found lying in urine and feces, prompting F2 to clean and change A2 personally due to lack of staff response.5. R13's review revealed:8/7/25 2:23 PM - During an interview with R13 it was revealed that call bell responses often take longer than 20 minutes to get assistance.6. R19's review revealed:7/21/25 3:48 PM - A concern form noted that on Sunday morning, 7/20/25, R19 waited approximately 1.5 hours for call bell response. R19 disclosed needing to use the bathroom and had to wait for F3 to assist, indicating staff were unavailable when needed.7. R20's review revealed:8/11/25 9:48 AM - 10:13 AM - R20's call bell rang continuously for 25 minutes before a staff person responded.8/11/25 3:05 PM - Findings were reviewed during the exit meeting with E1, E2 (Regional), and E3 (Regional nurse).
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
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined that for one (R6) out of three sampled residents for dental services, the facility failed to ensure the resident received dental se...
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Based on observation, interview and record review, it was determined that for one (R6) out of three sampled residents for dental services, the facility failed to ensure the resident received dental services. Findings include:A review of R6's clinical record revealed:9/27/23 - R6 was admitted to the facility.7/25/24 - A dental progress note documented that R6 wanted her teeth extracted and to receive dentures. The note documented that the treatment plan for R6 was to have new upper and lower dentures along with the extraction of the bottom teeth.12/17/24 - A dental progress note documented that R6 stated that she wanted her lower teeth extracted and full dentures made.3/31/25 - A dental exam note documented that R6 requested to have extractions.4/10/25 - A dental exam note documented that R6 was seen to be reviewed for teeth extractions.8/7/25 9:15 AM - During an interview, R6 stated that she has four teeth remaining on the bottom and has been asking to have them pulled for over a year. R6 stated that she wanted to have dentures. An observation was completed and it was noted that R6 has four remaining teeth on the bottom front. During this observation, R6 demonstrated how one of the four teeth can be moved all the way forward because it is loose.8/8/25 8:45 AM - During an interview, E4 (unit secretary) stated that the dental team can perform teeth extractions in the facility. E4 stated that they understand that R6 wants to have her teeth extracted and the dental team is coming to the facility on 8/29/25. E4 stated that she is unaware if R6 is scheduled to have them extracted.8/8/25 9:05 AM - During an interview, PC1 (dental company scheduler) stated that R6 is not scheduled to have extractions at that time. The appointment on 8/29/25 is for the new dentist to conduct their initial exam with R6.8/11/25 1:30 PM - During an interview, E1 (NHA) confirmed the delay in R6's teeth extraction and starting her denture process.8/11/25 3:05 PM - Findings were reviewed during the exit meeting with E1, E2 (Regional), and E3 (Regional nurse).
Jan 2025
39 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 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 multiple residents
2. Review of R46's clinical record revealed:
11/17/22 - R46 was originally admitted to the facility with several diagnoses including diabetes.
11/15/24 - A physicians order was written for R46 to rec...
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2. Review of R46's clinical record revealed:
11/17/22 - R46 was originally admitted to the facility with several diagnoses including diabetes.
11/15/24 - A physicians order was written for R46 to receive Insulin Glargine inject 20 units at bedtime for diabetes.
11/22/24 - An annual MDS assessment documented that R46 was cognitively intact and received insulin injections.
12/23/24 9:09 PM - An orders administration note in R46's clinical record documented that the ordered Insulin Glargine was not given due to awaiting for delivery.
12/24/24 8:42 PM - An orders administration note in R46's clinical record documented, that the ordered Insulin Glargine was not given due to being on order.
12/28/24 8:48 PM - An orders administration note in R46's clinical record written by E9 (LPN) documented, this med was reordered on 12/22, and this nurse call[ed] the pharmacy [to] ask for [Insulin Glargine] pen to be delivered the next day because the resident was out of this meds. The pharmacist hang up in my face sic Supervisor and the DON is aware of the situation. Still no delivery.
December 2024 - Review of R46's MAR lacked evidence that R46 received the ordered dose of 20 units Insulin Glargine at bedtime on 12/23, 12/24, 12/28, and 12/29. It is unclear how R46 received the insulin on 12/25, 12/26, and 12/27 when the refill had not been delivered and there were no insulins in the back up medication/Pixus.
1/16/25 10:23 AM - During an interview E7 (LPN) explained that all medications are Reordered in the software if low and that we have insulin in the reserve/emergency box.
1/16/25 10:37 AM - During an interview E2 (DON) stated that refills Can take 24 to 48 hours but that the pharmacy delivers at least twice a day to the facility. E4 (CCS) then stated We did identify some issues and have been working with them to improve. E2 then stated We started working to improve at least a few weeks ago.
1/17/25 8:30 AM - E2 (DON) provided a pharmacy order summary that indicated a request for a refill of R46's Insulin Glargine medication was sent on 12/22/24.
1/17/25 10:20 AM - During an interview with E9 (LPN) the re-ordering process was clarified and E9 stated that to refill medications staff Clicks on re-order meds to go straight to the pharmacy and maybe call to make sure you have it for the next day. If they have in the Pixus you can go to the supervisor for the Pixus. Insulin is not usually in the back up so most of the time we reorder that. The first time I ordered and called they said it was too early and we need a supervisor. I did go to the [DON] and he said he would take care of it. When I came back the med was not there and I called again and the pharmacy hung up on me.
1/17/25 10:41 AM - E2 (DON) provided the surveyor an inventory list of emergency medications held in the facility and confirmed Insulin Glargine was not on the list.
1/17/25 12:05 PM - During an interview E11 (NP) confirmed knowledge of R46's missed doses of the Insulin Glargine. E11 stated, They called me and I told them to monitor. E11 then showed the surveyor a composition note book with a dated hand written note regarding R46's missed doses of insulin.
1/23/25 8:42 AM - E2 provided the surveyor with an undated pharmacy memorandum regarding refilling of medications. E2 stated it was part of an education to staff provided a month ago and it's improved things. The memorandum read the following Attention Nursing Personnel then listed pharmacy contact information as well as a table of timeframe's to order medications and expected delivery time. The memorandum also indicated that STAT orders must be called into the pharmacy to notify the pharmacy that it's a STAT order.
1/23/25 1:53 PM - During an interview E13 (agency LPN) was unable recall R46 being out of the ordered insulin Glargine, E13 (LPN) stated, They are often out of medications at that facility and some people use other residents insulin's but I don't.
1/23/25 1:56 PM - During an interview E14 (agency LPN) was unable to recall R46 being out of the ordered insulin Glargine. E14 stated, If the resident is out then we have to give it depending whatever the insulin is. They keep a lot of insulin in the refrigerator and sometimes if its not then I guess we call the pharmacy and the doctor but I haven't run into that situation.
The four missed doses of the ordered Insulin Glargine for R46 placed the resident at risk for having a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death.
1/23/25 11:52 AM - Based on interviews and review of the facility documentation and other sources, an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and E4 (Corporate Clinical Support).
1/23/25 11:00 PM - The facility's Immediate Jeopardy was abated at this time. The acceptable abatement plan included implementation of new policies titled Verifying Diabetic Medications for New Admit Residents and Diabetic Medication administration for current residents. The proposed plan included education to one hundred percent of working staff and ongoing for the remaining staff currently unavailable and not working, and new hires. Staff confirmed no new admissions were scheduled for the rest of the day. Staff interviews confirmed completion of staff training. Staff confirmed that all current residents had insulin available on hand and current medication orders. E4 stated the facility is in the process of updating identified delivery issues with current pharmacy provider and will add insulin as an emergency medication to the supply.
1/28/25 11:30 AM - The facility's abatement was reviewed with E1 (NHA) and E4 (Corporate Clinical Support). It was determined through observation, interview and record review that the facility met all requirements for abatement on 1/23/25 at 11:00 PM.
Based on record review and interview, it was determined that for two (R299 and R46) out of five residents reviewed for unnecessary medication, the facility failed to ensure residents were free from a significant medication error when staff failed to administer insulin. Additionally, staff failed to conduct finger stick blood sugar monitoring, which included sliding scale insulin coverage based on the results. The facility's failure placed the residents at risk for a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death from untreated elevated blood sugar. Due to this failure an Immediate Jeopardy (IJ) was called on 1/23/25 at 11:52 AM. The IJ was abated on 1/23/25 at 11:00 PM. Findings include:
1. Review of R299's clinical record revealed:
10/4/24 5:00 PM - R299 was admitted with diagnoses including but not limited to diabetes mellitus.
10/4/24 - A discharge summary from hospital documented R299 had a diagnosis of diabetes mellitus, orders for insulin, and orders to monitor blood sugar.
10/4/24 - R299's medication administration record (MAR) lacked evidence of a blood glucose reading at dinner time and bed time. The MAR also lacked evidence of coinciding sliding scale insulin administration based on blood glucose reading.
10/5/24 12:04 AM - A telephone physician's order for Lispro (insulin) was entered into the electronic medical record. The order read as follows: Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/mL: Inject as per sliding scale: 0-150 = 0 units; 151-200 = 2 units; 201-250 - 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; greater than 400 give 10 units and call MD; give subcutaneously before meals and at bed time.
10/5/24 - An admission MDS documented R299 was diabetic and was receiving insulin.
10/5/24 8:00 AM - R299's MAR documented a blood glucose of 432 mg/dL (normal blood glucose is 80 mg/dL to 120 mg/dL) and fifteen units of Lispro was administered.
10/5/24 11:30 AM - A progress note documented Patient's (R299) family observed giving patient medications from home. Supervisor educated family that medications from home could not be given because there is no way to tell what exactly was given. Family stated patient needed pain medication. Supervisor explained to family the procedure with pain medications and informed them they were being delivered today. [Provider Group] NP and DON made aware.
10/5/24 untimed - A pharmacy manifest documented R299's medications were delivered to the facility. The manifest lacked evidence that R299's Lispro was delivered or ordered.
10/5/24 5:00 PM - A progress note documented that R299 was discharged .
1/16/25 2:20 PM - A copy of the emergency facility medication stock revealed that insulin was not available for emergency use.
1/17/25 8:30 AM - An interview with E2 (DON) confirmed that Lispro is not available in the facility emergency medication stock.
1/22/25 10:55 AM - An interview with FM1 revealed that at 9:00 PM on 10/4/24 R299 had not received bed time medications and FM1 notified the staff. FM1 stated that staff told her that medications needed to be ordered and were not available at this time.
1/22/25 11:03 AM - An interview with FM2 revealed that FM2 requested to speak to a supervisor after dinner on 10/4/24 to address multiple concerns. FM2 stated that the supervisor confirmed that R299's medications would not be delivered until 10/5/24 in the morning.
1/22/25 11:35 AM - An interview with E3 (ADON) stated the expectation for medication reconciliation and submission of orders is within an hour of admission. The primary nurse is expected to call the on call provider to review medication orders and input into the electronic medical system. E3 confirmed that R299 did not receive a blood glucose check on 10/4/24 at 5:00 PM or 9:00 PM and coinciding sliding scale insulin.
1/23/25 2:13 PM - An interview with E16 (LPN) revealed that E16 was unable to recall details of R299's admission.
1/23/25 3:34 PM - An interview with E17 (RN, UM) revealed that E17 was unaware of the expectation of reconciling medications within an hour of admission and unable to recall details of R299's admission.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on record review and interview, it was determined that for one (R85) out of three residents reviewed for pain, the facility failed to provide pain management according to professional standards ...
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Based on record review and interview, it was determined that for one (R85) out of three residents reviewed for pain, the facility failed to provide pain management according to professional standards of practice. R85 was not provided pain medication, causing unrelieved pain for approximately sixty four hours resulting in harm. Findings include:
Cross refer F657.
April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management.
November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant.
Review of R85's clinical record revealed:
12/12/24 - R85 was admitted to the facility with diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.
12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.
12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain. The care plan documented the goal as pain medication will be effective in controlling discomfort by next review. The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide disversional activities.
12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions. The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator. The MDS also documented that R85 had a BIMS score of 15 indicating R85 is cognitively intact.
12/2024 - A review of the December MAR documented that R85's pain level ranged from a score of 2/10 to 8/10. R85's pain level was noted at 10/10 prior to pain medication administration and scored as effective or score of 8/10 or below post pain medication administration.
1/2/25 5:41 PM - A physician's order documented oxycodone (narcotic pain medication) 10 mg tablet, give one tablet every six hours as needed for pain for six days ending on 1/6/25.
1/6/25 1:25 AM - The Januaury MAR documented R85 received a dose of PRN oxycodone 10 mg tablet documented 10/10 pain and a result of effective post pain assessment. The facility failed to use a pain scale for evaluation of pain with consistent measurement of pain pre and post administration.
1/6/25 - 1/8/25 - A review of the MAR documented R85's pain score was 10/10 every shift. R85 received PRN Tylenol during the aforementioned dates indicating 10/10 pain level and post administration score of ineffective during this time. The MAR lacked evidence of an oxycodone order in place or administered. The facility failed to use a pain scale for evaluation of pain with consistent measurement of pain pre and post administration.
1/7/25 1:38 PM - A progress noted documented Patient was unable to do PT today because she did not have her pain medication. The order was discontinued per provider. I gave her Tylenol but patient states that does not help at all .
1/8/25 00:01 AM - A physician's (E20) progress note documented a follow up visit with R85 to discuss pain medication use. The note stated that R85 continues to complain of low back pain and will be looking at long term use of narcotic pain medication use. E20 documented that he would provide temporary pain medication twice daily as needed and consult to pain management.
1/8/25 5:58 PM - A physician's (E20) order documented oxycodone 10 mg tablet, give one tablet every twelve hours as needed for chronic pain, fibromyalgia for ten days.
1/8/25 7:02 PM - A progress note documented .Patient has chronic pain and complains of pain being a 10/10. Patient was referred to pain management due to pain and narcotic dependence .
1/13/25 10:04 AM - An interview with R85 revealed she has had chronic pain in her lower back and was currently on a scheduled pain medication regimen. R85 revealed that recently that her pain medication perscription was no longer active and R85 was without scheduled pain medication for multiple days. R85 stated that when her pain was uncontrolled she was unable to participate in therapy and unable to get out of bed. R85 stated that she reported these pain levels to staff and no medication was ordered during that time.
1/17/25 8:30 AM - An interview with E2 (DON) confirmed that oxycodone is available in the facility emergency medication stock.
1/17/25 12:11 PM - An interview with E11 (NP) revealed that R85 was under E20's care for pain management. E11 stated that [R85] is pain medication seeking and I will not prescribe [R85] narcotics. Also E11 stated that is why R85 is under E20's care. E11 stated staff did not notify her that R85 was out of pain medication.
1/17/25 12:22 PM - An interview with E25 (scheduler) and E26 (RN UM) confirmed that R85 was referred to pain management with an outside provider and it was ordered on 1/8/25. E26 confirmed that the appointment was made on 1/16/25 due to E26 not being told of the aforementioned appointment. E26 stated R85 will be seen on 2/26/25 by pain management.
1/22/25 2:30 PM - An interview with E27 (RN) confirmed that R85 did not have a current order for pain medication from 1/6/25 to 1/8/25 and notified E11 on 1/7/25. E27 was unable to provide documentation that she reported R85 was out of medication.
1/23/25 2:44 PM - An interview with E20 confirmed he was not notified of the oxycodone prescription being discontinued and did refer R85 to pain management. E20 confirmed he will continue the current pain medication regimen until R85 is seen by pain management. E20 also stated he was unaware that the E11 was notified that R85 did not have any pain medication.
1/23/25 3:00 PM - Review of findings with E1 (NHA) confirmed that the facility did not have an active order for pain medication from 1/6/25 to 1/8/25 and should have consulted the provider regarding the ineffective pain medication administered in the absence of oxycodone. At this time, E1 confirmed that the facility failed to provide medication to control R85's pain resulting in approximately sixty four hours of severe uncontrolled pain rated at a level of 10 out of 10.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on interview and record review it was determined that for one (R85) out of thirty-seven residents reviewed in the investigative sample, the facility failed to ensure care preferences were being ...
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Based on interview and record review it was determined that for one (R85) out of thirty-seven residents reviewed in the investigative sample, the facility failed to ensure care preferences were being honored. Findings include:
Review of R85's clinical record revealed:
12/12/24 - Resident was admitted to the facility.
12/13/24 - A resident preference evaluation documented that it was very important for R85 to choose between a tub bath, shower, bed bath or sponge bath. The evaluation indicated that R85 preferred a shower.
12/18/24 - A physician's order documented showers two times a week on Wednesday and Saturday 7:00 AM to 3:00 PM shift.
1/13/25 9:55 AM - An interview with R85 revealed that the facility did not ask R85 regarding her preference to time or day of showers.
1/17/25 8:40 AM - An interview with E48 (CNA) revealed that the residents shower schedule in the electronic medical record does not match the typed schedule posted at the nursing station.
1/17/25 8:50 AM - An interview with E17 (UM, RN) confirmed that the unit shower schedule is based on room number and will be adjusted if the resident or family tells the facility they don't like the schedule.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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 F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two (R43 and R79) out of three residents reviewed for personal funds the facility failed to ensure residents had access to the their fun...
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Based on record review and interview it was determined that for two (R43 and R79) out of three residents reviewed for personal funds the facility failed to ensure residents had access to the their funds. Findings include:
The facility policy entitled, Deposit of Resident Funds last updated March 2021 indicated, Should the resident permit the facility to hold, safeguard, and manage his or her personal funds, the facility will: provide the resident access to funds of fifty dollars or less within twenty four hours, and access to funds in excess of fifty dollars within three banking days.
1. 11/2/24 - An MDS assessment documented that R79 was cognitively intact.
12/23/24 - A receipt in the facility records documented that R79 received 50.00 in personal funds from E17 (BOM).
1/13/25 10:48 AM - During an interview R79 stated, They had a change in the person who was disbursing the money and she had to be oriented. I wanted it for Christmas and I got it two days before Christmas. Which was too late because I wanted to send Christmas cards. I made the request at least the beginning of the month and I didn't get it until the week of (sic). I was talking about it to [E1 (NHA) and E17 (BOM)]; I usually just have to call and then I sign a slip.
1/22/25 10:54 AM - During an interview R79 reported requesting personal funds from [E17 (former BOM)] and then I told reception. Then I had to wait.
2. 12/24/24 - A receipt in the facility records documented that R43 received 100.00 in personal funds from E17 (BOM).
12/27/24 - An annual MDS assessment documented that R43 was cognitively intact.
1/21/25 11:45 AM - During an interview E17 (BOM) I came in mid December before that the (BOM)position was empty for quite some time. E17 confirmed that residents should be able to access personal funds within 24 hours if less than fifty dollars and no more than three business days for larger amounts. E17 provided the surveyor with two logs of personal funds received residents for December 2024 with no funds documented as disbursed from 12/13/24 - 12/23/24.
1/22/25 11:07 AM - During an interview R43 stated, I told [E18] (former BOM) that I wanted to take out some money but then she left and I had to wait for the other one [E17 BOM] to get acclimated so I had to wait. I did eventually get the money.
1/22/25 11:27 AM - E1 (NHA) notified the surveyor that E18 (former BOM) last date of employment was 11/5/24 and that E17 (BOM) started on 12/16/24. E1 stated I believe we had a regional person covering and reception was helping out as well. The facility lacked evidence of how this information was relayed to the residents.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that for one (R81) out of five residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance di...
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Based on interview and record review, it was determined that for one (R81) out of five residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive. Findings include:
Review of R81's clinical record revealed:
3/25/24 - R81 was admitted to the facility.
3/30/24 - An admission packet for the facility was completed for R81 and revealed that Exhibit G: advanced directed form documented R81 was a full code. The remainder of the form was left blank relating to questions regarding formulating an advanced directive.
10/2/24 - A quarterly MDS assessment documented a BIMS score of 15 indicating R81 was cognitively intact.
1/13/25 11:34 AM - An interview with R81 revealed that he was not offered to formulate an advanced directive.
1/14/25 1:35 PM - An interview with E41 (SW) revealed that advanced directives get discussed during the initial care plan meeting.
1/14/25 2:33 PM - An interview with E6 (Admissions) revealed that nursing staff is expected to ask resident questions on admission sheet regarding advanced directive. E6 confirmed that she did not ask R81 if he would like to formulate an advanced directive.
1/14/25 2:45 PM - An interview with E27 (RN) confirmed that nursing staff is responsible to discuss advanced directive with newly admitted residents. E27 presented R81's preferred intensity of medical care and treatment form from the clinical record dated 3/25/24 and 8/9/24. E27 confirmed that these forms were completed with R81 post admission. The aforementioned form addresses a resident's preferred code status and lacks evidence of information regarding advanced directive.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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
Based on interview and record review, it was determined that for one (R64) out of two residents reviewed for change in condition, the facility failed to consult the provider and notify the responsible...
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Based on interview and record review, it was determined that for one (R64) out of two residents reviewed for change in condition, the facility failed to consult the provider and notify the responsible party when R64 experienced a significant change in condition and plan of care. Findings include:
Cross refer F773
Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
12/4/25 - An admission MDS documented R64 was a BIMS of 7 indicating severe cognitive impairment.
1/10/25 - A progress note documented that FM3 reported that R64 was lethargic and not at her baseline. E27 (RN) documented R64's assessment and called the on-call provider.
1/10/25 1:34 PM - A progress note documented that R64 had a non-productive cough, mild confusion, speech unclear at times, elevated heart rate, was drowsy nd not her usual self. Additionally, R64 was given cough medicine, Tylenol, and Tums per provider order.
1/10/25 7:56 PM - A progress note documented that R64 refused dinner and continued with an elevated heart rate. Additionally, the progress note documented the on call provider was notified with new orders.
1/10/25 11:00 PM - A physician's order for R64 documented complete blood count (CBC), comprehensive metabolic panel (CMP), and infuse normal saline at 100 mL/hr total 1 liter.
1/11/25 1:37 PM (Saturday) - A lab result report for R46 documented the white blood cell count was high.
1/11/25 3:48 PM - A progress note documented that R46 pulled out peripheral line from left arm.
1/13/25 4:30 PM - A physician's order for R64 documented a chest x-ray with two views and Rocephin (antibiotic) inject one gram intramuscularly immediately (STAT) for white blood cell elevation.
1/14/25 3:25 PM - A physician's order for R64 documented Bactrim (antibiotic) 800-160 mg give one tablet two times a day for left base infiltrate (pneumonia) for five days.
1/15/25 1:15 PM - In an interview FM3 revealed she was unaware that R46 had a chest X-ray done, received labwork, was diagnosed with pneumonia, started on antibiotics as well as being changed to thickened liquids. FM3 stated she had not received an update on R46's condition since 10:00 PM on 1/10/25 when staff nurse called to notify her that R46 was ordered an IV related to dehydration.
1/15/25 1:45 PM - Interview with E27 (RN) confirmed that the progress notes lacked evidence of notification to FM3 about changes to plan of care for R46.
1/15/25 2:13 PM - Interview with E17 (RN, UM) confirmed that the progress notes lacked evidence of notification to the provider of R46's lab results.
The facility lacked evidence of notification to the provider of R46's lab results and lacked evidence of updating R46's responsible party of change in condition that changed the plan of care.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview, record review and review of other facility documentation, it was determined that for one (R64) out of one reviewed for grievances, the facility failed to ensure that resident conce...
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Based on interview, record review and review of other facility documentation, it was determined that for one (R64) out of one reviewed for grievances, the facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. Findings include:
Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
12/30/24 - A grievance form was filed by FM3 regarding missing clothing for R64 and a complaint related to staff care. The form documented that the grievance was resolved on 1/6/25 by E2 (DON).
1/13/25 12:33 PM - An interview with FM3 revealed that R64 was missing a pair of pajama bottoms and that a staff member threw them away. FM3 stated that on 12/30/24 she was in to visit R64 and she told FM3 about her pants being missing. FM3 stated that R64 was very upset and told her that the person who threw the pants away was not nice to her on the date in question. FM3 also stated that the facility did not rectify the missing pants with her or offer to replace them.
1/15/25 11:23 AM - An interview with E1 (NHA) and E2 (DON) confirmed that the facility had addressed the grievance. E2 stated that the staff member mentioned in the grievance was given education about customer service. E2 stated he did not offer to replace the pants or provide reimbursement. E1 called FM3 and requested a receipt for the pajama pants to reimburse.
The facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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
Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for misappropriation of resident property, the facility failed to recognize and consequentl...
