OCEAN GROVE POST ACUTE
For profit - Limited Liability company
181 Beds
PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES
Data: November 2025
Trust Grade
50/100
#36 of 43 in DE
Photo by Ocean Grove Post Acute
Photo by Ocean Grove Post Acute
Photo by Ocean Grove Post Acute
1 / 5 photos
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Ocean Grove Post Acute in Millsboro, Delaware has a Trust Grade of C, indicating it is average and sits in the middle of the pack among nursing homes. It ranks #36 out of 43 facilities in Delaware, placing it in the bottom half, and #9 out of 11 in Sussex County, meaning only two local options are worse. The facility is improving, with issues decreasing from 27 in 2024 to just 5 in 2025. However, it has a staffing rating of 0 out of 5 stars, which is a major concern; while turnover is low at 0%, the lack of adequate staffing may affect resident care. There have been no fines, which is a positive sign, but recent inspections revealed serious deficiencies, such as failing to properly manage medications for residents and lacking care plans for those with cognitive impairments, which raises concerns about the quality of care provided.
- Trust Score
- C
- In Delaware
- #36/43
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Delaware facilities.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 81 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 17%
No red flags
27 → 5 violations
★★☆☆☆
2.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Delaware average (3.3)
Below average - review inspection findings carefully
Chain: PRESTIGE HEALTHCARE ADMINISTRATIVE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 81 deficiencies on record
Jul 2025
5 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
Safe Environment
(Tag F0584)
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 for one out of four resident units the facility failed to provide a c...
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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 out of four resident units the facility failed to provide a clean and homelike environment. Findings include:
7/2/25 9:27 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have two areas approximately 6 in length, brown in color by the air conditioning unit.
7/2/25 9:33 AM - During an interview, E4 (Maintenance) confirmed the air conditioning unit in room [ROOM NUMBER] was leaking and recently just replaced. E4 confirmed the two large areas, brown in color next to the air conditioning unit.
7/2/25 9:37 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have approximately six circular areas, brown in color, linear pattern noted on the ceiling. room [ROOM NUMBER] also noted to have a large area, approximately 12 long, brown in color noted in the closet.
7/2/25 9:50 AM - During an observation on the Ocean Gardens unit, room [ROOM NUMBER] was noted to have a leaking shower head in the bathroom. While observing the leaking shower head, it was noted that the tiles in the shower were covered with a pink and gray substance, slippery in consistency. Also noted that multiple tiles and the baseboard lining was missing from the bathroom wall and floor.
7/2/25 10:28 AM - During an interview, E5 (Maintenance Director) and E6 (Maintenance Corporate) confirmed the aforementioned areas in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] were in disrepair and would put in a work order to complete.
7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E7 (IP) during the exit conference.
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 record review and interview it was determined that for one (R163) out of two residents reviewed for wound care, the facility failed to ensure that wound care was performed in accordance with ...
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Based on record review and interview it was determined that for one (R163) out of two residents reviewed for wound care, the facility failed to ensure that wound care was performed in accordance with the physician's ordered frequency. Findings include:
1. The facility policy on wound treatment and management last updated 3/25 indicated, Wound treatments will be provided in accordance with physicians orders .treatments will be documented in the electronic health record.
Review of R163's clinical record revealed:
5/22/25 - R163 was admitted to the facility with multiple wounds including on the right hip, leg and foot related to diabetes, and poor circulation resulting in some areas of dead tissue.
5/22/25 - A care plan for skin impairment was created for R163 with the intervention to administer treatment per physician's order.
5/26/25 - An admission MDS assessment documented R163 was cognitively intact and having multiple wounds that required care.
May 2025 - R163's TAR lacked evidence that daily wound care treatments were completed on 5/30/25. R163's progress notes lacked documentation regarding resident absence or refusal for that date.
6/18/25 - A Physician's order was written for R163 to receive daily wound care treatments and dressing changes to the right hip, right lower leg, right ankle and right heel.
June 2025 - R163's TAR lacked evidence that daily wound care treatments were completed on 6/12, 6/13, 6/19, and 6/20. R163's progress notes lacked documentation regarding resident absence or refusal on those dates.
6/23/25 11:16 AM - During an interview R163 stated, They don't always have enough staff, so my dressing is not changed every day like it's supposed to be.
6/26/25 10:00 AM - During an interview E28 (LPN) wound care nurse stated I told [R163] before if someone doesn't do it during the day then ask them to do it at night or tell me because sometimes, I am assigned to do other things. E28 then reported that R163 was compliant and wants to heal. E28 then confirmed the blank areas on R163's TAR to indicated missed treatments.
6/26/25 11:58 AM - During an interview E20 (RN) unit manager confirmed the findings and stated, I was unaware it wasn't always being done.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that for one (R27) out of six residents reviewed for medication review the facility failed to provide medications and/or biologicals, as ordered ...
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Based on record review and interview it was determined that for one (R27) out of six residents reviewed for medication review the facility failed to provide medications and/or biologicals, as ordered by the prescribe, to meet the needs of the resident. Findings include:
The facility policy on ordering medication updated June 2024, indicated, medications and related products are received from the pharmacy on a timely basis.
Review of R27's clinical record revealed:
6/4/25 - R27 was admitted