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Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for misappropriation of resident property, the facility failed to recognize and consequently report an allegation of misappropriation of resident property/funds no later than 24 hours. Findings include:
The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements.
3/4/25 - A grievance form was completed on behalf of R18 by E8 (AD) that documented, [R18] said he saw charges that were not his own on his credit card. He also said that someone has taken out a loan in his name. He was assisted with calling customer service. Further documentation on the grievance indicated the investigation was assigned by E7 (SW) to E5 (BOM) to complete the investigation of the grievance. E5 documented, [R18] was approached by BOM and a security officer. We asked if he would like to call the police and file a report. He declined. The grievance documented the resolution date as 3/6/25 and was signed by E1 (former NHA).
4/2/25 1:30 PM - During an interview E5 (BOM) confirmed being assigned to review R18's grievance related to missing money and stated that E1 (former NHA) was aware of R18's allegations.
4/2/25 1:54 PM - During an interview E4 (DON) stated he was previously unaware of R18's grievance related to an allegation of misappropriation of resident funds.
4/2/25 2:21 PM - During an interview E1 (former NHA) confirmed knowledge of R18's allegation of misappropriation of resident funds. E1 stated, I thought it was an old allegation of money way before I was there don't recall the resident or details.
4/3/25 11:45 AM - During an interview E5 (BOM) confirmed that R18's grievance related to missing money was not recognized as an allegation of misappropriation of funds and therefore was not reported to the State Agency.
4/3/25 2:12 PM - During an interview E7 (SW) confirmed that R18's grievance related to missing money was not recognized as an allegation of misappropriation of funds and therefore was not reported to the State Agency.
4/3/25 3:45 PM - Findings were reviewed during the exit meeting with E2 (NHA) and E4 (DON).
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
Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for allegations of misappropriation of resident property, the facility failed to provide ev...
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Based on record review and interview, it was determined that for one (R18) out of two (2) residents reviewed for allegations of misappropriation of resident property, the facility failed to provide evidence that the allegation was thoroughly investigated. Findings include:
The facility policy on abuse dated 12/2016 indicated Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Investigate and report any allegations of abuse within timeframe's as required by federal requirements.
3/24/25 - The facility submitted an incident report to the State Agency that alleged [R18] reported a previous employee was stealing money. Investigation started immediately. Police contacted.
4/1/25 9:07 AM - The surveyor requested a copy of the investigation related to R18's allegation of misappropriation of property.
4/3/25 12:32 PM - During an interview E4 (DON) confirmed the facility did not conduct interviews, obtain statements or complete an investigation regarding R18's allegation of misappropriation of property. E4 stated, We called the police.
4/3/25 3:45 PM - Findings were reviewed during the exit meeting with E2 (NHA) and E4 (DON).
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on interview, record review and review of other facility documents it was determined that for one (R148) out of three residents reviewed for discharge the facility failed to ensure that discharg...
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Based on interview, record review and review of other facility documents it was determined that for one (R148) out of three residents reviewed for discharge the facility failed to ensure that discharge requirements were met when the facility initiated discharge regarding R148 occurred on 10/9/24 without notice to the resident. Findings include.
Cross refer to F626.
Review of R148's clinical record revealed:
8/23/24 - R148 was admitted to the facility with multiple diagnoses including a history of major depressive disorder with severe psychotic symptoms, anxiety, and suicidal ideation.
8/26/24 - A five day MDS assessment documented that R148 was cognitively intact with a goal of remaining in the facility.
10/9/24 7:53 AM - A note in R148's clinical record documented that the resident was sent to the hospital for suicidal ideation.
10/9/24 - The Transfer/Discharge notice indicated the reason for R148's transfer as it is necessary for your welfare and needs cannot be met at the facility. The location of the transfer was to hospital ER. The notice was signed by R148. Accompanying the transfer notice was a notification of bed hold policy that was signed by R148, and an Acute Care Transfer document checklist.
10/9/24 2:56 PM - A social service note in R148's clinical record documented, Called [another nursing home] at 2:54 PM to see how to send over a referral for the resident.
10/9/24 - A discharge return not anticipated MDS assessment was completed for R148 with no discharge plan or referrals documented.
10/15/24 2:51 PM - A social service note documented, Returned the call from [inpatient psychiatric facility staff] on behalf of [R148] and they requested information on transferring the resident back to the facility. Social service director gave the information to the unit manager [E24(RN)].
October 2024 - The facility transfer list provided to the Ombudsman documented that R148 was transferred out for medical leave.
1/10/25 1:17 PM - During an interview E22 (SW) at inpatient psychiatric facility stated The facility would not allow [R148] to return and I got that from E6 (Admissions) but [R148] has been placed somewhere else.
1/22/25 10:21 AM - During an interview E6 (Admissions) stated that R148 Was having suicidal ideation with a plan that's why they sent her out to psych and the hospital sent her out to [inpatient psychiatric facility]. E6 confirmed that R148 was denied readmission to the facility following discharge from the inpatient psychiatric facility because At the time she owed us a large bill like seventy thousand and corporate was not letting me readmit her. E21 (Controller) my Corporate Director denied the readmission because the bill was so large and would not allow R148 to return until Medicaid approval. Then Medicaid denied.
1/22/25 11:51 AM - During an interview E24 (RN) former unit manager stated, [E6] (Admissions) said we wouldn't be allowing R148 back because of a large bill.
1/22/25 11:58 AM - During an interview E21 (Controller) confirmed that R148 was not allowed readmission to the facility. E21 stated that R148 Came in through the state program they stopped paying for her and we applied for Medicaid and it was denied. She was here eight months without payment. There should be a regular discharge letter. The surveyor requested a copy of the Medicaid denial, any appeal documents, a bill, and discharge notice. The requested documents were not received from the facility.
1/23/25 9:19 AM - During an interview E1 (NHA) confirmed the facility had no evidence of a discharge notice or discharge summary for R148.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R46's clinical record revealed:
11/10/24 8:29 AM - A progress note in R46's clinical record documented, Resident se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R46's clinical record revealed:
11/10/24 8:29 AM - A progress note in R46's clinical record documented, Resident sent to emergency room via 911.
11/15/24 9:50 PM - A progress note in R46's clinical record documented, Resident returned from acute care hospital.
November 2024 - Review of the facility transfer log documented that R46 was transferred to the hospital on [DATE]. Review of R46's electronic clinical record lacked evidence of a corresponding bed hold notification provided to R46 or a representative upon R46's transfer.
1/16/25 10:34 AM - The surveyor requested evidence of notice of the bed hold policy for R46's 11/10/24 hospitalization from E6 (Admissions).
1/16/25 11:41 AM - During an interview E6 (Admissions) confirmed that neither R46 nor her representative recived notification of the bed hold notice policy upon the residents transfer to the hospital.
3. Review of R61's clinical record revealed:
12/28/24 3:30 PM - A progress note in R61's clinical record documented, Resident was taken to Hospital.
12/31/24 - R61 was readmitted to the facility from the hospital.
December 2024 - Review of the facility transfer log documented that R61 was transferred to the hospital on [DATE] for acute care. Review of R61's electronic clinical record lacked evidence of a corresponding bed hold notification provided to R61 or a representative upon R61's transfer.
1/17/25 2:56 PM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
Based on record review and interview, it was determined that for three (R35, R46 and R61) out of three sampled residents for hospitalization, the facility failed to provide written bed hold notice to the resident and/or the resident's representative when transferred to the hospital. Findings include:
A facility policy and procedure titled Bed-Holds and Returns revised 10/2022 documented . 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Resident's regardless of payor source, are provided written notice about these policies at least twice.
1. Review of R35's clinical record revealed:
12/23/24 - R35's MDS 5 day admission assessment revealed the resident was cognitively intact with a BIMS score of 15.
1/10/25 - R35 was transferred to the hospital.
1/16/25 10:44 AM - During an interview E6 (AD) confirmed E35 had been transferred from the facility to the emergency room on 1/10/25 and admitted to the hospital. Additionally, E35's clinical record lacked evidence that notification of R35 being sent to the ER or a bed hold notice to either R35 and or R35's responsible representative.
1/16/25 2:51 PM - E6 confirmed and stated, No a bed hold notice had not been provided to R35 after transfer to the hospital or the responsible representative. Further review of R35's clinical record lacked evidence of any attempts to contact R35 or the responsible representative of a bed hold notice.
1/23/25 3:18 PM - Findings were confirmed with E1 (NHA).
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
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that for one (R148) out of three residents reviewed discharge the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that for one (R148) out of three residents reviewed discharge the facility failed to ensure R148 was readmitted to the facility or that the facility complied with discharge requirements. R148 was sent to the hospital on [DATE] and was not permitted to return to the facility. Findings include:
Review of R148's clinical record revealed:
8/23/24 - R148 was admitted to the facility with multiple diagnoses including a history of major depressive disorder with severe psychotic symptoms, anxiety, and suicidal ideation.
8/26/24 - A five day MDS assessment documented that R148 was cognitively intact with a goal of remaining in the facility.
10/9/24 7:53 AM - A note in R148's clinical record documented that the resident was sent to the hospital for suicidal ideation.
10/9/24 - The Transfer/Discharge notice indicated the reason for R148's transfer as it is necessary for your welfare and needs cannot be met at the facility the location of the transfer was to hospital ER. The notice was signed by R148. Accompanying the transfer notice was a notification of bed hold policy that was signed by R148, and an Acute Care Transfer document checklist.
10/9/24 2:56 PM - A social service note in R148's clinical record documented Called [another nursing home] at 2:54 PM to see how to send over a referral for the resident.
10/9/24 - A discharge return not anticipated MDS assessment was completed for R148 with no discharge plan or referrals documented.
10/15/24 2:51 PM - A social service note documented, Returned the call from [inpatient psychiatric facility staff] on behalf of [R148] and they requested information on transferring the resident back to the facility. Social service director gave the information to the unit manager [E24(RN)].
October 2024 - The facility transfer list provided to the Ombudsman documented that R148 was transferred out for medical leave.
1/10/25 1:17 PM - During an interview E22 (SW) from the in-patient psychiatric facility stated The facility would not allow [R148] to return and I got that from E6 (Admissions) but [R148] has been placed somewhere else.
1/21/25 1:47 PM - During an interview E23 (RN) confirmed that R148 was denied readmission to the facility. E23 stated, I know she couldn't come back, I was told she owed money.
1/22/25 10:21 AM - During an interview E6 (Admissions) stated that R148 Was having suicidal ideation with a plan that's why they sent her out to psych and the hospital sent her out to [inpatient psychiatric facility]. E6 confirmed that R148 was denied readmission to the facility following discharge from the inpatient psychiatric facility because At the time she owed us a large bill like seventy thousand and corporate was not letting me readmit her. E21 (Controller) my Corporate Director denied the readmission because the bill was so large and would not allow R148 to return until Medicaid approval. Then Medicaid denied.
1/22/25 11:51 AM - During an interview E24 (RN) former unit manager stated, [E6] (Admissions) said we wouldn't be allowing R148 back because of a large bill.
1/22/25 11:58 AM - During an interview E21 (Controller) confirmed that R148 was not allowed readmission to the facility.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
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
Based on record review and interview it has been determined that the facility failed to review and revise for one (R85) out of thirty-seven sampled residents' care plans. Findings include:
A facility ...
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Based on record review and interview it has been determined that the facility failed to review and revise for one (R85) out of thirty-seven sampled residents' care plans. Findings include:
A facility policy and procedure titled Using the Care Plan last revised 8/2006 documented . 1. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and or the MDS Assessment Coordinator . 2. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.
Cross refer F697
1. Review of R85's clinical record revealed:
12/12/24 - R85 was admitted to the facility with the diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.
12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.
12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain. The care plan documented the goal as pain medication will be effective in controlling discomfort by next review. The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide diversional activities.
12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions. The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator. The MDS also documented that R85's BIMS score was 15 indicating R85 was cognitively intact.
1/23/25 3:34 PM - An interview with E17 (RN UM) revealed that R85's care plan lacked revision related to acceptable pain level and appropriate interventions related to pain.
The care plan lacked evidence of an acceptable pain level and pain level goal for R85. The care plan also lacked non-pharmacological interventions for addressing R85's pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for two (R6 and R27) out of thirty seven residents sampled, the facility failed to provide services that meet professional standards of qua...
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Based on record review and interview, it was determined that for two (R6 and R27) out of thirty seven residents sampled, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments and admission progress notes. Findings include:
Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . admission Assessments * - RN .* = Once a care plan is established, the LPN may do assessments .
1. Review of R6's clinical record revealed:
12/12/24 - R6 was admitted to the facility.
12/12/24 - E45 (LPN) completed the following assessments: admission evaluation, bowel and bladder continence evaluation, elopement risk evaluation, fall risk evaluation, pain evaluation, side rail evaluation, transfer evaluation, and Braden scale assessment.
An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R6.
1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that R6's admission assessments were completed by an LPN.
2. Review of R27's clinical record revealed:
10/14/24 - R27 was admitted to the facility.
10/14/24 - E46 (LPN) completed the following assessments: admission evaluation, bowel and bladder continence evaluation, elopement risk evaluation, fall risk evaluation, side rail evaluation, and Braden scale assessment.
1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that R27's admission assessments were completed by an LPN.
An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R27.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that for one (R6) out of nine residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings inclu...
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Based on observation and interview, it was determined that for one (R6) out of nine residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include:
Review of R6's clinical record revealed:
12/12/24 - R6 was admitted to the facility.
12/13/24 - A care plan was initiated and documented that R6 was unable to do own activities of daily living (ADLs) without assistance related to general weakness and goal that R6 will be well groomed and odor free with the assist of staff while participating to their best ability for ninety days. The care plan documented interventions to assist R6 to pick out clothes, assist to attend activities, and toileting schedule as R6 allows.
12/19/24 - An admission MDS documented that R6 had an impairment to lower extremity on one side and also documented R6 was dependent for showering.
1/13/25 2:34 PM - An interview with R6 revealed that she had a shower on the previous day and no one had assisted her to clip her nails. R6 stated that no one had offered to clip her nails.
1/14/25 10:19 AM - An observation of R6 with long overgrown nails.
1/15/25 12:24 PM - An observation of R6 with long overgrown nails.
1/16/25 3:33 PM - An observation of R6 with long overgrown nails. An interview with E35 (RN) confirmed that R6 was supposed to have a shower on 1/15/24 and that R6 had long overgrown nails. E35 stated she would make sure R6's nails were clipped.
1/17/25 8:37 AM - An interview with E48 (CNA) confirmed that she gave R6 a shower and clipped her nails this morning.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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
Based on interview and record review, it was determined that for one (R64) out of two residents reviewed for change in condition, it was determined that the facility failed to follow physician orders....
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Based on interview and record review, it was determined that for one (R64) out of two residents reviewed for change in condition, it was determined that the facility failed to follow physician orders. Findings include:
Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
12/4/24 - An admission assessment for documented that R64 was independent for eating.
1/14/25 7:23 PM - A physician's order documented that R64 was on thickened liquids.
1/15/25 1:15 PM - An observation of R64's lunch tray revealed that R64 was served water, coffee, and juice all thin liquids. R64 was actively eating and drinking when observation occurred, during this time an observation of R64 drinking the thin liquids resulting in coughing.
1/15/25 1:30 PM - An interview with E48 (CNA) revealed that E48 was not informed that R46 was on thickened liquids during report and E48 went to replace the thin liquids with thickened.
1/15/25 1:35 PM - An interview with E51 (LPN) and E35 (RN) revealed that when a new diet is ordered the order gets entered in the electronic medical record (EMR) and a dietary communication slip is completed. If the order is completed after dietary is closed the nurse will deliver the dietary communication to the front desk to give to dietary in the morning.
1/15/25 1:45 PM - An interview with E52 (Secretary) confirmed that no dietary communication slip was left at the front desk for the dietary department.
1/15/25 2:00 PM - An interview with E53 (Dietician) revealed that she was unaware of the new order for R64. E53 reviewed the new order in the EMR and confirmed that the diet order was not input as a dietary order so therefore the electronic system did not communicate the new order to dietary. E53 also confirmed that no dietary communication slip was completed and given to the dietary department.
The facility failed to follow a physician's order when R64 was served thin liquids.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R37) out of two residents reviewed for ROM the facility failed to ensure that R37 received appropriate treatment and services to pr...
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Based on record review and interview it was determined that for one (R37) out of two residents reviewed for ROM the facility failed to ensure that R37 received appropriate treatment and services to prevent further decrease in range of motion when the annual contractures measurement comparison evaluation was not completed on time. Findings include:
The facility policy on Prevention and screening for contractures management last updated January 2025, indicated Secondary prevention targets early identification of a contractures to limit it's course and complications through scheduled screenings such as annual screenings or during clinical reviews.
1. Review of R37's clinical record revealed:
12/15/23 - An entry MDS assessment was created for R37.
12/18/23 - A contractures measurement comparison evaluation was completed for R37 that documented the resident had All joints within functional limits.
12/19/23 - A discharge return not anticipated MDS assessment was completed for R37.
1/2/24 - R37 was readmitted to the facility with several diagnoses including history of stroke, generalized muscle weakness, abnormalities of gait and mobility, and limitation of activities due to disability.
1/8/24 - An admission MDS assessment documented that R37 had an impairment on one side of an upper extremity.
1/26/24 - A care plan was created related to R37's potential for contractures. Interventions in the care plan included Therapy department to assess ROM and record findings yearly.
7/29/24 - An OT clarification order was written for R37's recertification of services to continue with OT 3-4x/wk for 30 days to address limitations. Treatment: ortho fit and train.
8/27/24 - An order was written for an OT evaluation for Trigger finger/use of carrot and Ortho consult for trigger finger.
8/28/24 - An order was written for R37 to wear a left extension splint placed at PM care, removed at AM care as tolerable. Resident able to self manage and remove as needed.
11/5/24 - R37's care plan related to potential for contractures was reviewed by the facility with no changes.
1/8/25 - An annual MDS assessment documented that R37 had an impairment on one side of an upper extremity.
1/13/25 10:34 AM - During an interview R37 stated, I want to see a doctor because my [left] hand worsened.
1/15/25 9:30 AM - The surveyor sent an email to E2 (DON) that requested the most recent contractures measurement comparison evaluation completed for R37.
1/15/25 10:11 AM - A contracture measurement comparison evaluation was completed by E34 (PT) for R37 that documented, Left joint contractures status severe; all joints functional limits except left hand Resident continues with left hand contractures. The evaluation was past the annual date of 12/18/24.
1/16/25 1:29 PM - During an interview R37 confirmed that prior to 1/15/25 therapy had not been to assess the residents hand in a long time.
1/16/25 1:56 PM During an interview E34 (PT) confirmed that the contracture measurement comparison evaluation was completed late. E34 stated, they should be done annually. The problem is our software doesn't alert on their anniversary date. When asked what prompted E34 to complete R37's recent assessment E34 stated, [E4 (CCS) asked me for it, I saw it wasn't done and went and did it. E4 present during the interview confirmed the request for R37's contractures measurement comparison evaluation was relayed to her by E2 (DON). When asked if the facility identified a change from the prior contractures evaluation, E34 stated, [R37] had no significant changes between the two. [R37] already has a palm-guard for that issue so that was established from OT in the summer. Review of R37's clinical record revealed an OT evaluation and corresponding interventions on 8/27/24 and 8/28/24 related to R37's left hand. However the clinical record lacked evidence of measurements and evaluation to determine degree of changes until the surveyor requested an evaluation on 1/15/25.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (CCS).
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
Based on record review and interview it was determined that for one (R47) out of two residents reviewed for accidents the facility failed to provide supervision for R47 to prevent an accident. The res...
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Based on record review and interview it was determined that for one (R47) out of two residents reviewed for accidents the facility failed to provide supervision for R47 to prevent an accident. The resident was left unsupervised during care and fell off the bed resulting in a head injury and needed to be sent to the hospital for evaluation and treatment. Findings include:
R47's clinical record revealed:
12/18/23 - R47 was admitted to the facility with diagnoses including but not limited to multiple sclerosis, paraplegia and hypothyroidism.
12/19/23 - A review of R47's care plan for falls documented . 1. Potential for falls r/t (sic) decreased mobility . 2. Bed in lowest position when care is not being provided .3. Bed mobility extensive assist . 4. Increased rounding (was added to the interventions on 7/16/24 as a result of the fall).
12/19/23 - A review of R47's care plan for ADLs (Activities for Daily Living) revised 1/13/25 dcoumented . 1. Unable to do own ADLS without assistance R/T (sic) MS (sic) and generalized weakness.
1/16/24 - A review of R47's care plan for ROM/Contractures revised 1/13/25 documented . 1. Maintain proper joint alignment while in bed or in chair.
6/25/24 - 9/25/24 R47's quarterly MDS assessment documented [R47] was dependent for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed).
7/16/24 6:00 AM - Review of a facility provided incident report documented Resident had a fall out of bed an aide was cleaning her up and went to grab something and patient rolled out of the bed. The CNA called for help and the patient was found on her back on the floor. Patient was noted to be A&O (sic) after the fall but was found with a small laceration to the back of the head with scant amount of bright red blood noted.
7/16/24 7:14 AM - E42's (RN) health status note documented, s/p (sic) unwitnessed fall 6:00 AM reported that resident fell out of the bed at which time this nurse went to room to assess where she was lying on the floor next to the bed on her back, with legs towards the head of the bed. Neurological checks initiated, AAO x3. VSS (sic). Resident reports hitting back of head, laceration to the back of head noted, with scant amount of bright red blood. NP (sic) on call made aware, new orders to send to ER (sic). Nursing supervisor called report to ED (sic) and call placed to emergency contact husband voice mail left. 6:50 AM EMTs (sic) arrived and transported resident to the hospital via stretcher, VSS (sic).
7/16/24 11:12 AM E43's (RN) health status note documented, Resident returned from hospital at 9:35 AM. CT (sic) of head without IV contrast results no intracranial injury or hemorrhage. Skin glue applied to laceration to the back of the head.
1/17/25 11:34 AM - During a telephone interview E37 (CNA) stated, Yes I was working on the 11-7 shift and it was my last rounds the facility doesn't use disposable washcloths, I had already rolled [R47] on to her right side to change her, but I didn't have enough washcloths and she was already laying on her side from when I started to change her, but I noticed that she was having a bowel movement and I didn't have enough wash cloths so I stepped right into the bathroom to wet some more washcloths and I left her on the right side that's the side I had rolled her onto when I started to change her, I stepped into the bathroom I should have put the bed down I was only leaving her for a second or two, she was stable on her right side, so I felt it was okay leaving her. I heard the fall when I went into the bathroom, I went straight to her, I yelled out for the nurse to let her know she had fell.
1/22/25 2:15 PM - E5 (RD) stated, [R47] has limited range of motion when bending her hips, knees and both shoulders.
1/22/25 2:23 PM - During an interview E44 (COTA) stated, [R47] can't use her left arm we have worked with her on positioning in bed anytime I have worked with her I have had to reposition her in the bed. E44 also stated, [R47] would not have had enough strength to remain laying on her side in the bed without rolling off the bed.
1/23/25 3:18 PM - Findings were confirmed with E1 (NHA).
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
5. Review of R3's clinical record revealed:
A CDC recommendation to prevent infection included: Maintain the bag below the level of the bladder. (https://www.cdc.gov Indwelling Urinary Catheter Insert...
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5. Review of R3's clinical record revealed:
A CDC recommendation to prevent infection included: Maintain the bag below the level of the bladder. (https://www.cdc.gov Indwelling Urinary Catheter Insertion and Maintenance).
9/26/23 - R3 was admitted to the facility with obstructive uropathy.
12/16/24 - R3 had a physician order for a foley catheter.
1/2/25 - A quarterly MDS assessment documented that R3 was dependent on staff for ADL's and had an indwelling catheter.
1/13/25 - 08:52 AM - During an observation, R3's foley catheter drainage bag was noted to be lying on the foot of R3's bed.
1/13/25 8:57 AM - During an interview, E58 (CNA) confirmed that R3's foley catheter drainage bag was on the bed.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
Based on interview and record review it was determined that for four (R4, R27, R61, R64 and R3) out of seven residents reviewed for bowel and bladder, the facility failed to respond to or provide services to maintain or restore bowel and bladder continence. Findings include:
1. Review of R4's clinical record revealed:
12/5/24 - R4 was admitted to the facility.
12/5/24 - A care plan was initiated for R4 but lacked evidence of addressing continence and plan of care related to continence.
12/5/24 3:30 PM - A bowel and bladder evaluation documented that R4 was continent of urine and lacked documentation regarding bowel continence.
12/12/24 - An admission MDS documented that R4 was always continent of bladder and occasionally continent of bowel and that no toileting program was indicated. The MDS also documented that R4 required partial or moderate assistance for toileting.
12/2024 - A review of the December CNA documentation record revealed that R4 was continent of bowel four times out of eighty opportunities.
1/2025- A review of the January CNA documentation record revealed that R4 was continent of bowel eight times out of forty six opportunities.
1/9/25 9:07 AM - An admission bowel and bladder evaluation documented that R4 was continent of urine and incontinent of bowel. The evaluation documented that a toileting program was not in use to manage R4's bowel continence.
1/13/25 2:16 PM - An interview with R4 revealed that he was continent of bowel at home and able to use the toilet independently. R4 stated that he can use a urinal and uses a brief while at the facility.
1/17/25 9:25 AM - An interview with E48 (CNA) confirmed that R4 requires staff assistance with toileting and is continent of urine. E48 stated that R4 is normally incontinent of bowel and does not use any assistive devices. E48 stated that R4 was not on a toileting program to her knowledge.
1/21/25 10:47 AM - An interview with E17 (RN, UM) confirmed that R4 was not on a toileting program and does not use assistive devices to maintain continence.
There was no evidence that the facility attempted to maintain bowel function for R4.
2. Review of R27's clinical record revealed:
10/14/24 - R27 was admitted to the facility.
10/14/24 - A care plan was initiated (R27) for incontinence of bowel and bladder with no memory recall and/or ability to retrain with the goal that R27 will be clean, dry, and comfortable with no skin breakdown for ninety days. The interventions included bowel and bladder assessments upon admission and quarterly, call bell within reach, check resident every two hours, and encourage highest level of independence of toileting as possible.
10/21/24 10:58 AM - A bowel and bladder assessment documented that R27 was incontinent of urine and was wet one to two times a day and continent of stool. The evaluation documented that a toileting program was not in use to manage R27 urinary continence.
10/21/24 - An admission MDS documented that R27 was dependent for toileting and requires assist of one for ADLs. The MDS also documented that R27 was frequently incontinent of bowel and bladder and that a urinary toileting program was initiated with no improvement.
10/2024 - A review of the October CNA documentation record revealed that R27 was continent of urine nine times out of fifty seven opportunities.
11/2024 - A review of the November CNA documentation record revealed that R27 was continent of urine eleven times out of ninety two opportunities.
12/2024 - A review of the December CNA documentation record revealed that R27 was continent of urine eleven times out of ninety five opportunities.
1/2025 - A review of the January CNA documentation record revealed that R27 was continent of urine five times out of fifty two opportunities.
1/17/25 9:33 AM - An interview with E48 (CNA) confirmed that R27 is staff assist of one for toileting and confirmed that resident is incontinent of bowel and bladder. E48 confirmed that R27 does not use a bed pan or commode for toileting and was not on a toileting program.
1/21/25 10:47 AM - An interview with E17 (RM UM) confirmed that R27 was not on a toileting program and does not use assistive devices to maintain continence.
There was no evidence that the facility attempted to maintain bladder function for R27.
3. Review of R61's clinical record revealed:
12/27/24 - R61 was admitted to the facility.
12/27/24 - A care plan was initiated for incontinence of bowel and bladder with no memory recall and/or ability to retrain with the goal that R61 will be clean, dry, and comfortable with no skin breakdown for ninety days. The interventions included bowel and bladder assessments upon admission and quarterly, call bell within reach, check resident every two hours, and encourage highest level of independence of toileting as possible
12/27/24 11:28 PM - A bowel and bladder assessment documented that R61 was occasionally incontinent of bowel and bladder and was a candidate for scheduled or prompted voiding.
12/2024 - A review of the December CNA documentation record revealed that R61 was incontinent of urine four times out of fourteen opportunities.
1/2025 - A review of the January CNA documentation record revealed that R61 was incontinent of urine twenty eight times out of forty seven opportunities.
1/3/25 - An admission assessment documented that R61 was dependent for toileting. The MDS also documented that R27 is occasionally incontinent of bowel and bladder and was not on a toileting program. R27 is also a BIMS of 15 indicating fully competent.
1/13/25 10:31 AM - An interview with R61 revealed that she was continent at home and is usually incontinent at the facility due to staff taking too long to answer the call bell.
1/17/25 9:41 AM - An interview with E28 (CNA) confirmed that R61 is a one person assist for toileting and is occasionally incontinent. E28 confirmed that R61 will use the toilet if staff assists her.
1/21/25 10:47 AM - An interview with E17 (RM UM) confirmed that R61 was not on a toileting program and does not use assistive devices to maintain continence.
There was no evidence that the facility attempted to maintain bladder function for R61.
4. Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
11/27/24 - A bladder and bowel evaluation documented R64 as frequently incontinent of both bowel and bladder. The evaluation also documented R64 was a candidate for scheduled or prompted voiding.
11/2024 - A review of the November CNA documentation record revealed that R64 was incontinent of urine two out of eleven opportunities and incontinent of bowel zero times out of eleven opportunities.
12/4/24 - An admission MDS documented R64 was a partial or moderate assist for toileting and R64 was occasionally incontinent of bladder and always continent of bowel. The MDS also documented R64 was not on a toileting program.
12/8/24 - A care plan documented that R64 had bladder incontinence related to activity intolerance, dementia, and impaired mobility with a goal of R64 being continent during waking hours through the review date. Interventions included checking R64 as needed and as required for incontinence and notify the provider of any possible medical causes for incontinence.
12/2024 - A review of the December CNA documentation record revealed that R64 was incontinent of urine fifteen times out of ninety six opportunities and incontinent of bowel seven times out of ninety six opportunities.
1/2025 - A review of the January CNA documentation record revealed that R64 was incontinent of urine fourteen times out of fifty two opportunities and incontinent of bowel ten times out of forty eight opportunities.
1/13/25 12:26 PM - An interview with FM3 revealed that R64 was occasionally incontinent of bowel and bladder while at home and FM3 expressed concern that she had come in to visit and found R64 soaked in urine on multiple occasions.
1/17/25 9:22 AM - An interview with E28 (CNA) confirmed that R64 is an assist of one staff for toileting and R64 remains continent if staff encourages R64 to toilet. E28 did not recall R64 being on a toileting schedule or program.
1/21/25 10:47 AM - An interview with E17 (RN, UM) confirmed that R64 was not on a toileting program.
There was no evidence that the facility attempted to maintain bladder or bowel function for R64.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for two (R11 and R91) out of two residents reviewed for tube feeding the facility failed to implement current professional standards of pra...
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Based on record review and interview, it was determined that for two (R11 and R91) out of two residents reviewed for tube feeding the facility failed to implement current professional standards of practice, to maintain acceptable parameters of nutritional status. Findings include:
for R11 the facility failed to label R11's tube feeding bottle to discern the tube feeding's date and time of expiration per standard of care. For R91, the facility failed to obtain an order for R91 to resume her tube feeding at the time of readmission to the facility. Findings include:
1. Review of R11's clinical record revealed:
10/2/23 - R11 was admitted to the facility with quadriplegia.
12/22/24 - A discharge MDS assessment documented that R11 required tube feeding for nutrition.
1/14/25 10:40 AM - An observation of R11's tube feeding bottle not labeled with a time or date of when the tube feeding had been initiated.
1/14/25 10:42 AM - During an interview, E12 (LPN) confirmed that the tube feeding was not labeled with date and time that the bottle had been hung and started.
2. Review of R91's clinical record revealed:
11/5/24 - R91 was admitted to the facility with ALS.
11/12/24 - R91's admission MDS admission assessment documented that R91 required tube feeding for nutrition.
1/13/25 11:51 PM - A nursing progress note included that R91 was readmitted to the facility at 4:23 PM.
1/14/25 - During an interview, FM4 stated that R91 did not have any tube feeding since the day before (1/13/25).
Review of the readmission physician orders revealed that the facility lacked evidence of a tube feeding order upon return on 1/13/24.
1/14/25 10:47 AM - During an interview, E50 (LPN) confirmed that R91 did not have a physician order to resume her tube feeding since her 1/13/25 readmission.
1/14/25 12:30 PM - A physician order for R91's tube feeding became an active order. R91 did not have an active physician order for approximately 20 hours.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined that for four (R10, R29, R67 and R80) out of seven residents sampled for respiratory care the facility failed to provide respiratory...
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Based on observation, interview and record review it was determined that for four (R10, R29, R67 and R80) out of seven residents sampled for respiratory care the facility failed to provide respiratory care based on professional standards for R10, R29, R67 and R80's nebulizer mask was not dated and not in a plastic bag when not in use. R10's nebulizer mask was dated 12/26/24. Further review of R10, R29, R67 and R80's records lacked evidence of orders to change and store nebulizer masks. Findings include:
A policy and procedure titled Aerosol Nebulizer Compressor undated documented 1. Proper cleaning, maintenance and storage will be followed to prevent infections and ensure the longevity of equipment . 2. Follow standard infection control precautions to prevent the spread of infections.
1. R10's clinical record revealed:
9/27/23 - R10 was admitted to the facility.
January 2025 - Review of R10's TAR lacked orders when to change and how to store R10's nebulizer mask when not in use.
1/13/25 8:59 AM - An observation of R10's nebulizer mask was dated 12/26/24 and laying on top of the resident's blanket.
1/13/25 12:38 PM - Another random observation revealed R10's nebulizer mask was laying on the bedside stand and not stored in a plastic bag.
1/13/25 2:48 PM - During an interview the surveyor asked E17 (RN) the process for storing a resident's nebulizer mask when not in use. E17 stated, I would need to check with someone before I answer that I'm not sure.
1/13/25 2:59 PM - During an interview and observation E35 stated, nebulizer masks should be stored in a Ziplock bag (plastic bag) when not in use. E35 confirmed [R10's] nebulizer mask was dated 12/26/24 and sitting on top of the resident's bedside table and not in a plastic bag.
2. R67's clinical record revealed:
12/2/22 - R67 was admitted to the facility.
January 2025 - Review of R67's TAR lacked orders when to change and how to store R67's nebulizer mask when not in use.
1/12/25 11:11 AM - During an observation R67's nebulizer mask and tubing was attached to the nebulizer machine sitting on the resident's bedside table. The mask was not dated or stored in a plastic bag.
1/13/25 2:42 - During an interview E36 (LPN) stated, I was trained to store the nebulizer mask at the bedside when not in use, that's what I have been shown.
1/13/25 2:52 PM - During an interview and observation E36 (RN) confirmed R67's nebulizer mask was not dated and attached to the nebulizer machine and not stored in a plastic bag.
3. R29's clinical record revealed:
12/6/22 - R29 was admitted to the facility.
1/12/25 9:56 AM - An observation revealed R29's nebulizer mask attached to tubing that was connected to a nebulizer machine. The mask was laying inside of R29's bedside table in a closed drawer and not in a plastic bag.
January 2025 - Review of R29's TAR lacked orders when to change and how to store R29's nebulizer mask when not in use.
1/13/25 2:46 PM - During an observation and interview E35 stated, the resident's mask is laying inside the bedside table drawer, it's not dated, I will take care of this.
4. R80's clinical record revealed:
10/1/24 - R80 was admitted to the facility.
1/13/25 10:18 AM - During an observation R80's nebulizer mask was attached to the nebulizer machine not dated or stored in a plastic bag.
January 2025 - Review of R80's TAR lacked orders when to change and how to store R80's nebulizer mask when not in use.
1/13/25 2:56 PM - During an observation and interview E35 stated, Oh I can see [R80's] mask from the hallway, it's not in a bag, I don't know why but I will take care of it.
1/13/25 3:25 PM - Findings were confirmed with E1 (NHA).
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
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 F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on interview and record review and other documentation as indicated, it was determined that for one (R300) out of five reviewed residents for pressure ulcers, the facility failed to ensure that ...
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Based on interview and record review and other documentation as indicated, it was determined that for one (R300) out of five reviewed residents for pressure ulcers, the facility failed to ensure that R300's medical care was supervised by a physician for the care of pressure ulcers. Findings include:
Cross refer F686
Review of R300's clincal record revealed:
8/28/24 - R300 was admitted to the facility.
11/4/24 10:40 PM - A practioner (E11) progress note documented that R300 was seen for a follow up visit wound to right heel. The progress note documented that nursing reported black heel with a small amount of drainage and treatment was betadine and dry dressing to cover. The physical exam documented skin as warm and dry. The progress not lacked evidence of physical characteristics of the wound care assessment by the provider.
11/5/24 2:05 PM - A pracitioner (E11) progress note documented that R300 was seen for follow up up visit for antibiotics and ESRD (end stage renal disease). The progress note documented that R300 was started on Keflex for the right heel wound and had no adverse effects or complaints noted. The physical exam documented skin as warm and dry. The progress not lacked evidence of the physical characteristics of the wound assessment by the provider.
11/8/24 11:55 AM - A skin assessment documented R300 had a deep tissue injury unstageable to right heel with the following measurements: 6.2cm L x 5.4cm W x 0cm deep. The wound was documented as necrotic with no drainage, wound odor, and soft boggy tissue with suspected infection. The assessment documented the current treatment as betadine to help dry the soft boggy tissue. R300 was on oral antibiotics and xray was ordered to rule out osteomyelitis. Additionally an ultrasound and arterial study was ordered.
1/17/25 12:06 PM - An interview with E11 (NP) confirmed R300 was one of her patients and stated I do not follow wound care, the wound NP does. I just order the medications related to wound care.
The facility lacked evidence that a provider (E11) physically assessed R300's right heel wound per the aforementioned progress notes.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (E39) out of five CNA's reviewed for annual performance reviews, the facility failed to ensure that the annual performance review wa...
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Based on record review and interview it was determined that for one (E39) out of five CNA's reviewed for annual performance reviews, the facility failed to ensure that the annual performance review was completed at least once every twelve months. Findings include:
1/2/23 - E39's most recent performance review was completed on 1/17/25. The facility lacked evidence of a performance review completed in 2024.
1/15/25 1:21 PM - During an interview E1(NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R32) out of one resident reviewed for medication administration, the facility failed to provide pharmacy services to refill medicat...
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Based on record review and interview it was determined that for one (R32) out of one resident reviewed for medication administration, the facility failed to provide pharmacy services to refill medications to avoid missed doses. Findings include:
Review of R32's clinical record revealed:
9/1/23 - R32 was admitted to the facility with multiple diagnoses including cirrhosis of the liver.
8/27/24 - A physician's order was written for R32 to receive lactulose 45ml twice a day for cirrhosis of the liver.
12/7/24 - A quarterly MDS assessment documented that R32 was cognitively intact.
12/30/24 9:02 AM - An order administration note in R32's clinical record documented, medication (lactulose) ordered not delivered, nurse called pharmacy.
12/31/24 9:59 AM - An order administration note in R32's clinical record documented, medication (lactulose) ordered, not delivered, will notify supervisor and call pharmacy.
12/31/24 3:09 PM - An order administration note in R32's clinical record documented, med (lactulose) not delivered, pharmacy called and said it would arrive by 3:00 pm, was not delivered.
December 2024 - Review of R32's MAR lacked evidence the resident received the ordered doses of lactulose on 12/30/24 and 12/31/24.
1/13/25 9:30 AM - During an interview R32 stated One time I had no lactulose for the three days. I was worried because without it I get confused, but I didn't.
1/17/25 11:45 AM - Review of pharmacy refill request for R32 revealed the request for lactulose was made on 12/30/24. The same date as the missed dose on 12/30/24.
1/17/25 11:48 AM - E2 (DON) confirmed that a delay in ordering resulting in R32's missed doses of lactulose.
1/23/25 8:42 AM - E2 provided the surveyor with an undated pharmacy memorandum regarding refilling of medications. The memorandum read the following Attention Nursing Personnel then listed pharmacy contact information as well as a table of timeframe's to order medications and expected delivery time. The memorandum also indicated that STAT orders must be called into the pharmacy to notify the pharmacy that it's a STAT order.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2, and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R27) out of five residents reviewed for unnecessary medications, the facility failed to limit an as needed (PRN) psychotropic medic...
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Based on record review and interview it was determined that for one (R27) out of five residents reviewed for unnecessary medications, the facility failed to limit an as needed (PRN) psychotropic medication to 14 days. Findings include:
Review of R27's clinical record revealed:
10/14/24 - R27 was admitted to the facility diagnoses including but not limited to visual hallucinations, auditory hallucinations, and vascular dementia with psychotic disturbance.
10/21/24 - An admission MDS assessment documented a BIMS score of 14 indicating R27 is cognitively intact and also documented R27 had physical, verbal, and other behaviors not directed at others.
11/13/24 8:49 PM - A physician's order documented alprazolam (anti-anxiety) 0.5mg: Give 0.5mg by mouth every eight hours as needed for anxiety with an indefinite stop date.
1/17/25 2:57 PM - An interview with E11 (NP) confirmed the order did not have a fourteen day stop date.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and review of other facility documentation, it was determined that for three out of five medication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and review of other facility documentation, it was determined that for three out of five medication storage refrigerators, the facility failed to facilitate the safe administration of medication to residents and staff. In addition, the facility failed to ensure that testing materials for COVID-19 would accurately reflect residents and employees COVID status. Findings include:
[DATE] 9:02 AM - An observation of the back-up medication refrigerator in the facility conference room revealed that the temperature monitoring logs were incomplete.
The following are the incomplete daily temperature log monitoring for the medications stored in the facility conference room refrigerator.
- [DATE] - 18 out of 31 days were incomplete.
- [DATE] - 10 out of 30 days were incomplete
- [DATE] - 8 out of 31 days were incomplete.
- [DATE] - 19 out of 31 days were incomplete.
- [DATE] - 16 out of 30 days were incomplete.
- [DATE] - 9 out of 31 days were incomplete.
- [DATE] - 27 out of 30 days were incomplete.
- [DATE] - The facility lacked evidence of any refrigerator temperature monitoring.
- [DATE] - The facility lacked evidence of any refrigerator temperature monitoring until the surveyor brought it to the attention of the facility on [DATE].
[DATE] 9:17 AM - During an observation and interview, E2 (DON) confirmed the missing temperature monitoring of the conference room refrigerator.
Medications that were stored inside of the conference room refrigerator were as follows:
- 10 five milliliters of flu vaccines.
- 83 single dose pre-filled syringes of flu vaccine.
- 17 single dose pre-filled doses of Hepatitis B vaccines.
- 2 COVID-19 pre-filled doses of COVID-19 vaccines.
[DATE] 10:33 AM - During an observation and interview with E3 (ADON), it was confirmed that in the Riverwalk number 1 medication refrigerator was a box of Tylenol suppositories that had been expired since [DATE].
[DATE] 10:45 AM - During an observation and interview with E3, it was confirmed that in the Riverwalk number 2 medication room was two holding boxes of COVID-19 testing mediums. One of which the holding boxes had 10 testing mediums that was noted to have approximately ¼ of an inch of water in (one of which had a black substance in it). The other holding box did not have water in it but had a piece of tape on it with the date of 7/10. E3 stated that there was a laboratory technician in the building, and we should consult her regarding the test mediums.
[DATE] 11:12 AM - During an observation and interview L1 (Lab Tech) confirmed that the vials of medium were not recommended to be used. L1 stated that she would contact the owner and operator of the lab about how to proceed. The lab owner on the phone with the lab tech stated that the vials should be disposed of in the biohazard trash.
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 F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined, for one (R64) out of four residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner o...
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Based on record review and interview, it was determined, for one (R64) out of four residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results. Findings include:
Cross refer to F580
Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
1/10/25 11:00 PM - A physician's order for R64 documented complete blood count (CBC), comprehensive metabolic panel (CMP), and infuse normal saline at 100 mL/hr total 1 liter.
1/11/25 1:37 PM (Saturday) - A lab result report for R46 documented the white blood cell count was high.
1/13/25 4:30 PM - A physician's order for R64 documented a chest xray with two views and rocephin (antibiotic) inject one gram intramuscularly immediately (STAT) for white blood cell elevation.
1/14/25 3:25 PM - A physician's order for R64 documented Bactrim (antibiotic) 800-160mg give one tablet two times a day for left base infiltrate (pneumonia) for five days.
1/15/25 2:13 PM - Interview with E17 (RN UM) confirmed that the progress notes lacked evidence of notification to the provider of R46's lab results.
The facility lacked evidence of promptly reporting abnormal lab results to the medical provider.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined that for one (R27) out of seven sampled residents for dental services, the facility failed to assist the residents in obtaining rou...
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Based on observation, interview and record review, it was determined that for one (R27) out of seven sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include:
Review of R27's clinical record revealed:
10/12/24 - An admission packet for R27 documented that R27 elected to receive dental services through the facility.
10/14/24 - R27 was admitted to the facility with vascular dementia.
10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-alzheimers dementia. The MDS also documented that R27 does not have dentures, broken teeth, or any abnormal mouth issues.
1/13/25 9:11 AM - An interview revealed that R27 wanted to see the dentist and stated she had not seen one since before she was admitted to the facility.
1/15/25 3:29 PM - A review of the electronic medical records lacked evidence that R27 had received dental services.
1/21/25 8:26 AM - An interview with E1 (NHA) confirmed that R27 had not received dental services because the dentist only comes to the facility once a year. E1 stated that the dentist had not come for the annual visit yet.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON), and E4 (Corporate Clinical Support).
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 F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation and interview it was determined that for one (R64) out of one residents reviewed for nutrition the facility failed to provide fluid in a form designed to meet the individuals need...
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Based on observation and interview it was determined that for one (R64) out of one residents reviewed for nutrition the facility failed to provide fluid in a form designed to meet the individuals needs. Findings include:
Review of R64's clinical record revealed:
11/27/24 - R64 was admitted to the facility.
12/4/24 - An admission MDS assessment documented that R64 was independent for eating.
1/14/25 7:23 PM - A physician's order documented that R64 was on thickened liquids.
1/15/25 1:15 PM - An observation of R64's lunch tray revealed that R64 was served water, coffee, and juice that were all thin liquids. R64 was actively eating and drinking when observation occurred; During this time R64 was observed drinking the thin liquids resulting in coughing.
1/15/25 1:30 PM - An interview with E48 (CNA) revealed that E48 was not informed that R46 was on thickened liquids during report and E48 went to replace the thin liquids with thickened.
1/15/25 1:35 PM - An interview with E51 (LPN) and E35 (RN) revealed that when a new diet is ordered the order gets entered in the electronic medical record (EMR) and a dietary communication slip is completed. If the order is completed after dietary is closed the nurse will deliver the dietary communication to the front desk to give to dietary in the morning.
1/15/25 1:45 PM - An interview with E52 (Secretary) confirmed that no dietary communication slip was left at the front desk for the dietary department.
1/15/25 2:00 PM - An interview with E53 (Dietician) revealed that she was unaware of the new order for R64. E53 reviewed the new order in the EMR and confirmed that the diet order was not input as a dietary order so therefore the electronic system did not communicate the new order to dietary. E53 also confirmed that no dietary communication slip was completed and given to the dietary department.
The facility failed to provide R64 fluid in a form designed to meet individual needs.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:
1/13/25 10:26 AM - During a tour of the kitchen, the surveyor observed E15 (Account Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E15 tested the sanitizing solution, the test strips from each of the buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization.
1/13/25 10:28 AM - During a tour of the walk-in freezer there were several discarded food items, including a breaded fish patty, a hash brown, and several other debris items laying on the freezeer floor.
1/13/25 10:53 AM - During the rinse cycle the automatic dishwashing machine temperature was too low. Several test trials revealed a max temp of 130 degrees Fahrenheit. The temperature in this type of warewashing machine must be [NAME] than 180 degrees Fahrenheit for proper sanitization during the rinse cycle.
1/13/25 12:30 PM - The refrigerator in the first nourishment room contained two turkey and cheese sandwiches with a creation date of 1/7/25, which should have been discarded before 1/10/25. The refrigerator in the second nourishment room contained an undated/labeled jar of spinach dip and an opened package of processed cheese food dated 10/24/24.
1/13/25 12:52 PM - The refrigerator in the dining room contained an opened half used bottle of prune juice with no date label, as well as several other opened and unopened items with room numbers, but no date lables.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Support)
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
Based on record review and interview, it was determined that for one (R500) out of thirty-four (34) residents reviewed, the facility failed to ensure the residents medical record was complete, accurat...
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Based on record review and interview, it was determined that for one (R500) out of thirty-four (34) residents reviewed, the facility failed to ensure the residents medical record was complete, accurately documented and readily accessible. Findings include:
The facility policy on charting and documentaion last updated 2001 indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.
Review of R500's clinical record revealed;
3/21/25 7:45 PM - A fall incident report documented, that R500 a resident with some baseline confusion experienced an unwitnessed fall.
3/21/25 7:45 PM - A neurological assesment form was initiated by E6 (RN) related to R500's unwitnessed fall to be completed through 3/24/25.
3/21/25 7:45 PM - A progress note written by E6 (RN) in R500's clinical record documented, Post fall this shift .Neuro checks done and in progress. Will continue to monitor. The progress note lacked specific information regarding the neurological checks.
3/21/25 7:47 PM - A progress note written by E6 (RN) in R500's clinical record documented, Resident resting and neuro checks in progress. The progress note lacked specific information regarding the neurological checks.
3/31/25 2:00 PM - Review of the neurological assesment form related to R500's unwitnessed fall lacked evidence of entries for completion of the neurological assessments from 3/21/25 at 7:45 PM through 11:30 PM.
3/31/25 3:01 PM - Surveyor attempted to contact E6 (RN) by telephone and received a text message that E6 was unavailable for interview due to air travel.
4/1/25 12:58 PM - During an interview E3 (DON) confirmed that the neurological assesment form related to R500's fall was incomplete.
4/3/25 3:07 PM - During an interview E6 (RN) confirmed that neurological assessments were completed on R500 following the residents fall on 3/21/25. E6 then produced neurological assessment documentaion on a green legal pad for the timeframe not documented on the neurological assessment form. E6 stated, I always document on my pad. My goal was to write it and transfer it to that form. I was the supervisor that shift. As I was writing they called me and I had to stop. When I returned the nurse had taken the sheet. E4 then scanned a copy of the assessment documentation on the note pad to R500's clinical record.
4/3/25 3:45 PM - Findings were reviewed during the exit meeting with E2 (NHA) and E4 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two (E28 and E49) out of six employees reviewed, the facility failed to ensure that mandatory communication training was completed. Find...
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Based on record review and interview it was determined that for two (E28 and E49) out of six employees reviewed, the facility failed to ensure that mandatory communication training was completed. Findings include:
1/15/25 - A review of the facility training worksheets lacked evidence of required communication training for the following staff:
E28 date of hire 6/29/23 - no record of communication training.
E49 date of hire 12/11/23 - no record of communication training.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected 1 resident
Based on record review and interviews it was determined that for two (E29 and E30) of out of six employees reviewed, the facility failed to ensure resident rights training was ongoing. Findings includ...
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Based on record review and interviews it was determined that for two (E29 and E30) of out of six employees reviewed, the facility failed to ensure resident rights training was ongoing. Findings include:
1/15/25 - A review of the facility training worksheets revealed lack of evidence of ongoing training on resident's rights for the following staff:
E29 date of hire 4/10/23 -most recent date of residents rights training 4/11/23.
E30 date of hire 10/23/23- most recent date of residents rights training 10/23/23.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two (E28 and E47) out of six employees reviewed, the facility failed to ensure that staff completed QAPI training. Findings include:
1/1...
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Based on record review and interview it was determined that for two (E28 and E47) out of six employees reviewed, the facility failed to ensure that staff completed QAPI training. Findings include:
1/15/25 - A review of the facility training worksheets lacked evidence of required QAPI training:
E28 6/29/23 date of hire, no record of training.
E47 7/19/23 date of hire, no record of training.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0945
(Tag F0945)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two (E29 and E30) out of six employees reviewed for required training the facility failed to ensure that infection control training was ...
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Based on record review and interview it was determined that for two (E29 and E30) out of six employees reviewed for required training the facility failed to ensure that infection control training was completed and consistent with policy standards. Findings include:
The facility policy on Infection Prevention and Control Plan last updated 2024, indicated there would be ongoing education for all facility personnel.
1/15/25 - A review of the facility's training worksheet lacked evidence of ongoing infection control training for the following staff:
E29 date of hire 4/10/23 most recent infection control training completed on 4/10/23.
E30 date of hire 10/23/23 most recent infection control training completed on 10/23/23.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0946
(Tag F0946)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for three (E28, E29, and E30) out of six employees reviewed, the facility failed to ensure that annual training of the compliance and ethics...
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Based on record review and interview it was determined that for three (E28, E29, and E30) out of six employees reviewed, the facility failed to ensure that annual training of the compliance and ethics program was completed for an organization operating five or more facilities. Findings include:
1/15/25 - A review of the facility's training worksheet lacked evidence of required training on the facilities compliance and ethics programs for the following staff:
E28 6/29/23 date of hire, no record of training.
E29 4/10/23 date of hire, last date of training 4/10/23.
E30 10/23/23 date of hire, last date of training 10/23/23.
1/23/25 4:34 PM - During an interview E1(NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for four (E30, E32, E39, and E40) out of five CNA'S reviewed, the facility failed to ensure that the required minimum twelve hours of in-ser...
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Based on record review and interview it was determined that for four (E30, E32, E39, and E40) out of five CNA'S reviewed, the facility failed to ensure that the required minimum twelve hours of in-service training was completed. Findings include:
1/15/25 - A review of the facility training worksheet lacked evidence of the required twelve hours minimum in-service training for the following CNA's:
E39 had a hire date of 1/2/23. From 1/2/24 - 1/2/25, 1.05 hours of training were completed.
E32 had a hire date of 9/26/23. From 9/26/23 - 9/26/24, 0.0 hours of training were completed.
E40 had a hire date of 10/9/23. From 10/9/23 - 10/9/24, 0.0 hours of training were completed.
E30 had a hire date of 10/23/23. From 10/23/23 - 10/23/24, 0.0 hours of training were completed.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.
1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two (E28 and E29) out of six staff reviewed, the facility failed to ensure that required behavioral health training was completed in acc...
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Based on record review and interview it was determined that for two (E28 and E29) out of six staff reviewed, the facility failed to ensure that required behavioral health training was completed in accordance with the Facility Assessment. Findings include:
The Facility Assessment last updated December 2024, indicated that the facility maintained an average of one to ten residents with behavioral symptoms. Staff training, education and competencies, indicated that All staff are assigned training and attend training sessions in the facility annually and as designated.
1/15/25 - A review of the facility training worksheet lacked evidence of behavioral health training for the following staff:
E28 (DA)- date of hire 6/29/23 no documented behavioral health training.
E29 (RN) - date of hire 4/10/23 no documented behavioral health training.
1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the missed training's.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and interview it was determined that for eight (R3, R4, R27, R46, R57, R63, R89 and R91) out of thirty-seven residents investigated the facility failed to develop person centere...
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Based on record review and interview it was determined that for eight (R3, R4, R27, R46, R57, R63, R89 and R91) out of thirty-seven residents investigated the facility failed to develop person centered care plans. Findings include:
1. Review of R46's clinical record revealed:
11/22/24 - An annual MDS assessment documented that R46 received insulin.
11/15/24 - A physicians order was written for R46 to receive Insulin Glargine 20 units at bedtime.
11/16/24 - A physicians order was written for R46 to receive Insulin Aspart (with Niacinamide) 12 units one time a day for diabetes.
1/16/25 - Review of R46's care plans lacked evidence of a care plan that addressed the residents use of insulin and diagnosis of diabetes.
1/16/25 2:20 PM - E1 (DON) provided a care plan that addressed R46's diabetes and use of insulin. The creation date of the care plan was 1/16/25. E1 confirmed the finding.
2. Review of R57's clinical record revealed:
8/27/24 - Physicians orders were written for R57 to receive an anti-anxiety and an anti-depressant medication.
9/6/24 - An annual MDS assessment documented that R57 received anti-anxiety and anti-depressant medications.
12/7/24 - A quarterly MDS documented that R57 received anti-anxiety and anti-depressant medications.
1/15/24 - Review of R57's care plans lacked evidence that they addressed R57's anxiety and depression, use of anti-anxiety medications and anti-depressant medications.
1/15/25 1:53 PM - E1 (DON) confirmed the findings and created corresponding care plans to address R57's use of antidepressant and anti-anxiety medications.
3. Review of R63's clinical record revealed:
4/18/22 - R63 was admitted to the facility with dementia.
4/24/24 - An annual MDS assessment documented that R63 was severely cognitively impaired.
1/13/25 8:53, 1/14/25 1:46 PM, 1/15/25 11:41 AM, and 1/17/25 8:33 AM, R63 was observed with approximately one half of an inch of gray and black facial hair on her chin.
1/17/25 8:33 AM - During an interview E10 (CNA) confirmed R63's extensive facial hair. E10 stated that R63 is combative with care and especially showers. E10 added that R63 will not let anyone shave her because she does not like anything near her face.
1/17/25 8:37 AM - During an interview, E12 (LPN) confirmed that R63 did not have a care plan for refusals of shaving and bathing.
4. Review of R89's clinical record revealed:
5/22/24 - R89 was admitted to the facility with multiple sclerosis, a stroke and was paraplegic.
5/22/24 - R63's fall care plan included for her call bell to be in reach and to apply non-skid footwear except during hygiene.
5/29/24 - A quarterly MDS assessment documented that R89 was totally dependent on staff for all care and could not walk.
Although R89 had a fall care plan in place, it was not comprehensive and patient centered related to R89's paraplegic status, and resultant inability to utilize the call bell and or walk.
1/22/25 approximately 1:45 PM - E2 (DON) confirmed that R89's care plan was not appropriate for R89's status.
5. Review of R91's clinical record revealed:
11/5/24 - R91 was admitted to the facility with a tracheostomy and dependent on a ventilator.
11/12/24 - An admission MDS assessment documented that R91 had a tracheostomy and was ventilator dependent.
Review of R91's care plan revealed that the facility failed to create a comprehensive care plan to include her respiratory status.
1/22/25 approximately 1:45 PM - E2 (DON) confirmed that R91 did not have a care plan for her respiratory status.
6. Review of R3's clinical record revealed:
9/26/23 - R3 was admitted to the facility with a diagnosis of dementia.
1/2/25 - A quarterly MDS documented that R3 was severely cognitively impaired and had a diagnosis of non-Alzheimers dementia.
Review of R3's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care.
1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R3 did not have a care plan for dementia care.
7. Review of R4's clinical record revealed:
12/5/24 - R4 was admitted to the facility.
12/18/24 - An admission MDS documented that R4 was always continent of urine and occasionally incontinent of bowel.
Review of R4's careplan revealed that the facility failed to create a comprehensive care plan to include bowel incontinence.
1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R4 did not have a care plan for bowel incontinence.
8. Review of R27's clinical record revealed:
10/14/24 - R27 was admitted to the facility with vascular dementia.
10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-Alzheimers dementia.
Review of R27's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care.
1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that R27 did not have a care plan for dementia.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
Jul 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 F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R2) out five residents reviewed for discharge the facility failed to implement an effective discharge plan that addressed R2's need...
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Based on record review and interview it was determined that for one (R2) out five residents reviewed for discharge the facility failed to implement an effective discharge plan that addressed R2's needs related to a community primary care physician, open wounds, insulin dependence, and visual impairment. Findings include:
The facility policy on resident initiated discharge last updated October 2022, indicated Residents may initiate a discharge from the facility. For resident intiated discharges the medical record contains: documented discussions with the resident containing details of discharge planning and arrangements for post-discharge care.
Review of R2's clinical record revealed:
2/21/23 - R2 was admitted to the facility with multiple diagnoses including diabetes, and unspecified cataracts. R2 was listed as their own responsible party. CW1 was listed as a care conference person.
2/21/23 (initiated) - R2's care plan for discharge planning uncertain; patient has voiced desire to discharge back to the community was reviewed on 4/17/24. Goal will be discharge to a safe environment with appropriate resources times 90 days. Interventions included to develop a discharge plan with resident and family. Assist case manager/case worker to develop safe discharge plan. There were no changes to interventions made since the creation of this care plan.
3/6/23 - A progress note written by E3 (MD) documented, Patient seen secondary to previous concerns about patient wanting to leave the facility.
8/18/23 - A progress note written by E14 (NP) documented, Patient is inquiring when he could possibly see ophthalmologist due to visual deficits and him not being able to see how to administer insulin appropriately as what is preventing him from discharging. At this time no additional concerns from nursing staff. Patient has been a long-term care resident at Polaris since February 2023. Patient feeds himself. Appetite has been satisfactory Patient able to communicate his needs. Able to walk independently without any assistive devices. Patient continent of bowel and bladder and is independent with his ADLs. Patient used to live in a shelter and was homeless. Patient not happy with having to stay here. Patient very independent with ADLs.
10/3/23 - A progress note in R2's clinical record documented that R2 Returned from eye surgery appointment in stable condition.
2/28/24 - An annual MDS assessment documented that R2 was moderately visually impaired, a diabetic who received insulin, and cognitively intact. R2 had participated in the goal setting portion of the assessment with a desire to return to the community, the active discharge plan segment was marked no.
4/25/24 - A progress note written by E13 (NP) documented, [R2] seen today for [new] open wound to right top of foot.
5/5/24 - A wound care note in R2's clinical record documented, Resident refused dressing change stating that he just wanted a band aid and he will put it on himself. Band aid was given. The clinical record lacked evidence that R2 was able to demonstrate the ability to complete wound care independently.
5/15/24 9:10 PM - A behavior note in R2's clinical record written by E15 (RN) documented, [E17 (CNA)] approached this nurse to report that [R2] had his call light on and when she answered the light,[ R2] was naked from the waist down with his penis in his hands masturbating and pornography playing on his phone. Initially, the assistant assumed he had an accident and needed assistance. [R2] then continued to masturbate and asked the assistant not to tell anyone. [R2] then requested [E16 (CNA)] to come in the room and propositioned [E16] to be his girlfriend or sex partner.[ E16] then reminded [R2] that she is here to work and care for the residents in this building and sexual relationships between staff and residents are strictly prohibited.
5/16/24 - A progress note written by E5 (RN) documented, Seen by wound care team. No change in therapy. Wound healing with new granulation tissue present. Educated again about tight fitting shoes and standing for long periods of time. The note lacked evidence that R2 was educated on how to complete a dressing change and lacked evidence that R2 demonstrated ability to complete a dressing change independently.
5/16/24 untimed - A 30 day discharge notice was issued to R2. The notice indicated, Effective June 16, 2024 you will be discharged to a [hotel]. You are being discharged for the following reasons: Your health has improved sufficiently so that you no longer need the services provided by our facility. The safety of other individuals in the facility is endangered, the health of other individuals in endangered.
5/17/24 12:20 PM - A police report documented arrival to the facility for a disorderly complaint. No arrest were made. The investigative narrative documented, [E2/PC2] stated after this occurred, she conducted a deep dive into PC3's past. She found that S1 [R2] had served his jail time for past crimes. PC2 stated that she was uncomfortable with PC3 [R2/S1] being there anymore. Additionally the report documented, [E17/PC4] would be the victim and if she didn't want to proceed on any charges we wouldn't .[R2 /PC3] agreed to leave the facility.
5/17/24 - untimed -R2 decided to discharge from the facility.
5/17/24 1:06 PM - A discharge form form signed by R2 documented that R2 was being discharged to the home/community. There was no documented community physician. Home care services, medical equipment, scheduled appointments were marked no. Medication education was completed on all medications ordered at discharge including insulin to be injected before meals. Demonstration of ability to self administer insulin independently was not documented. Wound treatment information was written, there was no documentaion regarding demonstration of ability to complete the dressing changes independently.
5/17/24 2:05 PM - A progress note written by E6 (RN) documented, Discharge instructions and medications reviewed with resident and all questions answered. Resident discharged with all belongings. Medications called in to Walmart in Georgetown by NP. The progress note lacked evidence that R2, a visually impaired resident, was able to demonstrate the ability to self administer insulin or complete a dressing change to the wound on his foot independently.
During an interview on 7/2/24 at 12:23 PM, with R2 it was confirmed the facility did not educate R2 on how to self administer insulin or dressing changes and did not observe R2 perform self administration of insulin or dressing change independently. R2 stated, I was released with a wound on my foot, they gave me some wound care there and stuff when I left. That's it. They really didn't do shit. R2 reported completing dressing changes independently since his discharge from the facility.
During an interview on 7/2/24 at 1:44 PM, E8 (former CNA) reported providing care for R2 throughout the duration of his care. E8 stated With assistance he could shower. He would walk around. Only time he needed assistance was with his vision.
During an interview on 7/2/24 at 2:00 PM, E6 (RN) stated she was aware that R2 had an open wound. When asked if R2 had a visual impairment, E6 responded, As far as I know they were corrected because he had recent surgery and his vision was greatly improved. E6 then confirmed that she did not perform any demonstration and did not visualize return demonstration of R2's ability to self administer insulin or complete dressing changes.
During an interview on 7/2/24 at 2:18 PM, E5 (RN) and current WCN stated that in terms of teaching related to R2's open wound, When we would see him we would show him what we did and I went over that with him then and on discharge and I gave him supplies. When asked where R2 provided return demonstration of his ability to independently complete a dressing change E5 stated, No he did not but he did verbalize understanding of how to do it.
During an interview on 7/4/24 at 6:30 AM, with PO1 (police officer) it was revealed that he responded to the facility on 5/17/24 at 12:20 PM, for an incident that happened on 5/15/24. PO1 stated that he mostly interacted with the DON (E2) who told him that she had done a deep dive into the resident and he had committed crimes and they wanted him out of the building. PO1 spoke to the main victim who wasn't giving the whole story so he could not use her information. The other two staff he spoke to told him the resident had exposed himself to them. The officer also interviewed the resident who shared that he had put the call bell on by accident and was in his room alone pleasuring himself when staff walked in. PO1 stated that facility staff wanted R2 out of the facility immediately. PO1 told facility staff that he could not do that. PO1 then asked R2 if he'd be cool with getting set up in a hotel of his choosing and he agreed to leave the facility.
During an interview on 7/8/24 at 9:32 AM, E12 (former SW) explained she was not involved with R2's discharge but did sign the discharge form.
During an interveiw on 7/8/24 at 11:46 AM, with CW1 it was reported that, [R2's] discharge I feel was out of compliance. I believe he was being treated for a wound and I'm not certain he was properly educated about that and how to manage that on his own, he can't see very well. There was not a time for a discharge meeting to plan the discharge. We knew [R2] wanted to be in the community I had referred him to NFT for housing assistance. [R2] wasn't located for days, Tuesday or Wednesday [an estimated four days after facility discharge]. When asked what services were then facilitated for R2, CW1 stated, a primary care provider because he is diabetic, an optometrist for his impaired vision. Housing because, he did not have housing. There was still a need to help him with financial status.
During an interview on 7/8/24 at 12:41 PM, with E18 (NP) for wound care when asked whether R2 was able to complete a dressing change independently, E18 stated, Physically and mentally yes, the only possible barrier may have been his vision. E18 confirmed that she had not observed R2's ability to perform dressing changes independently.
During an interview on 7/9/24 at 9:50 AM, E6 (RN) who completed R2's discharge form confirmed that a community physician was not designated on the form. E6 stated, social work fills that out.
During an interview on 7/9/24 at 10:05 AM, E13 (NP) confirmed calling in prescriptions for medications and dressing change supplies for R2. E13 confirmed that she would not be R2's healthcare provider in the community and was unaware of what physician if any had been selected for R2 to assist with further prescriptions, and management of clinical issues. E13 stated that designation of a physician is arranged by social services.
Findings were reviewed during the exit conference on 7/9/24 AT 10:30 AM with E1 (NHA) and E2 (DON).
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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that for one (R2) out of five residents reviewed for discharge the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that for one (R2) out of five residents reviewed for discharge the facility failed to ensure continuity of medically related social services upon the residents discharge. R2 discharged from the facility on 5/17/24 and was not connected with the community caseworker for an estimated four days. Findings include:
The facility policy on social services last updated September 2021, indicated, Social services is responsible for meeting or assisting with the medically related social service needs of residents .helping residents with transitions of care services (for example, community placement options, home care services, transfer agreements etc.); Not all medically related social servcies are provided by the a qualified social worker. However the facility is responsible for ensuring that all residents are provided these services by staff or through referrals made to an outside agency.
Review of R2's clinical record revealed:
2/21/23 - R2 was admitted to the facility with multiple diagnoses including diabetes and unspecified cataracts. R2 was listed as their own responsible party. CW1 was listed as a care conference person.
2/28/24 - An annual MDS assessment documented that R2 was cognitively intact, and had participated in the goal setting portion of the assessment with a desire to return to the community.
4/17/24 - A R2's care plan for discharge planning uncertain at this time was reviewed. Patient has voiced desire to discharge back to the community. Goal will be discharge to a safe environment with appropriate resources times 90 days. Interventions included to develop a discharge plan with resident and family. Assist case manager/case worker to develop safe discharge plan.
5/16/24 - A 30 day discharge notice was issued to R2.
5/17/24 untimed - A note document R2 decided to discharge from the facility.
5/17/24 1:06 PM - A discharge form for R2 documented, For additional resources in your community contact: Aging and Adult Services. The discharge form lacked evidence of CW1's name or contact information.
5/17/24 2:05 PM - A progress note written by E6 (RN) documented, Discharge instructions and medications reviewed with resident and all questions answered. Resident discharged with all belongings. Medications called in to Walmart in Georgetown by NP.
During an interview on 7/2/24 at 11:18 AM, E11 (SSA) confirmed that she did not notify CW1 of R2's decision to discharge and stated that E12 (former SW) may have done the notification.
During an interview on 7/8/24 at 9:32 AM, E12 (former SW) explained that she is normally involved in resident's discharge process but that in R2's discharge It never works that way but for some reason I was told about the discharge after the fact of it already in motion. I signed off the paperwork but everything was mostly done. They called [CW1] and told her about the 30 day discharge on [DATE]. Then [CW1] called and asked for a meeting, [E1 (NHA)] and [E2 (DON]) declined [CW1's] request to meet and discuss discharge and told me I needed to decline it also. E12 confirmed that she did not contact CW1 when R2 decided to discharge from the facility.
During an interview on 7/8/24 at 11:46 AM, CW1 stated, I'm the case manager/case worker so whenever there is a resident discharge a discussion should be had and I request a meeting to ensure a safe discharge of [R2]. When asking for meetings they were declined on the invitation. Its been a challenge; not being notified in a timely manner of concerns or issues prior to the escalation of a discharge. Specifically with [R2] I was notified via email of the written discharge notice on a Thursday [5/16] and I communicated that a discharge meeting should occur first. I reached out to [E12 (former SW]) and was informed she was told to decline my meetings. Come that Monday 5/20/24 I was reviewing [R2's] chart and realized he was discharged and there was no way of myself of getting a hold of him. His vision is not to where he can safely see and I was concerned. We weren't able to get a hold of him right away. Where they said they booked a room for him the hotel said they had no knowledge of that. Another team member called around to different hotels until he was located that Tuesday or Wednesday. I was not clear on what he may need, but at the very least we needed to set up a primary care physician, an optometrist and vision services and management because he is a diabetic. Housing because he did not have housing. There was still a need to help him with financial's. CW1 confirmed that the failure to receive notice upon R2's decision to discharge from the facility resulted in a lapse of continuity of medically related social services and that the access to resources and services was delayed during the time when R2's whereabouts were unknown.
During an interview on 7/9/24 at 9:50 AM, E6 (RN) who completed R2's discharge confirmed that she did not attempt to contact CW1 during or prior to R2's decision to discharge from the facility. E6 stated, social work handles that.
During an interview on 7/8/21 at 12:16 PM, both E1 (NHA) and E2 (DON) confirmed that the facility did not contact CW1 when R2 decided to discharge from the facility. E1 stated, [R2's] alert and oriented, had a phone and capacity to call [CW1].
Findings were reviewed during the exit conference on 7/9/24 AT 10:30 AM with E1 (NHA) and E2 (DON).
Apr 2024
17 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
Based on interviews, record review and review of facility documentation, it was determined that for one (R57) out of five residents reviewed for accidents, the facility failed to ensure residents were...
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Based on interviews, record review and review of facility documentation, it was determined that for one (R57) out of five residents reviewed for accidents, the facility failed to ensure residents were provided adequate supervision to prevent accidents resulting in harm. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 10/24/22. Findings include:
Review of R57's clinical record revealed:
9/28/22 - R57 was admitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheostomy.
9/28/22 - A care plan documented that R57 had a potential for (actual falls) related to decreased mobility, poor safety awareness.
10/11/22 - R57 was readmitted to the facility. R57's fall risk evaluation was a score of 7, revealing a low fall risk.
10/17/22 - R57's admission MDS documented that R57 had a documented BIMS score of 15, revealing an intact cognitive state and was an extensive assist of two staff for transferring. R57 had impairments on both sides for upper and lower extremities.
10/19/22 11:10 AM - A facility incident report revealed that, resident (R57) being transferred from shower stretcher to bed and slipped out of Hoyer lift.
10/19/22 11:50 AM - A facility progress note by E21 (former LPN) documented, This nurse notified via phone by RT that resident had fallen from Hoyer lift to floor. Entered resident room to find her lying on the floor. 911 was initiated by RT. Supervisor notified. A&O x 4, c/o pain in back of head, denies blurred vision, denies LOC. Pressure applied to back of head r/t moderate bleeding. VSS, EMT and Paramedics arrived and took over care. Family (resident's mother) notified by phone.
10/19/22 1:00 PM - A physician note by E22 documented that, Patient (R57) seen status post fall, patient had a fall and sustained a hematoma on the back of her head, with bleeding noted left-sided wound. Patient's neuro remained intact vital stable, patient reported 4 out of 10 pain in the back of her head. Patient was sent to ED for further evaluation and treatment.
10/19/22 untimed - A facility investigation report revealed a written statement by E26 (Former CNA) that documented, . I (E26) always look for help when their [sic] isn't any, I try. I got her (R57) in the air and tried transferring her feet to the bed. While turning her (R57) feet, she started to slip. I yelled help twice grabbing her feet to try to keep her in the air. By the time help came in . she (R57) was on the floor .
10/19/22 untimed - A facility investigation report revealed a written statement by E27 (RT) had documented that E27 had returned to the nurse's station after a break and saw the curtains closed for R57's room. R57 returned to her room from the shower room and stuck her head through the curtain and asked E26 if she needed any help. E26 replied that she did not need any help. E27 replied that she would be sitting at the nurse's station. A few minutes later E26 and R57 screamed for help. E27 ran into the room and R57 was on the floor.
10/23/22 11:56 AM - A skin evaluation note by E21 documented, . Skin is warm dry and intact with exception of laceration with 4 staples to back left side of head related to previous fall .
11/8/22 - E26 was terminated from the facility.
The Facility's 5 day follow up summary documented the root cause of the incident was that the lift was not completed by two employees; the outcome of the investigation was that 1. Staff member failed to ask for help with transfer 2. Sling was placed improperly; the system changes that were put in place were in-servicing and competencies on Hoyer lift for the nursing staff.
4/10/24 12:02 PM - An interview with R57 revealed that on 10/19/22 E26 was bringing her back to her room after getting a shower. E26 began to use the Hoyer lift to move her back to bed. R57 stated she asked E26 if the Hoyer lift was for a 2 person assist and that E26 stated there was no staff to help. R57 recalled being raised up in the air and then sliding out of the sling headfirst when she then hit her head and blacked out.
4/11/24 8:51 AM - An interview with E20 (former DON 2) revealed that E26 attempted to put R57 back to bed by herself resulting in the fall. E20 stated that she interviewed E26 who stated that she knew she should not have tried to use the Hoyer lift by herself.
4/11/24 11:16 AM - An interview with E1 (NHA) revealed that E26 was suspended pending an investigation and they did not return when she was terminated on 11/8/22. The facility audited the evaluations on the Hoyer lift for the residents. The facility had in-service training and physical return demonstrations with signatures for the trainings that began 10/19/22 and completed 10/24/22. The facility's in-service training documentation included: Mechanical lift use policy, How to use a Mechanical lift Caregiving series education, Safe Lifting and Movement of Residents policy, a Video on the use of a Mechanical lift and a Patient Lifts Safety Guide.
Based on the review of the facility's thorough investigation, documented response, completion of in-service training and audits, staff interviews and no further incidents related to injuries using a Hoyer lift, R57's accident was determined to be past non-compliance harm. The plan of correction was initiated on 10/19/22 and completed on 10/24/22.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 and E2 (DON).
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
3. Review of R57's clinical record revealed:
7/13/23 - R57's quarterly MDS documented that R57 had a documented BIMS score of 15, revealing an intact cognitive state and was totally dependent of two s...
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3. Review of R57's clinical record revealed:
7/13/23 - R57's quarterly MDS documented that R57 had a documented BIMS score of 15, revealing an intact cognitive state and was totally dependent of two staff for toilet use. R57 had impairments on both sides for upper and lower extremities.
11/13/23 - A facility incident report documented that on 11/11/23 at 6:45 AM, E16 (former CNA) was argumentative with R57 when E16 came into R57's room to change her.
11/20/23 - A facility follow-up report documented that it was determined that E16 did speak inappropriately to R57.
11/27/23 - E16 was terminated from the facility.
4/10/24 9:39 AM - An interview with E12 (Agency RN) revealed that she went into R57's room to help E16 to perform care. E16's tone became hostile towards R57. E12 was not able to recall the words exchanged but stated that E16 and R57 were talking back and forth during which time E16's tone .went from a normal tone of 1 to a 10. E12 stated, she stepped in and said to E16 that she cannot talk to the resident that way.
4/10/24 12:09 PM - An interview with R57 revealed that on the morning of 11/16/23 at approximately 6:50 AM, E16 was in the room and woke R57 up due to a noise. R57 asked E16 if she was going to change her. R57 stated, [E16] began to get loud and asked her, do you want to be changed? R57 then replied, Yes, I do. At that point [E57] turned her head to the nurse and said, do you hear this? E12 said, she heard [E16]. E16 was asking R57 in a loud and aggressive manner, do you need to be changed because I got to go Are you refusing to be changed? I need to go. E12 had told E16 that the patient is always right. While E16 and E12 was proceeding to change R57, E16 kept telling me to be quiet, because I kept saying it was a problem. Then E16 told E12 that R57 did not like her and R57 said, I don't have a problem with anyone, I don't know her. Afterwards, R57 stated she was upset and crying. R57 stated she has not had any issues with other staff since.
4/11/24 8:48 AM - An interview with E17 (former DON 1) revealed that E16 denied speaking inappropriately to the resident but E12 did corroborate what R57 had reported.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
Based on observations, interviews and record review, it was determined that for three (R7, R23 and R57) out of three sampled residents reviewed for dignity, the facility failed to promote care in a manner and environment that maintained or enhanced their dignity and respect. Findings include:
1.Review of R7's clinical record revealed:
2/23/24 - R7 was admitted to the facility.
4/10/24 10:08 AM - An observation of E33 (CNA) and E34 (CNA) in room with R7 providing care with door open. R7's unclothed, lower body from thigh down to feet was able to be observed from open door.
4/10/24 10:50 AM - An interview with E33 and E34 confirmed that care was completed with the door open leaving R7 exposed to the hallway.
2. Review of R23's clincal record revealed:
5/24/23 - R23 was admitted to the facility.
4/11/24 10:17 AM - An observation of E35 (CNA) in room with R23 providing care with the door open. R23's care occurred till 10:27 AM. R23's unclothed, lower body from thigh down to feet was able to be observed from hallway.
4/11/24 10:28 AM - An interview with E35 confirmed that R23's care was completed with door open and R23's unclothed body was exposed to the hallway.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Review of the facility policy titled, Change in a Resident's Condition or Status last dated 2/2021 documented . 1. Our facility promptly notifies the resident, his or her attending physician, and the ...
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Review of the facility policy titled, Change in a Resident's Condition or Status last dated 2/2021 documented . 1. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status, changes in level of care, billing/payments, resident rights, etc.
Review of R8's clinical record revealed:
7/1/21 - R8 was admitted to the facility with a diagnosis including but not limited to hypertension, stroke, left side weakness and depression.
1/5/24 - Review of the facilities diet requisition form revealed R8 was on a regular textured diet and thin liquids.
2/15/24 12:47 PM - A physician's order written by E4 (MD) for R8 documented . 1. Regular diet dysphagia mechanical soft texture thin liquids consistency. Patient may have regular pleasure foods.
2/15/24 1:25 PM A plan of care note written by E14 (RD) revealed that R8's diet was downgraded for safety. In addition, a facility diet requisition form revealed R8's diet was changed to dysphagia mechanical soft texture on 2/15/24.
4/9/24 12:07 PM - An interview with E13 (LPN) revealed that if a resident's diet had changed nursing would notify the contact person.
4/9/24 2:37 PM - During an interview E14 revealed, I downgraded R8's diet texture, but did not notify R8's contact person of the change. In addition, E14 said, I assumed that nursing would have notified R8's contact person.
4/9/24 3:00 PM - Further review of R8's clinical record lacked evidence that R8's contact person was notified R8's diet texture had been downgraded from regular textured food to an altered regular mechanical textured diet.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
2. Review of R57's clinical record revealed:
10/11/22 - R57 was readmitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheo...
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2. Review of R57's clinical record revealed:
10/11/22 - R57 was readmitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheostomy.
1/18/24 - MDS quarterly documented R57 as totally dependent.
4/7/24 1:00 PM - An observation and interview with R57 revealed the sip and puff (type of call bell) was next to the bed in a position that R57 was unable to use.
4/7/24 1:44 PM - An observation of E37 (CNA) leaving the room with R57's lunch tray and the sip and puff was next to the bed in a position that R57 was unable to use.
4/7/24 1:53 PM - During an observation and interview with E36 (Respiratory Therapist) it was confirmed that the resident did not have her sip and puff, but she would be able to call out for help.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
Based on observation, record review and interview it was determined that for two (R131 and R57) out of 40 initial pool residents screened the facility failed to ensure that the residents call bell was in reach and that the resident was capable of using it. Findings include:
The facility policy on the resident call system last updated September 2022 indicated, Each resident is provided with a means to call staff directly for assistance .The resident call system remains functional at all times. If the resident has a disabiity that prevents him/her from using the call system an alternative means of communication that is usable for the resident is provided and documented in the care plan.
1. Review of R131's clinical record revealed:
3/25/24 - R131 was admitted to the facility with multiple diagnoses including spinal injury.
3/25/24 9:52 PM - A nurse's note documented, R131 was, Alert and oriented and able to make needs known a quadriplegic and requires maximum assistance of two .Resident a quadriplegic and unable to sign paperwork.
3/25/24 - The admission evaluation assessment documented R131 unable to use the call light/call bell.
4/1/24 - An admission MDS assessment documented R131 had impairments to all extremities and an active diagnosis of quadriplegia (paralysis of all four limbs).
During the intial pool screening on 4/7/24 at 9:29 AM, R131 was observed with a standard push button call bell fastened to the fitted sheet, shoulder height, close to the side rail and a metal bell on the farthest end of the over bed table. R131 confirmed both bells were out of reach and that he was unable to use either call bell. R131 stated, I talked to someone and every aide, I'm paralyzed they gave me this bell I'm unable to use either one. I can use a large round soft touch bell if placed by my chin or head. That's what I had at the last nursing home. R131 confirmed that staff checked on him regularly.
During an interview on 4/7/24 at 12:30 PM, E28 (RN) unit manager was asked if there were any soft touch call bells in the facility. E28 was unsure and explained she would have maintenance look. E28 then accompanied the surveyor to R131's room, and confirmed the resident was unable to use the current call bells in the room.
During an interview on 4/7/24 12:51 PM, E28 (RN) unit manager provided the surveyor with an invoice dated 3/27/24 for the order of a touch and breath call bell system. E28 was asked if leadership was aware that R131 was unable to use the call bell system currently in his room. E28 stated, I don't think management knew but someone knew because we ordered it. I will have maintenance put it in. E28 could not confirm when the touch and breath call bell systems were delivered to the facility.
4/7/24 1:05 PM - E28 (RN) unit manager and E9 (ICP) were observed entering R131's room with call bell equipment.
During an interview on 4/7/24 at 1:36 PM, R131 was able to return demonstrate ability to use breath call bell system, and confirmed satisfaction.
During an interview on 4/10/24 at 11:07 AM, E1 (NHA) was unable to provide documentation regarding delivery of the breath call bell system. E1 stated, We didn't sign for it but it was here on Sunday.
During an interview on 4/10/24 at 12:06 PM, E2 (DON) reported that if a resident was assessed as unable to use the standard push button call bell, I would expect them to report that to their supervisor and then the supervisor get in contact with maintenance. Which they did and we didn't have a breath call bell and maintenance ordered it. E2 was unable to confirm the date of delivery of the breath call bell.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R287) out of three residents reviewed for discharge the facility failed to provide R286 the Notice to Medicare Provider Non-Covera...
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Based on record review and interview, it was determined that for one (R287) out of three residents reviewed for discharge the facility failed to provide R286 the Notice to Medicare Provider Non-Coverage (NOMIC) form before services were terminated. Findings include:
R287's clinical record revealed:
3/20/24 R287 was discharged to home.
4/11/24 approximately 10:30 AM - During an interview, E1 (NHA) confirmed that the NOMIC form was not provided to R287. As part of R287's resident rights, the NOMIC form notifies the beneficiary of his or her right to an expedited review of the service termination.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
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
Based on record review and interview it was determined that for one (R53) out of three residents reviewed for abuse the facility failed to recognize and immediately report an allegation of abuse. Find...
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Based on record review and interview it was determined that for one (R53) out of three residents reviewed for abuse the facility failed to recognize and immediately report an allegation of abuse. Findings include:
The facility policy on Abuse, last updated April 2021 indicated that staff, Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframe's required by federal requirements.
3/25/24 - The facility reported an incident to the State Agency that alleged, On 3/21/24 there was a disagreement between roommates and a room change was recommend by the on call nurse for that shift.
4/11/24 9:00 AM - Review of the facility incident report and investigations revealed a statement dated 3/12/24 written by E24 (LPN) that documented, [R17] said he threw soda cans at [R53] and called him an asshole and a retard I heard [R53's] wife yelling but I am not sure what was said I heard both residents yelling at each other. Another statement dated 3/21/24 written by E25 (RN) documented, [R17] agreed that he called his roommate a retard and initiated incident and he also accepted that he threw soda cans against curtain which were lying on the floor between bed a and bed b.
During an interview on 4/11/24 at 9:18 AM, E23 (RN supervisor) stated, I was called that night by the nurse and asked to move the residents. They told me that they had gotten into an argument and they were yelling at each other. E23 explained she was not aware that R17 threw the soda can at R53.
During an interview on 4/11/24 9:25 AM, E2 (DON) confirmed that the resident to resident incident between R53 and R17 was not recognized as an allegation of abuse and therefore not immediately reported. E2 stated, I was made aware the 22nd when I saw the statements, I verified it with the supervisor. It [soda-can] hit the curtain. E2 clarified that because the soda can didn't hit R53 that the incident was not recognized as allegation of abuse and not immediately reported.
During an interview on 4/11/24 11:20 AM, R53 stated that R17, Threw a soda can at me and my wife .He threatened me and called my Wife me an ass-hole got me and my Wife wet [with soda] so me and my wife screamed, the nurses came in and he got moved.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to ensure accuracy of the MDS assessment. Findings...
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Based on on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to ensure accuracy of the MDS assessment. Findings include:
Review of R42's clinical record revealed:
5/9/23 - R42 was admitted to the facility.
5/15/23 - An admission MDS assessment for R42 documented that the cognitive, behaviors, mood and pain level sections, were not assessed.
During an interview on 4/9/24 at 1:22 PM, E15 (Director of Reimbursement Services) confirmed the finding. E15 stated, it was missed, we didn't get to it. [R42] should've been interviewed.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview, and record review it has been determined that for one (R68) out of one resident reviewed for PASARR, the facility failed to ensure a referral for a new PASARR Level I and II screen...
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Based on interview, and record review it has been determined that for one (R68) out of one resident reviewed for PASARR, the facility failed to ensure a referral for a new PASARR Level I and II screening occurred by or before the 60th day. R68 was remained in the facility beyond the authorization timeframe. Findings include:
A facility policy and procedure titled, admission Criteria, documented . 1. All new admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid Pre-admission Screening and Resident Review (PASARR) process.
Review of R68's clinical record revealed:
7/26/23 - A review of R68's PASARR Level I screen outcome revealed an approval period of 60 days for R68 a resident with a mental health disability in the nursing facility.
8/30/23 - R68 was admitted to the facility with diagnoses including but not limited to bipolar disorder, anxiety disorder and major depressive disorder.
11/6/23 - A review of R68's PASARR Level I screen outcome determination revealed R68 was referred for a PASARR Level II for a confirmed mental health disability. Additionally, R68's PASARR Level I screen was not done within the required authorization timeframe; by or before the 60th day.
11/13/23 - A review of R68's PASARR Level II determination revealed: short term approval without specialized services with an approval end date of 3/12/24.
4/9/24 1:41 PM - During an interview E15 (DRS) confirmed R68's PASARR Level I screen had not occurred by or before the 60th day. In addition, E15 confirmed R68's PASARR Level II's approval ended 3/12/24.
4/11/24 12:58 PM - During an interview E1 said, [R68] was supposed to be discharged and had not been.
The facility failed to coordinate the PASARR screening process for a resident with a mental health disability within the determined short term approval period as required.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to develop a care plan to address the residents use o...
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Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to develop a care plan to address the residents use of an anticoagulant. Findings include:
Review of R42's clinical record revealed:
5/9/23 - R42 was admitted to the facility.
5/9/23 - A physicians order was written for R42 to receive an anticoagulant medication one tablet by mouth two times a day for blood clot prevention.
5/15/23 - An admission MDS assessment documented R42 received anticoagulant medication.
2/15/24 - A quarterly MDS assessment documented R42 received anticoagulant medication.
Review of R42's care plans lacked evidence that care plan was created that addressed the residents use of an anticoagulant medication.
During an interview on 4/9/24 at 1:25 PM E15 (Director of Reimbursement Services) confirmed the finding.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
4. Review of R75's clincal record revealed:
3/8/24 - R75 was admitted to the facility.
4/3/24 - A review of R75's care plan meeting lacked evidence of input from a CNA, dietary, activities, and the m...
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4. Review of R75's clincal record revealed:
3/8/24 - R75 was admitted to the facility.
4/3/24 - A review of R75's care plan meeting lacked evidence of input from a CNA, dietary, activities, and the medical director.
4/10/24 1:02 PM - An interview with E1 (NHA) confirmed that the care plan meeting lacked evidence of the necessary members for input.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
Based on record review and interview, it was determined that for four (R33, R45, R55, and R75) out of of twenty-three (23) sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. Findings included:
1. Review of R33's clinical record revealed:
7/31/20 - R33 was admitted to the facility.
4/9/24 - A review of quarterly care plan meetings for 12/13/23 and 3/6/24 lacked evidence of input from the Physician and the CNA.
2. Review of R45's clinical record revealed:
6/13/23 - R45 was admitted to the facility.
4/9/24 - A review of quarterly care plan meetings for 1/3/24 and 4/3/24 lacked evidence of input from the Physician and the CNA.
3. Review of R55's clinical record revealed:
8/24/22 - R55 was admitted to the facility.
4/9/24 - A review of quarterly care plan meeting for 12/20/23 lacked evidence of input from the Physician, nurse and the CNA. A review of the quarterly care plan meeting for 3/24/24 lacked evidence of input from the Physician and CNA.
4/10/24 9:25 AM - In an interview, E6 (CNA) stated that CNA's do not participate in care plan meetings, and they do not provide input. The higher ups meet with residents.
4/10/24 9:40 AM - In an interview, E7 (CNA) stated that when working on a different unit, she would ask to participate in resident care plan meetings. While not invited, E7 stated she would contribute. E7 stated she took it upon herself to participate in the other unit where E7 said she worked closely with the nurses.
4/10/24 1:02 PM - In an interview, E1 (NHA) stated that the medical provider participates by entering new orders. CNA's have contact with nurses all the time and provide input in this manner, but she acknowledged she has no way of proving CNA involvement.
4/10/24 2:07 PM - In an interview, E8 (CNA) stated that CNA's do not attend care plan meetings unless resident specifically requests that the CNA be present. CNA's are informed after the care plan meeting if there are changes.
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
Based on observations, interviews and record review, it was determined that for two (R24 and R57) out of four residents reviewed for position and mobility, the facility failed to turn and reposition t...
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Based on observations, interviews and record review, it was determined that for two (R24 and R57) out of four residents reviewed for position and mobility, the facility failed to turn and reposition the resident in accordance with professional standards of practice to prevent skin breakdown. Findings include:
1. Review of R24's clinical record revealed:
11/19/23 - R24 was readmitted to the facility with diagnoses including but not limited to hypoxic ischemic encephalopathy, anoxic brain damage and persistent vegetative state.
9/3/23 - An annual MDS assessment documented that R24 was totally dependent for turning and repositioning with two person physical assist. R24 had impairments on both sides for upper and lower extremities.
3/4/24 - A nursing Braden Scale documented R24 with a score of 10 (10 - 12 is considered high risk of skin breakdown).
3/14/24 - A care plan for R24 last included to turn and reposition at least every two hours while in bed.
On the following dates and times, R24 was observed lying in bed on her back with the head of the bed upright at approximately a 45 - 60-degree angle while R24's wedges were observed in the room on a chair on 4/8/24: 8:22 AM, 9:35 AM, 10:38 AM, 11:40 AM, 12:15 PM and 2:01 PM.
R24 was observed lying in bed on her back for four hours without any turning.
4/9/24 11:25 AM - During an interview, E8 (CNA) stated R24 sits up with a pillow under one of her shoulders.
4/9/14 11:45 AM - During an interview, E18 (CNA) stated R24 gets turned side to side every 2 hours using positioning wedges.
The facility failed to ensure that R24 was turned and repositioned every two hours.
2. Review of R57's clinical record revealed:
10/11/22 - R57 was readmitted to the facility with diagnoses including but not limited to quadriplegia, spinal muscular atrophy, morbid obesity and tracheostomy.
7/13/23 - A quarterly MDS assessment documented that R57 was totally dependent for turning and repositioning with two person physical assist. R57 had impairments on both sides for upper and lower extremities.
12/1/23 - R57's care plan included to turn and reposition at least every two hours while in bed.
1/13/24 - A nursing Braden Scale documented R57 with a score of 11 (10 - 12 is considered high risk of skin breakdown).
1/18/24 - R57's quarterly MDS assessment documented that R57 had a documented BIMS score of 15, revealing an intact cognitive state and was dependent on staff to turn side to side.
On the following dates and times, R57 was observed lying in bed on her back with the head of the bed at approximately a 30-degree angle on 4/8/24: 8:20 AM, 9:37 AM, 10:41 AM, 11:50 AM and 12:16 PM.
R57 was observed lying in bed on her back for four hours without any turning.
4/9/24 11:25 AM - During an interview, E8 (CNA) stated R57 is turned to the left and right with pillows, one on each side.
4/9/14 11:45 AM - During an interview, E18 (CNA) stated that she has not seen R57 on her side, that she is always on her back. R57 has wedges for her legs, but she is always on her back.
4/10/24 12:49 PM - During an interview, R57 stated that the staff do not turn her from left to right, that she stays laying on her back.
The facility failed to ensure that R57 was turned and repositioned every two hours.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review it was determined that for one (R75) out of one resident reviewed for incontinence, the facility failed to respond to or provide services to restore b...
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Based on observation, interview and record review it was determined that for one (R75) out of one resident reviewed for incontinence, the facility failed to respond to or provide services to restore bladder continence. Findings include:
A facility policy titled, Urinary Continence and Incontinence assessment and management revised August 2022 stated the staff will appropriately screen for, and manage individuals with urinary incontinence. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.
Review of R75's clinical record revealed:
3/8/24 - R75 was admitted to the facility.
3/8/24 4:39 PM - A admission bowel and bladder continence evaluation documented R75 was incontinent.
3/12/24 11:31 AM - Review of R75's bowel and bladder program evaluation revealed R75 was a candidate for scheduled prompted voiding.
3/14/24 10:02 AM - An admission MDS revealed that R75 is frequently incontinent and a toileting program was not attempted.
4/9/24 10:37 AM - - During an observation R75 stated, I need to use the bathroom. FM1 (Spouse) put the call bell on for assistance. E33 (CNA) entered the room at 10:50 AM.
4/9/24 11:00 AM - An observation of E33 providing care confirmed that R75 was incontinent and that E33 did not offer or assist R75 with the urinal.
4/9/24 12:00 PM - A review of the CNA task flow sheet revealed that E33 documented not applicable for bed pan and urinal use for R75.
4/9/24 2:46 PM- During an interview FM1 revealed, staff did not assist R75 with toileting when the call light was on. FM1 also said, [R75] was continent of bowel and bladder when E31 (COTA) from therapy assisted him with toileting.
4/10/24 8:52 AM - An interview with E32 (COTA) revealed R75 could voice when he has the urge to use the bathroom and had initiated the use of the bed pan and urinal for R75.
4/10/24 10:50 AM - An interview with E33 (CNA) and E34 (CNA) revealed R75 was not able to sustain continence. E33 and E34 confirmed when assigned to R75 the urinal or bed pan had not been offered to promote continence.
4/10/24 11:46 AM - During an interview E28 (RN) confirmed the admitting nurse does the bowel and bladder evaluation. E28 revealed R75 is more alert at this time, and his care plan should have been updated with this change.
4/11/24 8:15 AM - During an interview E31 (COTA) stated, [R75] is able to verbalize the need to use the toilet. E31 revealed that R75 is encouraged to the use the bedpan and urinal during therapy. E31 said, I do not think that direct care staff is following the recommendation.
4/11/24 8:30 AM - - During an interview E29 (Rehab. Director) stated, I spoke with nursing on 4/10/24 and requested staff use the bedpan and urinal for [R75].
4/11/24 11:11 AM - An interview with E30 (RN UM) confirmed that upon admission all residents are placed on a every two hour continence check to verify continence and that is considered the facilities toileting program.
4/11/24 11:54 AM - A review of the CNA task flow sheet for R75 lacked evidence of a every two hour continence check on admission.
The facility failed to provide care and services that promoted maintaining and/or restoring continence.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
2. Review of R3's clinical record revealed:
8/25/22 - R3 was admitted to the facility with diagnoses including but not limited to acute respiratory failure, difficulty swallowing and hypertension.
11/...
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2. Review of R3's clinical record revealed:
8/25/22 - R3 was admitted to the facility with diagnoses including but not limited to acute respiratory failure, difficulty swallowing and hypertension.
11/28/23 5:20 PM - A physician's order documented . 1. Tracheostomy care change oxygen tubing, canister and humidifier bottle one time a day every Monday and as needed.
4/7/24 10:08 AM - R3 was observed sitting in the wheelchair in her room, further observations revealed that R8's tracheal suction machine equipment had not been changed, the suction canister had thick secretions and had a date of 1/26/24 and tubing for the suction equipment was not dated.
4/8/24 12:34 PM - Day 2 observations revealed R3's tracheal suction machine equipment had not been changed and the canister contained the same thick secretions as observed and dated 1/26/24.
4/9/24 12:59 PM - During an interview and observation E13 (LPN) confirmed R3's suction machine equipment had not been changed and the suction canister contained secretions and was dated 1/26/24. E13 stated, I'm not sure why it has not been changed, but I will change it.
The facility failed to provide R3 with respiratory care as required by a physicians order in changing tracheostomy care equipment routinely and as needed.
These findings were reviewed at the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
Based on observation, interview and record review, it was determined that for two (R3 and R66) out of two residents reviewed for respiratory care,the facility failed to provide respiratory care consistent with professional standards of practice. For R3, the facility failed to ensure the canister and tubing for suctioning had been changed. For R66, the facility failed to ensure the oxygen tubing and humidifier bottle were labeled. Findings include:
1. 3/11/24 - R66 was admitted to the facility.
3/17/24 - An admission MDS documented R66 was cognitively intact and had diagnoses that included Chronic obstructive pulmonary disorder (COPD) and hypoxic respiratory failure unspecified.
A facility policy titled Oxygen Administration revised October 2010 included Oxygen tubing will be changed and dated weekly, refillable humidifiers will be dated and changed weekly, disposable humidifiers will be dated and discarded when empty.
3/12/24 - A physician order included 4L via nasal cannula to maintain oxygen saturation greater than 92%.
3/11/24 - 4/10/24 - Review of EMAR's lacked evidence that the oxygen tubing and the humidifier bottle were changed weekly.
4/7/24 and 4/8/24 - Several random observations revealed that the oxygen tubing and humidifier bottle was not labeled and dated.
4/8/24 9:20 AM - During an interview E11 (RN) confirmed that R66's oxygen tubing and humidifier bottle were not dated.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to ensure pharmacist recommendations were reviewed by...
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Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to ensure pharmacist recommendations were reviewed by the attending physician. Findings include:
The facility policy for MRR's last updated May 2019, indicated The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.
2/5/224 11:47 - A Pharmacist Consultant Note documented, Medication Regimen Reviewed: Recommendations Made.
Review of R42's 2/5/24 MRR revealed a lack of physician response to the recommendations to evaluate and consider discontinuing use of vitamin c and to consider switching timeframe of laxative.
During an interview on 4/10/24 at 1:07 PM, E1 (NHA) confirmed the facility was unable to locate a physician response to the February 2024 MRR.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to complete AIMS testing every six months for a resid...
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Based on record review and interview it was determined that for one (R42) out of five residents reviewed for medication review the facility failed to complete AIMS testing every six months for a resident on antipsychotic medications. Findings include:
The facility policy on psychotropic medication use, last updated July 2022 indicated, Psychotropic medication is any medication that affects brain activity associated with mental processes and behaviors. Psychotropic medications are monitored with AIMS testing as required.
Review of R42's clinical record revealed:
7/18/23 - A physicians order was written for R42 to receive an antipsychotic medication daily.
7/18/23 - R42 received an AIMS test assesment for side effects related to antipsychotic medication use.
7/2023 - A care plan for use of antipsychotic medications included the intervention for - AIMS testing per facility protocol.
4/10/24 - Review of R42's clinical revealed AIMS testing had not been completed for R42 in nine months.
During an interview on 4/11/24 at 8:30 AM, E3 (ADON) confirmed the findings.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
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 it was determined that the facility failed to ensure that all nourishment refrigerators were maintained in a sanitary condition and food is stored safely to prevent food-borne ill...
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Based on observation it was determined that the facility failed to ensure that all nourishment refrigerators were maintained in a sanitary condition and food is stored safely to prevent food-borne illness. Findings include:
1. 4/7/24 8:45 AM -The following was observed in the Reserve Unit nourishment refridgerator:
-Boost dated 10/17/23.
-Sandwich in green and white wrapper dated 2/21.
-Brown paper bag unmarked.
-Partially eaten pretzel salad undated.
-Cheese doodles opened unlabeled.
-Salad dressing dated 9/8/23.
4/7/24 9:47 AM - The above was confirmed and removed from the refridgerator by E38 (Supervisor).
2. 4/8/24 - The nourishment refrigerated adjacent to the small dining room in the Riverside unit had a large semi-dried spill of orange liquid on the middle and bottom shelves of the door, and the full-sized refrigerator located in that same dining room contained an undated unlabeled small plastic food storage bowl of leftover food.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 and E2 (DON).
MINOR
(B)
Minor Issue - procedural, no safety impact
Safe Environment
(Tag F0584)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that for one (room [ROOM NUMBER]) out of 59 rooms observed the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined that for one (room [ROOM NUMBER]) out of 59 rooms observed the facility failed to ensure cleanliness. Findings include:
During daily observations of resident rooms the following was observed in room [ROOM NUMBER] :
4/7/24 10:53 AM - Three circular large brown stains on the fitted sheet of a occupied bed. A large circular dried pooling of the same brown liquid on the floor.
4/8/24 2:34 PM - The fitted was sheet clean. The large brown circular stain remained on floor also two pieces of balled paper napkins.
4/9/24 9:04 AM - A large brown circular stain remains on floor and the balled paper napkins were no longer present.
During an interview on 4/9/24 at 9:40 AM, E10 (housekeeper) confirmed the stain on the floor of room [ROOM NUMBER]. E10 stated, There are three total housekeepers every day and a floor technician mainly to take care of the floors, trash, and common areas. Housekeepers sweep and mop everyday.
During an observation on 4/9/24 at 1:56 PM, the large brown circular stain remained on the floor of room.
During an observation on 4/11/24 at 10:00 AM, the stain was no longer present.
These findings were reviewed during the exit conference on 4/11/24 at 2:26 PM with E1 (NHA) and E2 (DON).
Mar 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined for one (R1) out of three sampled residents, the facility failed to make...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined for one (R1) out of three sampled residents, the facility failed to make contact with the Physician in a timely manner when the resident had a change in condition, when R1 had a new onset of vomiting. Findings include:
Cross-refer F684
A facility policy titled Change in a Resident's Condition or Status, last revised May 2017, included, .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): .significant change in the resident's physical/emotional/mental condition .specific instruction to notify the Physician of changes in the resident's condition .A significant change of condition is a major decline or improvement in the resident's status that: Will not normally resolve itself without intervention by staff .
The following was reviewed in R1's clinical record:
2/22/23 - R1 was admitted to the facility after a surgical procedure.
2/24/23 12:00 AM - An initial encounter assessment note by E9 (FNP) documented, .appears very ill, unstable. Patient will need to be closely monitored .No vomiting or diarrhea, abdomen distended .Abdomen: Soft, distended, nontender, hypoactive bowel sounds.
According to an outside facility record on 2/25/23 as stated by E17 (Provider Administrator):
- 2:42 AM - The facility placed a call to the Provider.
- 2:43 AM - The Provider returned a call to the facility, but was unable to reach a Nurse.
- 6:37 AM - The facility placed another call to the Provider who did not answer.
- 7:03 AM - A call was made from the Provider to the facility, where they were able to talk to the Nurse.
2/25/23 7:16 AM - A nurse's note documented, .hyperactive BS [bowel sounds], abd [abdomen] distended, denial pain on palpation, n/v [nausea and vomiting] with [NAME] (sic) yellow emesis .generalized weakness .
3/9/23 12:42 PM - An interview with E5 (RN) stated the first time she was aware of R1 having vomited was on 2/25/23 around 12:00 AM to 12:30 AM. E5 stated R1 vomited before she entered the room and had vomit on his gown and bed. E5 stated the vomit wasn't clear, it was yellow. E5 stated she helped clean R1 up and checked his vital signs, which were normal. E5 could not remember when she called the Provider, but stated when E10 (on call Provider), called back .I was in another room because they can't page you or anything . E5 stated she was unable to remember when she called the Provider or when the Provider returned her call the second time. However, E5 stated that E10 asked, How do (sic) his abdomen look? E5 stated, I said [to the Provider], I don't know him; I just see him. I don't know how he came in; I don't know if he different. But he has some distension. I told him [E10] what the vital signs were. E5 stated that R1 vomited two times during her shift unless it wasn't reported to me. E5 stated, Just before 7:00 AM the Aides said he was vomiting again, but I was already off [completed her work shift].
3/10/23 9:55 AM - An interview with E1 (NHA) and E3 (Director of Clinical Services) confirmed that they were unaware of the facility having a written process of contacting an on-call Physician if the on-call Provider couldn't be reached.
3/10/23 at 12:20 PM - An interview with E2 (DON) stated the wait time for a response from a Practitioner is two to three hours. If staff do not get a response after two to three hours, they can call E2 and she will call the Medical Director. If the resident is in critical condition, staff can send the resident to the hospital without waiting for a response from a Practitioner.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Director of Clinical Services) on 3/10/23 during the exit conference, beginning at 3:40 PM.
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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R4) out of three residents reviewed for a change in condition, the facility failed to notify the Ombudsman when R4 was transferred...
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Based on record review and interview, it was determined that for one (R4) out of three residents reviewed for a change in condition, the facility failed to notify the Ombudsman when R4 was transferred to the hospital. Findings include:
Review of R4's clinical record revealed:
9/29/22 - R4 was admitted to the facility.
1/4/23 9:08 PM - R4 was transferred to the hospital.
The clinical record lacked evidence of notification to the Ombudsman of the hospital transfer on 1/4/23.
3/9/23 3:51 PM - In an email correspondence, E4 (Ombudsman) confirmed that the facility failed to notify the Ombudsman's office when R4 was transferred to the hospital.
The facility was cited for failure to notify the Ombudsman of resident transfers on their last annual and complaint survey dated 10/18/22.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Director of Clinical Services) on 3/10/23 during the exit conference, beginning at 3:40 PM.
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 record review, interview, and other facility documentation as indicated, it was determined that for one (R1) out of thr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and other facility documentation as indicated, it was determined that for one (R1) out of three sampled residents reviewed for change of condition, the facility failed to identify and monitor a significant change of condition for 6.5 hours. Findings include:
The following was revealed in R1's clinical record:
2/22/23 - R1 was admitted to the facility after a surgical procedure.
2/24/23 12:00 AM - An initial encounter assessment note by E9 (FNP) documented, .appears very ill, unstable. Patient will need to be closely monitored .No vomiting or diarrhea, abdomen distended .Abdomen: Soft, distended, nontender, hypoactive bowel sounds.
The actual time of the above assessment was unclear, but during an interview, E9 (FNP) validated that it was sometime on 2/24/23 after the vital signs were obtained at 8:13 PM. E9 was unable to state the exact time of the assessment.
2/25/23 2:11 AM - Vital signs were obtained, but no further assessment was noted.
2/25/23 4:58 AM - A temperature and pulse oximetry were obtained on R1, but no further assessment was noted.
There was a lack of evidence of how the facility monitored R1 on 2/25/23 from 12:30 AM to 7:03 AM.
2/25/23 7:16 AM - A nurse's note documented, .hyperactive BS [bowel sounds], abd [abdomen] distended, denial pain on palpation, n/v [nausea and vomiting] with [NAME] (sic) yellow emesis .generalized weakness .
2/25/23 7:30 AM - A nursing note, Patient found with emesis (vomit) during rounds at 0030 (12:30 AM), was cleaned and situated. when (sic) rechecked on patient was vomiting again, yellow emesis, abd [abdomen] distended, provider notified, order received KUB [kidney, ureter, and bladder X-ray(s)] .order placed .
The nursing note was unclear as to whether R1 was assessed and monitored between the hours of 12:30 AM and 7:30 AM
2/25/23 8:00 AM - A nurse's note documented the following vital signs and assessment:
- Blood Pressure (BP): 71/45 mmHg (millimeters of mercury); a normal blood pressure for most adults is defined as a systolic pressure (top number) of less than 120 and a diastolic pressure (bottom number) of less than 80. The BP was extremely low.
- Pulse: 108 bpm (beats per minute); a normal resting pulse is 60 to 100 beats per minute.
- 97.8 Degrees Fahrenheit (normal).
- Pulse oximetry: 78% Room Air; a normal level of oxygen is usually 95% or higher. R1 was given 2L [liters] of oxygen.
- Respirations: 22 (normal).
The aforementioned nurse's note on 2/25/23 at 8:00 AM is unclear of the exact time vital signs were obtained because the vital sign task sheet documents the vital signs were obtained between 9:33 AM - 9:36 AM on 2/25/23, instead of at 8:00 AM.
2/25/23 8:00 AM - A nurse's note documented, Patient continues to have emesis, abdomen distended with no bowel sounds .call placed to provider, was not able to reach the provider, supervisor notified, called 911 resident sent to ER [Emergency Room] for evaluation.
It is unclear as to the time of the above assessment and notification to the Provider. The assessment does not state the actual times when R1 had episodes of emesis and therefore does not say if the above assessment was performed during each of those occurrences. In addition, the note does not mention the time of the call to the Provider, it was simply a summary of the events.
3/9/23 12:42 PM - An interview with E5 (RN) stated the first time she was aware of R1 having vomited was on 2/25/23 around 12:00 AM to 12:30 AM. E5 stated R1 vomited before she entered the room and had vomit on his gown and bed. E5 stated the vomit wasn't clear, it was yellow. E5 stated that she helped clean R1 up and checked his vital signs, which were normal. E5 could not remember when she called the Provider, but stated when E10 (on call Provider), called back .I was in another room because they can't page you or anything . E5 stated she was unable to remember when she called the Provider or when the Provider returned her call the second time. However, E5 stated that E10 asked How do[es] his abdomen look? E5 stated, I said [to the Provider], I don't know him; I just see him. I don't know how he came in; I don't know if he different. But he has some distension .I told him [E10] what the vital signs were . E5 stated that R1 vomited two times during her shift unless it wasn't reported to me. E5 stated, Just before 7:00 AM the aides said he was vomiting again, but I was already off [completed her work shift].
During the time when E5 (RN) stated R1 was vomiting on 2/25/23 between 12:00 AM to 12:30 AM, E5 placed a call to the Provider at 2:42 AM, a call was returned at 2:43 AM by E10 (Provider), but E5 was unavailable. E5 stated they were in another resident's room at the time of the call back and were unable to get the call from E10.
3/9/23 3:42 PM - An interview with E17 (Provider Administrator) stated two calls were made from the facility between 11:00 PM on 2/24/23 to 7:00 AM on 2/25/23. The first call was made at 2:42 AM when the facility called the on call Provider and one minute later the Provider called back. The second call was made at 6:37 AM when the facility called the Provider and 26 minutes later the Provider called back.
3/9/23 4:04 PM - An interview with E10 (Provider) stated, They made a call at 2:42 AM and I was on call. I tried to call to reach back to them .as soon as I heard the patient had vomited and I thought I would have got through to her [E5 (RN)], but that was not possible. I made multiple attempts to reach back through .I did not get through. Then at around 6:00 AM something, I got in touch with them. E10 stated, They [E5] told me the patient had vomited .they got vital signs, and everything was stable. I asked her [E5] if the vomit was coffee color and she [E5] said no. I asked if there was any weakness or drop in blood pressure and she [E5] said no. E10 stated he then asked for a Stat KUB.
Although the Nurse denied a change in vital signs and a description of the emesis, there was no evidence that E5 (RN) saw the resident a second time during the shift.
Although the Provider E10 was notified on 2/25/23 at 7:03 AM that R1's vitals signs were within normal limits, the clinical record lacked evidence of a complete assessment, including a full set of vital signs after 2:11 AM on 2/25/23.
3/10/23 6:03 AM - An interview with E12 (CNA) confirmed that R1 vomited prior to her and E5 (RN) entering the resident's room on 2/25/23 around 12:00 AM to 12:30 AM. E12 stated that R1 vomited three times during her shift and she reported it to E5 during the one incident when E5 was not present. E12 stated she last saw the resident in his room clean and dry at 6:00 AM without any emesis on him or towels or in the emesis basin. E12 believed she gave report and left the facility at 6:30 AM on 2/25/23.
3/10/23 9:03 AM - An interview with E9 (FNP) stated, This patient was very frail when he came in, appeared ill. E9 also stated, He wasn't coherent enough to cooperate with the exam . E9 stated R1 would be rated to be alert to person and sometimes alert to place with periods of confusion. Every now and then, he [R1] was able to form complete sentences. E9 stated she documented Continue to Monitor in her note and .any significant changes: more lethargic (abnormal drowsiness), febrile (having a fever); if the physical exam on him changes; if his lung sounds change; if his abdomen gets more distended; bowel sounds you don't hear at all; if you notice any increased drainage out of his wounds; appetite decreases. If any of those things change within this 24-hour time period of him being here with him already being acutely ill. That should prompt them [the facility] to notify me. E9 confirmed that any significant change would also include vomiting. E9 also confirmed with the vomiting and abdominal distension [of R1's assessment], this was a change in condition and the Provider should have been contacted and .if they don't get a hold of the Provider, they have a Supervisor phone here .they can send me a text from the Supervisor phone asking me what they need. E9 stated anytime there is a change in condition You should automatically do a full assessment.
3/10/23 9:55 AM - During an interview with E1 (NHA) and E3 (Director of Clinical Services), they confirmed there was lack of recognition of the change in condition by E5 (RN) to contact the on-call Provider sooner.
3/10/23 2:32 PM - An interview with E6 (RN, Unit Supervisor) stated E5 (RN) said R1 vomited. E6 believed that E5 told her R1 vomited around 12:00 AM on 2/25/23. Afterwards, E6 stated that E5 Tried to call Provider, but was not able to get the Doctor on call. E6 stated she was not on the same unit as E5 and did not see E5 attempting to call back after being unable to get the on call Provider. E6 stated by 6:00 AM, E5 was still trying to call the on call Provider.
The facility failed to monitor and observe the decline in R1 from the assessment performed by E9 (FNP) and realize this was a significant change in condition, causing a delay on the priority of contacting the on call Provider. The delay in reaching the on call Provider further resulted in a 6.5 hour time lapse and a subsequent delay in treatment.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Director of Clinical Services) on 3/10/23 during the exit conference, beginning at 3:40 PM.
Oct 2022
26 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
Based on observation and interview, it was determined the facility failed to ensure that residents were treated with respect and dignity for two (R21 and R45) during random observations. Findings incl...
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Based on observation and interview, it was determined the facility failed to ensure that residents were treated with respect and dignity for two (R21 and R45) during random observations. Findings include:
1. 10/06/22 12:58 PM - During a random meal observation in the Riverwalk Main Dining room, E19 (CNA) verbalized that her two remaining are feeders, where other residents were sitting and could hear the comments. An interview immediately with E19 revealed that R21 was one of the feeders referred as R21 needed to be fed her meal.
2. 10/10/22 9:11 AM - During an interview with R45, the residents door was closed to offer privacy and confidentiality. E32 (MD) knocked on the door and immediately opened the door without obtaining permission from R45 to open and enter the room.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review, interview, and review of facility policy and procedure, it was determined that for one (R100) out of four residents reviewed for respiratory services, the facility failed to en...
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Based on record review, interview, and review of facility policy and procedure, it was determined that for one (R100) out of four residents reviewed for respiratory services, the facility failed to ensure immediate consultation with the resident's attending physician when R100 had a significant change in condition, as evidenced by R100's oxygen saturation decreasing to 90%. Findings include:
Cross refer F695, Example #1.
Review of R100's clinical records revealed the following:
6/24/22 - R100 was admitted to the facility from the hospital with diagnoses including pneumonia, chronic obstructive pulmonary disease, and pulmonary fibrosis.
6/24/22 - The admission Physician's Orders were written for the facility to administer oxygen via nasal cannula, as needed to maintain oxygen saturation of 92% or above.
6/29/22 9:38 AM - The Weight and Vitals Summary documented that R100's oxygen saturation was 90% on room air.
6/29/22 7 AM to 3 PM - The Medication Administration Record (MAR) documented by E9 (LPN, UM) that the oxygen saturation was 90% and that oxygen at 2 l/minute via NC was being administered.
6/29/22 10:36 AM - An Alert Note by E25 (LPN, UM) documented, Resident discharged from facility against medical advise, resident's daughters in facility to pack up belongings .LOA (Leave of absence) 1033 (10:33 AM) .
There was lack of evidence that the facility identified R100's significant change in condition when R100's oxygen saturation decreased to 90%, as documented on the above clinical records.
10/13/22 beginning at 2:40 PM - An interview with E25 confirmed there was lack of evidence that R100's attending physician was immediately consulted when R100's oxygen saturation decreased to 90% on 6/29/22 at 9:38 AM.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on a random observation and interview, it was determined that for one (R22) resident, the facility failed to secure her confidential medical records. Findings include:
During an observation on 1...
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Based on a random observation and interview, it was determined that for one (R22) resident, the facility failed to secure her confidential medical records. Findings include:
During an observation on 10/12/22 from 4:22 PM to 4:44 PM. E24 (RN) failed to ensure personal privacy and confidentiality when R22's electronic Medication Administration Record was displayed on top of the medication cart and information not secured when E24 left the medication cart in the hallway until 4:44 PM. An interview immediately after this observation with E24 confirmed that she failed to ensure that R22's private and confidential information was not secured.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
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
Based on record review, interview and review of the facility policy, it was determined that for one (R8) out of one resident reviewed for abuse, the facility failed to report an allegation of abuse im...
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Based on record review, interview and review of the facility policy, it was determined that for one (R8) out of one resident reviewed for abuse, the facility failed to report an allegation of abuse immediately within 2 hours to the State Agency. Findings include:
The facility's policy entitled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised April 2021, stated that if an alleged abuse is suspected, the suspicion must be reported immediately to the administrator and State licensing agency within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
Review of R8's clinical record and facility documents revealed the following:
10/9/22 3:30 PM - The facility's incident/accident statement by E24 (RN) stated that R8 had a back and forth disagreement between her and and another male resident (R29). During the altercation, R29 grabbed both of R8's forearms and left bruises.
10/11/22 10:32 AM - It was reported to the State Agency two days after the resident to resident altercation.
10/14/22 3:57 PM - During an interview with E2 (DON), it was confirmed that the facility failed to report an allegation of abuse on 10/9/22 in a timely manner to the State Survey Agency.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
2. Review of R105's clinical record revealed:
9/21/22 - R105 was admitted to the facility.
During an interview on 10/6/22 at 12:29 PM FM4 answered no, to receiving a copy of R105's care plans and stat...
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2. Review of R105's clinical record revealed:
9/21/22 - R105 was admitted to the facility.
During an interview on 10/6/22 at 12:29 PM FM4 answered no, to receiving a copy of R105's care plans and stated, It's hard to get any information.
Review of R105's TAR revealed an unmarked/blank section in the space designated for completion of the baseline care plan.
During an interview on 10/10/22 at 2:15 PM, E25 (RN) confirmed that a baseline care plan was not completed for R105.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on interview and record review, it was determined that for two (R100 and R105) out of three residents reviewed for baseline care plans the facility failed to develop a baseline care plan. Findings include:
1. Review of R100's clinical record revealed:
6/24/22- R100 was admitted to facility.
10/12/22 - Record review lacked evidence that a baseline care plan was developed within 48 hours after R100' s admission.
10/13/22 3:46 PM - An interview with E2 (DON) confirmed that the facility was unable to provide evidence that a baseline care plan was developed within 48 after R100's admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for two (R45 and R5) out of 25 residents reviewed care plans, the facility failed to conduct an IDT (Interdisciplinary Team) care plan meet...
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Based on record review and interview, it was determined that for two (R45 and R5) out of 25 residents reviewed care plans, the facility failed to conduct an IDT (Interdisciplinary Team) care plan meeting for R45. For R5, the facility failed to review and revise the fall care plan. Findings include:
1. The following was reviewed in R45's clinical record:
7/31/20 - R45 was admitted to the facility.
On 11/20/21 and 2/20/22 - Quarterly MDS Assessments were completed.
There was lack of evidence that an IDT Care Plan Meeting was held after the completion of the above assessments.
8/23/22 - An Annual MDS Assessment was completed.
There was lack of evidence that an IDT Care Plan Meeting was held after the completion of the above assessment.
10/12/22 10:29 AM - An interview with E5 (Social Services) confirmed that the facility was not able to provide evidence that IDT Care Plan meetings were held following the above MDS Assessments.
2. The following was reviewed in R5's clinical record:
3/9/22 - R5 was admitted to the facility
4/5/22 - A care plan was implemented for potential for (actual) fall related to decreased mobility with a goal that R5 would not sustain or be injured from a fall.
7/27/22 - R5 experienced a fall without injury. To prevent similar incident occurrence, the facility implemented a new intervention in which a signage was placed on R5's door for staff to knock and open door slowly when entering the room.
There was lack of evidence that the facility reviewed and revised the above fall care plan to include the intervention for signage to be posted on R5's door to her room.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that for two (R45 and R101) out of five sampled residents reviewed for activities of daily living the facility failed to maintain ...
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Based on observation, interview, and record review, it was determined that for two (R45 and R101) out of five sampled residents reviewed for activities of daily living the facility failed to maintain good oral hygiene and bathing. Findings include:
1. Review of R45's clinical records revealed the following:
7/31/20 - R45 was admitted to the facility.
8/23/22 - The Quarterly MDS Assessment indicated that R45 was independent in daily decision making and required extensive assistance of two plus staff to complete personal hygiene which included oral care.
10/10/22 9:10 AM - An interview with R45 revealed that she has not brushed her teeth following this morning's breakfast and that she was waiting on staff to provide her the toothbrush and toothpaste.
10/10/22 11:19 AM - During a subsequent interview with R45, she stated that she has not brushed her teeth today.
10/10/22 11:23 AM - During an interview with R45's assigned CNA (E17) revealed, it was her understanding that R45 used toothettes (disposable, single-use oral care sponges attached to a stick used for oral care) proceeded to enter into R45's room in an attempt to locate the toothettes. R45 verbalized that my toothbrush is in the bag back there and pointed to her night stand. E17 indicated that she was unable to locate the toothbrush and proceeded to leave R45's room.
10/10/22 1:15 PM - During a follow-up interview, R45 stated she was able to brush her teeth after the 11:23 AM interview.
The facility failed to ensure that oral care was provided to R45 who was dependent on staff to perform this activities of daily living.
2. Review of R101's clinical record revealed:
12/8/21 - R101 was admitted to the facility.
12/14/21 - An admission MDS assessment documented R101 required limited assitance of two people for hygiene/hair washing.
12/8/21 - R101's care plan for ADL's lacked evidence of interventions for R101's assistance with hygiene.
Review of R101's CNA documentation report, a record of care received, revealed R101 was to receive a bath/shower/hair washing Wednesdays and Saturdays during the 3-11 PM shift. R101 did not receive bath/shower/hair washing:
December 2021 -three out of seven opportunities
January 2022- one out of nine opportunities
February 2022-three out of eight opportunities
March 2022 -one out of four opportunities
The missed dates were not documented as resident refusals.
During an interview on 10/14/22 10:30 AM, E2 (DON) reported resident hair is to be washed during showers and documented in the shower slot on the CNA documentation report.
During an interview on 10/14/22 at 11:55 AM, E33 MDS coordinator confirmed the findings.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R22) out of two residents sampled for hearing/vision, the facility failed to ensure that R22 received proper treatment to maintain...
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Based on record review and interview, it was determined that for one (R22) out of two residents sampled for hearing/vision, the facility failed to ensure that R22 received proper treatment to maintain hearing abilities. Findings include:
Cross Refer F656 Ex. # 5
Review of R22's clinical record revealed:
1/18/22 - R22 was admitted to the facility.
8/7/22 - Review of R22's quarterly MDS revealed that R22 had minimal difficulty with hearing meaning difficulty in some environment when person speaks softly or setting is noisy.
8/12/22 - Review of R22's Physician Order Summary Report revealed that R22 had a physician's order for an audiology consult and treatment as needed. The order status was marked Discontinued.
10/10/22 9:55 AM - During observation when this Surveyor knocked on R22's room to greet Good morning, R22 was looking at the Surveyor pointing at her right ear and waved her hand for surveyor to come closer. R22 stated that she can't hear very well especially with some noise and that she used to wear a hearing aid before.
10/12/22 2:27 PM - When interviewed, E7 (LPN) stated that she was not aware of R22's hearing difficulty and will check with Social Services.
10/13/22 8:45 AM - During interview, E5 (Social Services) stated that she was not aware of R22's hearing difficulty.
There was a lack of evidence that the facility identifed that R22 was having difficulty with hearing.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
4. Cross Refer F657, example #3
Review of R22's record revealed the following:
A facility policy titled, CPAP/BIPAP (bi-level positive airway pressure) Support revised March 2015, stated, Review the p...
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4. Cross Refer F657, example #3
Review of R22's record revealed the following:
A facility policy titled, CPAP/BIPAP (bi-level positive airway pressure) Support revised March 2015, stated, Review the physician's order to determine .the pressure (CPAP .) for the machine.
1/18/22 - R22 was admitted to the facility with diagnoses including sleep apnea, a sleeping disorder in which breathing repeatedly stops and starts.
8/25/22 - R22 was careplanned for potential for respiratory distress with interventions including the use of a C-PAP machine.
10/10/22 9:47 AM - During observation, a C-PAP machine with face mask was observed laying on top of R22's bedside table. R22 stated she wears them every night .So I can sleep better.
10/12/22 2:20 PM - Joint observation with E7 (LPN), revealed R22's C-PAP machine and face mask sitting on R22's bedside table.
10/12/22 2:22 PM - During interview, E7 stated that R22 wears her C-PAP at night and takes it off in the morning. E7 further confirmed that R22 did not have a physician's order for C-PAP pressure setting.
10/13/22 1:09 PM - In an interview, E3 (ADON) confirmed that R22 did not have an active physician's order for the use of CPAP machine.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on observation, interview, record review, and review of other facility documents, it was determined that for three (R100, R45 and R22) out of four residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice and the resident's comprehensive person-centered care plan. Findings include:
1. Cross refer F580, Cross refer F655, Example #1
Review of R100's clinical records revealed the following:
6/24/22 - R100 was admitted to the facility from the hospital with diagnoses including pneumonia, chronic obstructive pulmonary disease, and pulmonary fibrosis.
6/24/22 - The admission Physician's Orders were written for the facility to assess R100 every shift for fever, shortness of breath, sore throat, cough, pulse oximetry and lung sounds and to write a progress note of any abnormal findings. In addition, to administer oxygen via nasal cannula, as needed to maintain oxygen saturation of 92% or above. Lastly, an oxygen order at 2 liters per minute via nasal cannula continuously every shift.
6/29/22 9:38 AM - The Weight and Vitals Summary documented by E26 (Agency LPN ) stated that R100's oxygen saturation was 90% on room air.
6/29/22 7 AM to 3 PM - The Medication Administration Record (MAR) documented by E9 (LPN, UM) that the oxygen saturation was 90% and that oxygen at 2 liters per minute via nasal cannula was being administered.
There was a lack of evidence that the facility implemented the order for PRN oxygen to maintain oxygen saturation 92% or above when R100's oxygen saturation was documented at 90% on 6/29/22 at 9:38 AM.
6/29/22 10:36 AM - An Alert Note by E25 (LPN, UM) documented, Resident discharged from facility against medical advise, resident's daughters in facility to pack up belongings .LOA (Leave of absence) 1033 (10:33 AM) .
There was lack of evidence that the facility responded to the low oxygen saturation of 90%, to include comprehensive assessment of respiratory system, including auscultation of lung sounds and consultation with the physician.
10/13/22 beginning at 2:56 PM - An interview with E25 (LPN, UM) confirmed the lack of comprehensive respiratory assessment when R100 was documented as having decreased oxygen saturation of 90% on 6/29/22 at 9:38 AM.
10/13/22 beginning at 3:00 PM - An interview with E9 (LPN, UM) revealed that she does not recall if she was assigned to R100 on 6/29/22 during the 7:00 AM to 3:00 PM shift and does not recall when R100 was documented to have had an oxygen saturation of 90% on the MAR and what actions, if any were taken. E9 stated that an Agency Nurse (E26, LPN) had documented the 90% oxygen saturation in the EMR system, however, E26 no longer was employed by the facility.
2. Cross refer F656, Example #1.
Review of R45's clinical records revealed the following:
7/31/20 - R45 was admitted to the facility.
9/23/22 - A Physician's Order was written for oxygen at 3 liters per minute via nasal cannula.
10/6/22 12:25 PM - During an observation of R45's oxygen concentrator with E3 (ADON), the oxygen was set at 2.5 liters/minute via nasal cannula (NC) and E3 confirmed that the order was for 3 liters/minute.
10/10/22 11:40 AM - During an observation of R45's oxygen concentrator with E9 (LPN, UM), the oxygen was set at 4 liters via NC and E9 confirmed that the order was for 3 liters via NC.
The facility failed to ensure R45's order for oxygen was carried out as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R105) out of one resident reviewed for dialysis the facility failed to ensure dialysis services were received when R105 missed a sc...
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Based on record review and interview it was determined that for one (R105) out of one resident reviewed for dialysis the facility failed to ensure dialysis services were received when R105 missed a scheduled dialysis appointment due to the facility's failure to arrange transportation. Findings include:
Review of the facility Dialysis contract initiated 2/1/20 indicated, The facility will have the responsibility for arranging and will bear all cost relating to transportation of any resident to and from dialysis center.
9/21/22 - R105 was admitted to the facility with multiple diagnoses including, end stage renal disease. R105 had admitting orders to receive dialysis on Mondays, Wednesdays and Fridays.
10/3/22 5:16 AM - A note in R105's clinical record documented, transportation called and did not have patient scheduled for pickup this AM. [Dialysis Center] notified and will call this AM to reschedule transport today. Patient notified of delay for dialysis. R105's TAR revealed the resident did not receive dialysis until the next scheduled dialysis date of 10/5/22.
During an interview on 10/6/22 at 12:30 PM FM4 reported that R105 Missed dialysis because they [the facility] didn't schedule it.
During an interview on 10/13/22 at 10:08 AM E37 (transportation coordinator) confirmed R105's missed dialysis appointment and showed the surveyor a transportation form for R105 to receive transportation to dialysis that was dated 10/3/22. R105 was admitted to the facility 9/21/22.
During an interview on 10/13/22 at 11:18 AM E25 (RN unit manager) confirmed the facility does not arrange transportation to dialysis for new residents.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for two out of three sampled medication carts the facility failed to ensure that an account of all controlled drugs were maintained. Finding...
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Based on record review and interview it was determined that for two out of three sampled medication carts the facility failed to ensure that an account of all controlled drugs were maintained. Findings include:
10/17/22 beginning at 11:30 AM - The following Narcotic Count Sheets were reviewed, which lacked evidence that the facility maintained account of all controlled drugs and following findings were confirmed with E9 (LPN, UM):
- Medication Cart #4 lacked signatures of either the outgoing or on coming nurses on 10/5/22, 10/8/22, and from 10/15/22 through day shift on 10/17/22.
- Medication Cart #5 lacked signature of either the outgoing or on coming nurse on 10/7/22 and 10/10/22.
10/18/22 beginning at approximately 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R104) out of five residents sampled for unnecessary medications the facility failed to limit a PRN (as needed) psychotropic medicat...
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Based on record review and interview it was determined that for one (R104) out of five residents sampled for unnecessary medications the facility failed to limit a PRN (as needed) psychotropic medication orders to 14 days . Findings include:
Cross Refer F756 example #3
Review of R104's clinical record revealed:
6/16/22 - R104 was admitted to the facility.
6/20/22 - R104 had a physician's order for Lorazepam ) concentrate 2 mg/ml give 0.25 ml by mouth every 6 hours PRN (as needed) for anxiety/SOB (shortness of breath).
6/24/22 - A Pharmacy Consultant recommended the physician's order be limited to 14 days.
7/31/22 - A Pharmacy Consultant Resident Recommendation suggested physician's order include a length of therapy up to 90 days.
10/17/22 - Review of R104's Medication Administration Records from June 2022 through August 2022 revealed the following:
-June 2022 - R104 received 1 dose of PRN Lorazepam
-July 2022 - R104 received 12 doses of PRN Lorazepam
-August 2022 - R104 received 4 doses of PRN Lorazepam
The facility failed to provide evidence that R104 was reassessed by the physician for the need to extend the use of Lorazepam for more than 14 days.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of the facility's policy, it was determined that for two (R45 and R21) out of four residents reviewed for dental services, the facility failed...
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Based on observation, interview, record review and review of the facility's policy, it was determined that for two (R45 and R21) out of four residents reviewed for dental services, the facility failed to assist in obtaining routine dental services. Findings include:
Review of the facility's policy and procedure titled Dental Services with a revision date of December 2016 stated, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .
1. Review of R21's clinical record revealed:
10/30/20 - R21 was admitted to the facility.
11/6/21 - The Annual MDS Assessment indicated that R21 was moderately impaired for daily decision making, required extensive assistance of one staff for personal hygiene, and had no oral health issues.
10/7/22 8:34 AM - A random observation revealed R21 with missing upper and lower teeth and R21 denied pain or discomfort of her teeth, gums, and/or mouth. R21 states she was uncertain if she had received any dental services, including routine dental.
There was lack of evidence that R21 was offered and/or received routine dental services.
10/12/22 1:00 PM - An interview with E2 (DON) confirmed that the facility was unable to provide evidence that R21 was offered and/or received routine dental services.
2. Review of R45's clinical record revealed:
7/31/20 - R45 was admitted to the facility.
8/23/22- The Annual MDS Assessment indicated that R45 was independent with daily decision making and had no oral health issues.
10/7/22 11:24 AM - A random observation revealed R45 with upper and lower teeth and R45 denied pain or discomfort of her teeth, gums, and/or mouth. R45 stated she has not had any dental services, including routine since admission to the facility on 7/31/20.
There was lack of evidence that R45 was offered and/or received routine dental services.
10/12/22 1:00 PM - An interview with E2 (DON) confirmed that the facility was unable to provide evidence that R45 was offered and/or received routine dental services.
10/18/22 beginning at approximately 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R105) out of two residents reviewed for rehabilitation services the facility failed to ensure speech services were provided in acco...
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Based on record review and interview it was determined that for one (R105) out of two residents reviewed for rehabilitation services the facility failed to ensure speech services were provided in accordance with the residents plan of care. R105 was ordered to receive eight visits over four weeks and received three visits total over three weeks. Findings include:
Review of R105's clinical record revealed:
9/21/22 - R105 was admitted to the facility.
9/21/22 - The following order was written for R105, Speech therapy evaluate and treat as indicated.
9/22/22 - A speech therapy evaluation and plan of treatment for R105 documented a frequency of eight visits in four weeks, from 9/22/22 - 10/21/22.
Review of R105's speech therapy encounter notes revealed R105 was visited by the speech therapist a total of three times, 9/22, 9/27, and 10/13 over three weeks.
During an interview on 10/6/22 at 12:47 PM, FM4 reported to the surveyor, There's no full time speech therapist on staff so he's not getting amount of visits prescribed.
During an interview on 10/14/22 at 11:42 AM, E35 (DOR) confirmed the facility did not have a full time speech therapist on staff. E35 stated speech therapist visit, 2-3 times a week if they can.
During an interview on 10/14/22 at 12:37 PM, E35 (DOR) confirmed that at present R105 had received three our of eight scheduled visits. E35 also stated that R105 had none scheduled at present and that two to three per week typically would have been needed to meet R105's ordered eight visits in four weeks.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R28) out of five residents reviewed for COVID -19 vaccination the facility failed to provide evidence that COVID-19 vaccination was...
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Based on record review and interview it was determined that for one (R28) out of five residents reviewed for COVID -19 vaccination the facility failed to provide evidence that COVID-19 vaccination was offered to the resident. Findings include:
The facility policy for COVID-19 vaccination of residents and staff created May 2021, indicated, The facility will offer all unvaccinated residents (or the resident representative) vaccination against COVID-19.
Review of R28's clinical record revealed:
6/4/22 - R28 was admitted to the facility.
R28's immunization record documented the resident as having refused COVID 19 vaccination.
10/14/22 1:28 PM - The surveyor requested R28's documentation of refusal and education regarding COVID-19 vaccination. E29 (ICP) presented the surveyor with a refusal of COVID 19 vaccination dated 10/14/22. E29 stated she believed R29 refused previously but did not have the documentation and obtained the refusal presented to the surveyor that day after surveyor request the documentation.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
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 random observation and interview it was determined that the facility failed to keep temperatures at a comfortable level...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation and interview it was determined that the facility failed to keep temperatures at a comfortable level in the facility. Findings include:
10/6/22 1:30 PM - During an interview with R106, it was reported that I am freezing my [a$%] off too cold to get out of bed for therapy.
10/17/22 10:15 AM - An observation of R201 with a blanket over the upper body while sitting in the wheelchair in the common area near the activities/dining room (where the large fish tank is located). An unidentified visitor that was sitting next to R201 stated that it was cold and suggested that R201 return to his room where it may be warmer and R201 returned to his room.
10/17/22 12:30 PM - During an interview R110 revealed that she was cold and that she had reported to the nurse that she was cold.
10/17/22 at approximately 12:35 PM - During an interview and observation, R200 in 214 reported that it felt like it was 65 degrees. R200 was observed to have on a sweatshirt and pointed out the gloves that she uses to keep her hands warm.
10/17/22 - During an interview in the afternoon around 2:00 PM, E37 (Agency Nurse) revealed that if a resident complains of being cold that E37 would get them a blanket. E37 further revealed that there were problems going on with temperatures.
10/17/22 1:05 PM - 1:10 PM - During observations and interview with E36 (Maintenance Director) it was confirmed that the following temperature in room [ROOM NUMBER] was 69.5 degrees and in 214 the air temperature coming from the vent was 63 degrees and 65.3 degrees at the thermostat. It was further revealed that facility has a maintenance system to submit maintenance issues and if the temperatures need adjusting a message can be submitted and it will be addressed. Maintenance can adjust the temperatures remotely. Immediately following the interview maintenance was checking all the temperatures.
10/17/22 - A review of the maintenance log from September to October 17, 2022 it revealed the following:
-9/14/22 Administrative offices reported it was so cold. Temperature was turned up to make it warmer.
-9/19/22 temperature on Riverwalk was turned down all the way.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on interview, observation, and record review, it was determined that the facility failed to make the information available to residents regarding how to file a grievance or complaint anonymously...
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Based on interview, observation, and record review, it was determined that the facility failed to make the information available to residents regarding how to file a grievance or complaint anonymously. Findings include:
The facility policy titled, Grievances/Complaints, Filing revised April 2019, stated, .#5. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously .
Review of the Resident Council meeting minutes from October 19, 2021 through October 4, 2022, lacked evidence that there was a process or information on how to file a grievance anonymously was discussed with residents.
10/10/22 2:30 PM - During the Resident Council meeting, in response to the question,'Do you know how to file a grievance including filing a grievance anonymously?, nine residents who attended the meeting responded no.
10/11/22 9:42 AM - An observation of the facility bulletin boards on the first and second floors lacked the required posted information on how to file a complaint or grievance anonymously with the facility.
10/13/22 8:50 AM - During an interview, E5 (Social Service) confirmed the process and information for filing a grievance anonymously was not posted in the facility.
The facility failed to have a process for residents to file grievances or complaints anonymously.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
3. Cross Refer F623 Ex. # 2
Review of R103's clinical record revealed:
3/2/22 - R103 was admitted to the facility.
R103's progress notes documented that the resident was transferred to the hospital o...
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3. Cross Refer F623 Ex. # 2
Review of R103's clinical record revealed:
3/2/22 - R103 was admitted to the facility.
R103's progress notes documented that the resident was transferred to the hospital on 3/27/22, 4/27/22, 5/27/22 and 7/26/22.
Review of R103's clinical record lacked evidence that a bed hold notices were provided to the resident/responsible party when R103 was transferred to the hospital on those above dates.
10/17/22 2:00 PM - In an interview, E1 (NHA) confirmed the absence of documentation that R103 or her resposible party was provided with bed hold notices following her transfers to the hospital.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on record review and interview it was determined that for three (R50, R52 and R103) out of three residents reviewed for hospitalization the facility failed to ensure the resident/representative was provided with a bed hold notice. Findings include:
The facility policy on bed holds and returns last updated March 2022, indicated that, Residents/representatives would be provided written information regarding the bed-hold policies .at the time of transfer or if emergent within 24 hours.
1. Review of R52's clinical record revealed:
6/28/22 - R52 was admitted to the facility.
7/18/22 8:43 AM - A progress note documented R52 was transferred to the hospital.
Review of R52's clinical record lacked evidence that a bed hold notice was provided to the resident/responsible party.
During an interview on 10/11/22 11:45 AM E1 (NHA), confirmed the absence of documentation that R50 and R52 were provided with bed hold notices following their transfers to the hospital.
2. Review of R50's clinical record revealed:
8/9/22 - R50 was admitted to the facility.
8/24/22 3:02 PM - A progress noted documented R50 was transferred to the hospital.
Review of R50's clinical record lacked evidence that a bed hold notice was provided to the resident/responsible party.
During an interview on 10/11/22 11:45 AM E1 (NHA) confirmed the absence of documentation that R50 and R52 were provided with bed hold notices following their transfers to the hospital.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Cross Refer F685
Review of R22's clinical records revealed the following:
1/18/22 - R22 was admitted to the facility.
R22's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Cross Refer F685
Review of R22's clinical records revealed the following:
1/18/22 - R22 was admitted to the facility.
R22's admission MDS and quarterly MDS dated [DATE] and 5/5/22 revealed that R22 had adequate hearing with no difficulty in normal conversation.
8/7/22 - Review of R22's quarterly MDS revealed that R22 had minimal difficulty with hearing meaning difficulty in some environment for example, when person speaks softly or setting is noisy.
10/6/22 9:45 AM - In an interview, R22 stated that she could not hear very well out of her right ear.
There was lack of evidence that a care plan was developed to address R22's hearing difficulty.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
2. Review of R33's clinical record revealed:
8/25/22 R33 was admitted to the facility.
8/31/22 - An admission MDS assessment documented R33 received special treatments such as oxygen, suctioning and tracheostomy care. On 9/25/22, the same assessment was modified to add ventilator use.
10/10/22 3:08 PM - Review of R33's clinical record lacked evidence of a care plan for the care of the resident's tracheostomy and mechanical ventilator.
10/10/22 - After the surveyor inquired about the care plans they were created for R33's use of mechanical ventilation, tracheostomy care, and potential for respiratory distress.
3. Review of R101's clinical record revealed;
12/8/21 - R101 was admitted to the facility.
12/14/21 - An admission MDS assessment documented R101 required limited assitance of two people for hygiene.
12/8/21 - R101's care plan for ADL's was created with the following interventions, assist resident to pick out own clothes, assist to attend activities of choice, assist with meal tray: opening items and set up as needed. PT/OT to evaluate and treat as indicated. Toileting schedule as resident allows.
The care plan lacked evidence of interventions for R101's assistance with hygiene.
4. Review of R107's clinical record revealed:
9/22/22 - R107 was admitted to the facility with multiple diagnoses including seizure disorder, and diabetes.
9/28/22 - An admission MDS assessment documented R107 as receiving the following medications: antipsychotics, antidepressants, and anticoagulants.
10/10/22 - Review of R107's clinical record lacked evidence of care plans regarding the residents use medications to manage a seizure disorder, diabetes and use of antipsychotics, antidepressants, and anticoagulants.
10/11/22 - After the surveyor inquired about the care plans they were created for R107's use of anticoagulant therapy, antidepressant therapy, diabetes and seizure disorder.
Based on record review and interview, it was determined that for five (R22, R33, R45, R101 and R107) out of 25 residents reviewed for care plans, the facility failed to develop and implement a comprehensive person centered care plan. Findings include:
1. Cross refer F695, Example #2.
Review of R45's clinical records revealed the following:
7/31/20 - R45 was admitted to the facility.
9/23/22 - A Physician's Order was written for oxygen at 3 liters per minute via nasal cannula.
There was lack of evidence of a respiratory care plan for oxygen administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
4. Review of R102's clinical record revealed:
8/18/22 - R102 tested positive for COVID 19.
8/18/22- An order was written for R102 to receive Paxlovid tablet therapy for respiratory infection due to CO...
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4. Review of R102's clinical record revealed:
8/18/22 - R102 tested positive for COVID 19.
8/18/22- An order was written for R102 to receive Paxlovid tablet therapy for respiratory infection due to COVID 19 for five days.
8/18/22 9:52 PM - A note in R102's clinical record regarding administration of the Paxlovid documented, Medication not available, waiting for delivery from pharmacy.
8/19/22 1:00 AM - A note in R102's clinical record documented, Medication still have not arrived. Phoned pharmacy and they stated the form was missing patient information, they re-faxed the form to be filled out with patient information.
8/19/22 7:55 PM - A note in R102's clinical record regarding administration of the Paxlovid documented, Medication not available, waiting for delivery from pharmacy. The clinical record lacked evidence that a physician was notified at that time.
8/20/22 7:59 AM - A physician's note in R102's clinical record documented, She is seen today for follow up after I saw her yesterday due to request of her daughter due to her cough, She tested positive [for COVID 19] yesterday and CXR was done which was positive for pneumonia. I started her on Paxlovid and Dexamethasone (steroid) yesterday .
8/21/22 9:55 AM - A note in R102's clinical record regarding administration of the Paxlovid documented, Continue to await delivery.
8/22/22 11:10 PM - A physician's note in R102's clinical record documented, She tested positive [for COVID 19] last week .I started her on Paxlovid and Dexamethasone for COVID infection .but she never received Paxlovid as pharmacy never sent it. She is no longer eligible for Paxlovid as she is not in window period.
During an interview on 10/14/22 at 2:57 PM, E1(NHA) and E2 (DON), E2 stated, the facility's process for obtaining medications for new orders was to, Call the pharmacy then we have it processed. If it's not delivered we can call and see where it is and have it delivered from our back up pharmacy in town if the specific medication is there. Our pharmacy reaches out to other pharmacies as well but the medication [Paxlovid] was unavailable. At time of exit the facility was unable to provide evidence of correspondence with other pharmacy's and immediate notification of the physician regarding a lack of availability of the prescribed Paxlovid to treat R102 for COVID 19.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on interview and record review, it was determined that the facility failed to ensure that for three (R25, R45 and R21) out of five residents reviewed for unnecessary medications, the facility failed to assess the residents for signs or symptoms of constipation and administer medications as ordered for no bowel movement (BM) after three days. In addition, for one (R102) out of three residents reviewed for infection control, the facility failed to ensure the resident received prescribed medication to treat an infection. Findings include:
1. Review of R25's clinical record revealed:
6/11/22 - R25 was admitted to the facility.
6/11/22- Review of the physician's orders included medications for constipation:
- Milk of Magnesia as needed for if no BM in three days.
- Dulcolax Suppository as needed for constipation if no result from Milk of Magnesia within eight hours.
- Fleet Enema as needed for constipation or no BM from Dulcolax in eight hours, call MD if no results in eight hours.
6/12/22 - The care plan for potential for constipation due to decreased mobility and history of constipation included a goal that R25 will have a BM every three days (9 shifts). Interventions included BM protocol (ordered laxatives) as needed, bowel medicine as ordered, inform MD if not effective or if loose stool occurs, encourage mobility as resident is able.
7/1/22 through 10/6/22 - The CNA documentation of R25's BM activity revealed that the facility failed to ensure that physician's orders were implemented when R25 failed to have bowel activity for nine (9) shifts on the following dates:
- Ending on day shift on 7/18/22, total of 21 shifts
- Ending on day shift on 7/26/22, total of 20 shifts
- Ending on evening shift on 7/31/22, total of 13 shifts
- Ending on day shift on 8/12/22, total of 18 shifts
- Ending on night shift on 8/17/22, total of nine shifts
- Ending on evening shift on 9/16/22, total of nine
- Ending on night shift on 9/28/22, total of nine
- Ending on day shift on 10/6/22, total of 25 shifts
10/18/22 8:30 AM - An interview with E3 (ADON) revealed that during the survey, the facility identified that the night shift licensed nurses were not accessing the EMR report for residents who had not had a BM in three days or nine shifts, thus, resulting in failure to assess the resident for constipation and implement the orders for the bowel protocol.
2. Review of R45's clinical records revealed:
7/31/20 - R45 was admitted to the facility.
7/31/20 - Review of the physician's order included the following medications for constipation:
- Milk of Magnesia as needed for if no BM in three days.
- Dulcolax Suppository as needed for constipation if no result from Milk of Magnesia within eight hours.
- Fleet Enema as needed for constipation or no BM from Dulcolax in eight hours, call MD if no results in eight hours.
9/6/22 (Initial date of 8/2/20) - The care plan for potential for constipation due to decreased mobility and history of constipation included a goal that R45 will have a BM every three days. Interventions included BM protocol (ordered laxatives) as needed, encourage mobility as resident able, monitor and encourage fluids as per dietary needs and as ordered, and monitor consistency and frequency of bowel movements.
8/1/22 through night shift on 10/17/22 - The CNA documentation of R45's BM activity revealed that the facility failed to ensure that physician's orders were implemented when R25 failed to have bowel activity for total of 12 shifts on night shift on 8/6/22 and on night shift on 10/17/22.
3. Review of R21's clinical records revealed:
6/28/22 - R21 was readmitted to the facility from the hospital.
6/28/22- Review of the physician's order included medications for constipation:
- Lactulose as needed for if no BM in three days.
- Dulcolax Suppository as needed for constipation if no result from Lactulose within eight hours.
- Fleet Enema as needed for constipation or no BM from Dulcolax in eight hours, call MD if no results in eight hours.
6/28/22- The care plan for potential for constipation due to decreased mobility and history of constipation included a goal that R21 will have a BM every three days. Interventions included BM protocol (ordered laxatives) as needed, encourage mobility as resident able, monitor and encourage fluids as per dietary needs and as ordered, and monitor consistency and frequency of bowel movements.
8/1/22 through night shift on 10/17/22 - The CNA documentation of R21's BM activity revealed that the facility failed to ensure that physician's orders were implemented when R21 failed to have bowel activity for three days from 8/8/22 evening shift through night shifts on 8/12/22 for total of 11 shifts.
10/18/22 8:30 AM - An interview with E3 (ADON) confirmed that the facility failed to implement the physician's orders for Lactulose when R21 had no BM for three days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
4. Review of R21's clinical record revealed the following:
9/21 through 9/22 - The review of the facility's monthly regimen review (MRR) report, the monthly Pharmacist Consultant Resident Recommendat...
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4. Review of R21's clinical record revealed the following:
9/21 through 9/22 - The review of the facility's monthly regimen review (MRR) report, the monthly Pharmacist Consultant Resident Recommendations Report revealed the following:
- The facility failed to ensure for the following seven (7) MRR reports with irregularities identified by RPh1(Pharmacist) were reported to the attending physician, the facility's medical director, and director of nursing, and these reports were acted upon: 9/26/21, 10/31/21, 11/28/21, 1/25/22, 2/23/22, 3/21/22, 4/30/22, 5/28/22, 6/24/22, 6/30/22, 7/31/22, 8/28/22, and 9/22/22.
- The facility failed to have evidence that a MRR was conducted between the the MRR dated 11/28/21 and 1/25/22.
5. Cross Refer F842, Example #2.
Review of R45's clinical record revealed the following:
9/2021 through 9/2022 - The review of the facility's monthly regimen review (MRR) report, the monthly Pharmacist Consultant Resident Recommendations Report revealed the following:
The facility failed to ensure for R45, eight monthly irregularities identified by RPh1 (Pharmacist) were reported to the attending physician, the facility's medical director, and director of nursing, and these reports must be acted upon. The monthly reports were dated - The facility failed to ensure for the following eight (8) MRR reports with irregularities identified by RPh1 were reported to the attending physician, the facility's medical director, and director of nursing, and these reports were acted upon: 12/24/21, 1/24/22, 2/23/22, 3/31/22, 5/27/22, 6/24/22, 7/31/22, and 8/28/22.
6. Review of R25's clinical record revealed the following:
6/11/22 - R25 was admitted to the facility.
6/2022 through 9/2022 - The review of the facility's monthly regimen review (MRR) report, the monthly Pharmacist Consultant Resident Recommendations Report revealed, the facility failed to ensure four (4) monthly irregularities identified by RPh1 (Pharmacist) were reported to the attending physician, the facility's medical director, and director of nursing, and these reports must be acted upon. The monthly reports were dated 6/24/22, 7/31/22, 8/28/22, 9/22/22.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on record review and interview, it was determined that for six (R9, R22, R104, R21, R25, and R45) out of six residents sampled for medication review, the facility failed to consistently act on irregularities identified during medication regimen reviews (MRRs) by the pharmacist . In addition, for R21, the facility failed to have evidence that a MRR was conducted between the the MRR dated 11/28/21 and 1/25/22. Lastly, the facility failed to develop policies and procedures for the monthly MRR that included, but not limited to, time frames for different steps in the MRR process and steps the facility must take when the pharmacist identifies an irregularity that requires urgent action to protect the resident. Findings include:
1. Cross Refer F842, example #4
Review of R22's clinical record revealed:
10/10/22 - R22's MRR's from September 2021 - September 2022 were reviewed. The pharmacist identified irregularities on the following dates: 11/28/21, 1/24/22, 2/23/22, 3/21/22, 4/30/22, 5/28/22, 7/31/22, and 8/28/22.
There was no response by E32 (Medical Director) found in the clinical record.
2. Cross Refer F842, example #3
Review of R9's clinical record revealed:
10/12/22 - R9's MRR's from September 2021 - September 2022 were reviewed. The pharmacist identified irregularities on the following dates: 3/21/22, 4/30/22, and 9/21/22.
There was no response by E32 (Medical Director) found in the clinical record.
3. Cross Refer F758
Review of R104's clinical record revealed:
10/12/22 - R104's MRR's for June 2022 and July 2022 were reviewed. The pharmacist identified irregularities on the following dates: 6/24/22 and 7/31/22.
There was no response by E32 (Medical Director) found in the clinical record.
10/12/22 11:20 AM - During an interview, E2 (DON) stated that prior to this surveyor's inquiry, in order for her to review incomplete EHR (electronic health records) evaluations/assessments including the monthly Pharmacy Consultant Resident Recommendations, she would look at all the pending tasks. The tasks under the monthly pharmacy review showed completed for her when accessed. E2 further stated that it must have something to do with how the pharmacy documentation was saved and typed in the EHR that automatically populated a completed task for her when she reviewed.
10/12/22 11:25 AM - E2 confirmed that there was no physician response to several months of R9, R22 and R104's pharmacy recommendations and they were not in the clinical record.
10/14/22 10:30 AM - In an interview, RPh1 (Pharmacy Consultant) stated that at the beginning of this year, he was advised by the facility corporate to save and lock his documentation everytime he conducts the monthly pharmacy medication review and transcribes it in the Pharmacy Consultant Resident Recommendations tab of the facility's EHR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. [DATE] 8:26 AM - The medication room on the unit was observed with the entry door opened and medications visible on the count...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. [DATE] 8:26 AM - The medication room on the unit was observed with the entry door opened and medications visible on the counter.
During an interview on [DATE] 8:31 AM E27 (RT) accompanied the surveyor to the medication room and confirmed the open door and visible medications. E27 then closed the door and demonstrated that the door locked upon closing and a badge must then be swiped for entry.
[DATE] 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on observation, interview, and review of other facility documentation it was determined that the facility failed to store and maintain drugs in accordance with acceptable professional standards by having expired or discontinued medications or biologicals in two out of three medication carts and one out of two medication storage rooms. Additionally, the facility failed to ensure for one out of three medication rooms and two out of three medication carts inspected, that the drugs and biologicals were kept in locked compartments with only authorized personnel having keys to access. Findings include:
The facility's policy titled, Storage of Medication , with a revision date of 4/2007, indicated .The facility shall not use discontinued, outdated .drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .7. Compartments (including, but not limited to, drawers, cabinets, rooms, .carts .) containing drugs and biologicals shall be locked when not in use .10. Only persons authorized to prepare and administer medications shall have access to the medication room, including keys.
1. [DATE] 10:20 AM - During random observation of the Reserve Unit's medication storage room with E25 (LPN, UM), the following expired biologicals were observed:
- Juven (nutritional supplement) packets, 20 packets with expiration date of 8/2022
- Povidone iodine (a skin disinfectant) solution 16 oz, two bottles with expiration date of 9/2022
2. [DATE] 10:45 AM - During random observation of medication cart #4 with E7 (LPN) revealed the following expired and/or discontinued medications or biologicals:
- unopened bottle of Advil containing 10 tablets with expiration date of 3/2022
- Juven supplement packets, four (4) packets with an expiration date of 8/2022
- opened tube of Santyl ointment with an expiration date of [DATE]
- discontinued Lispro insulin pen for R23
- discontinued Lantus insulin for R22
3. [DATE] beginning at 4:22 PM - E24 (RN) left the medication cart #4 unlocked, unsecured and unattended in the hallway and entered R22's room to administer her medications. On top of the medication cart, there were two medications unsecured inside the medication cart. At 4:44 PM, E24 confirmed that the medication cart and the two medications were not locked in the medication cart for approximately 22 minutes. E24 immediately placed the medications in the medication cart and locked the cart.
4. [DATE] beginning at 10:15 AM - During random observation of medication cart #2 revealed the cart was unlocked and unattended. At 10:18 AM, E25 (LPN, UM) walked by the cart and proceeded to lock the cart and interview immediately after this observation with E25 confirmed that the cart was unlocked and unattended until 10:18 AM and should have been locked.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of other documentation as necessary, it was determined that for four (R9, R22, R25,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of other documentation as necessary, it was determined that for four (R9, R22, R25, and R45) out of 38 sampled residents, the facility failed to ensure that medical records were accurate. Findings include:
Review of The National Pressure Ulcer (PU) Advisory Panel staging, revised in April 2014 revealed the following staging a PU:
- Stage 2 Pressure Injury: Blister or shallow open sore with red/pink color. Deeper tissues/fat, granulation tissue, slough and eschar are not present.
1. Review of R25's clinical records revealed the following:
6/11/22 - R25 was admitted to the facility.
6/11/22 11:28 AM - The admission Nursing Assessment and the Skin Only Progress Note lacked evidence of a PU of the heel.
There was lack of documentaion of additional PU on admission.
6/13/22 1:00 AM (electronically dated and signed 6/14/22 and 10:27 AM respectively) - The Encounter Progress Note by E31 (NP) documented, .History of Present Illness: .on 6/2/22 .Physical Exam .Skin: .right heel blister .
There was lack of evidence of identifying the right heel blister as a PU and comprehensively assessing and documenting the characteristics of the PU, including the stage of the PU.
10/7/22 11:55 AM - An interview with E2 (DON) revealed R25 was admitted with PU of sacrum and on the right heel.
10/17/22 8:40 AM - An interview with E31 (NP) revealed that her first assessment of R25 was during day shift on 6/13/22 and it was her understanding that the blister on R25's right heel was present on admission to the facility on 6/11/22. E31 stated the the blister was intact and not open without maroon or purple color. The interventions initiated upon admission were to float the heels and to apply sure prep (skin protectant).
10/17/22 approximately 10:30 AM - E2 (DON) provided hospital records dated 5/27/22 which provided evidence that R25 had a right heel intact fluid filled blister prior to R25 being admitted to the facility on [DATE] and verbalized that the facility did not document the presence of the PU on admission.
2. Cross refer F756, Example #5.
Review of R45's clinical record revealed the following:
9/30/21 and 10/31/21 - The facility's two, monthly regimen review (MRR) reports lacked evidence of the signature of RPh1 (Pharmacist), however, E34 (Former ADON) electronically signed the report.
3. Cross Refer F756, Example #2.
Review of R9's clinical record revealed the following:
9/26/21 - The facility's monthly regimen review (MRR) lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
10/31/21 - The MRR lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
4. Cross Refer F756, Example #1.
Review of 22's clinical record revealed the following:
9/1/21 - The facility's MRR Report lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
9/26/21 - The MRR lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
10/31/21 - The MRR lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
11/28/21 - The MRR lacked evidence of the signature of the Pharmacy Consultant and included the electronic signature of E34 (Former ADON).
10/18/22 beginning at approximately 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and review of other documentation as indicated, it was determined that the facility failed to maintain an effective infection prevention and control program by failing...
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Based on observation, interview, and review of other documentation as indicated, it was determined that the facility failed to maintain an effective infection prevention and control program by failing to clean and disinfect the blood glucose meter between resident uses. In addition, failed to ensure adherence to infection control practices when staff picked up a resident's oral medication using her bare hand, thus, contaminating the medication and failed to discard the medication. Findings include:
Review of the manufacturer's instructions for Assure Prism Multi Blood Glucose Monitoring System (a glucometer) revealed the following:
- .The meter should be cleaned and disinfected after use on each patient .(meter) may only be used for testing multiple patients when .the manufacturer's disinfection procedure is followed .A variety of the most commonly use EPA registered wipes have been tested and approved for cleaning and disinfecting the (meter) .
1. During random medication pass observation on 10/12/22 beginning at 3:53 PM, E36 (RN) performed FSBS on R40 by using the Assure Prism meter and after the use, E36 cleansed the glucometer with alcohol pad. An interview immediately after the observation confirmed that E36 used an alcohol pad to clean the meter and failed to use an approved EPA approved cleaning and disinfectant wipe.
2a. During random medication administration observation on 10/12/22 beginning at 4:22 PM, E24 (RN) after performing FSBS on R22 by using the Assure Prism meter, E24 stated that she uses alcohol pad to clean the meter after resident use but if she had time, she would use a disinfectant wipe. E24 proceeded to the nurses station where she was met by E3 (ADON) who stated that the facility used an EPA approved disinfectant wipe to clean and disinfect the meter in between resident use.
2b. During random medication observation beginning 10/12/22 at approximately 4:30 PM, E24 poured an oral medication (one tablet) into a medication cup and proceeded to administer to R22, however, the pill dropped out of the medication cup onto R22's clothing. E24 subsequently picked up the pill with her bare right hand, placed it back into the medication cup, gave the cup to R22 who proceeded to swallow the medication. An interview immediately after the above observation with E24 confirmed that she picked up the pill with her bare hand and she should have discarded the medication as it was contaminated.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
2. Cross Refer F625 Ex. # 3
Review of R103's clinical record revealed:
3/2/22 - R103 was admitted to the facility.
Review of R103's nurse progress notes revealed that R103 was transferred to the hops...
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2. Cross Refer F625 Ex. # 3
Review of R103's clinical record revealed:
3/2/22 - R103 was admitted to the facility.
Review of R103's nurse progress notes revealed that R103 was transferred to the hopsital on 3/27/22, 4/27/22, 5/27/22 and 7/26/22.
10/13/22 2:30 PM - Review of R103's clinical record lacked evidence of notification of transfer to the Ombudsman for the transfers on 3/27/22, 4/27/22, 5/27/22 and 7/26/22 .
10/13/22 5:11 PM - In an email correspondence, E5 (SW) confirmed the findings.
10/18/22 9:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).
Based on record review and interview it was determined that for two (R50 and R103) out of two residents reviewed for hospitalization the facility failed to provide notice of the transfer to the Ombudsman. Findings include:
1. Review of R50's clinical record revealed:
8/9/22 - R50 was admitted to the facility.
8/24/22 3:02 PM - A progress noted documented R50 was transferred to the hospital.
Review of R50's clinical record lacked evidence of notification of the transfer to the Ombudsman.
During an interview on 10/11/22 at 11:11 AM E1 (NHA) and E5 (SW) confirmed the findings.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview it was determined that for three out of three units the facility failed to ensure the nurse staff data posting requirement was accurate and complete. Findings includ...
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Based on observation and interview it was determined that for three out of three units the facility failed to ensure the nurse staff data posting requirement was accurate and complete. Findings include:
1. 10/7/22 8:37 AM - During a random observation of the facility's ventilator unit, the staff posting displayed was dated for the day prior, 10/6/22, the finding was immediately confirmed by E29 (ICP).
10/12/22 12:26 PM - During a random observation of the facility's ventilator unit, the staff posting displayed was dated for the day prior, 10/11/22, the finding was immediately confirmed by E7 (LPN).
2. 10/11/22 - Observations of the two units, The Reserve and The Riverwalk from 9:42 AM - 9:55 AM revealed the total number of hours worked for nurses was not broken down into Registered Nurses and Licensed Practical Nurses, but was combined for both categories.
10/14/22 10:02 AM - In an interview, E6 (Scheduler) confirmed that the nurses hours were documented in the staff posting collectively and not broken down into Registered Nurses and Licensed Practical Nurses.
10/18/22 9:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Special Focus Facility, 2 harm violation(s), $127,199 in fines. Review inspection reports carefully.
- • 89 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $127,199 in fines. Extremely high, among the most fined facilities in Delaware. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Polaris Healthcare And Rehabilitation Center's CMS Rating?
CMS assigns POLARIS HEALTHCARE AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Delaware, 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 Polaris Healthcare And Rehabilitation Center Staffed?
CMS rates POLARIS HEALTHCARE AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 67%, which is 20 percentage points above the Delaware average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Polaris Healthcare And Rehabilitation Center?
State health inspectors documented 89 deficiencies at POLARIS HEALTHCARE AND REHABILITATION CENTER during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 83 with potential for harm, and 3 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 Polaris Healthcare And Rehabilitation Center?
POLARIS HEALTHCARE AND REHABILITATION 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 NATIONWIDE HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 100 certified beds and approximately 91 residents (about 91% occupancy), it is a mid-sized facility located in MILFORD, Delaware.
How Does Polaris Healthcare And Rehabilitation Center Compare to Other Delaware Nursing Homes?
Compared to the 100 nursing homes in Delaware, POLARIS HEALTHCARE AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.3, staff turnover (67%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Polaris Healthcare And Rehabilitation Center?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Polaris Healthcare And Rehabilitation Center Safe?
Based on CMS inspection data, POLARIS HEALTHCARE AND REHABILITATION CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Delaware. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Polaris Healthcare And Rehabilitation Center Stick Around?
Staff turnover at POLARIS HEALTHCARE AND REHABILITATION CENTER is high. At 67%, the facility is 20 percentage points above the Delaware average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Polaris Healthcare And Rehabilitation Center Ever Fined?
POLARIS HEALTHCARE AND REHABILITATION CENTER has been fined $127,199 across 2 penalty actions. This is 3.7x the Delaware average of $34,351. 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 Polaris Healthcare And Rehabilitation Center on Any Federal Watch List?
POLARIS HEALTHCARE AND REHABILITATION CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.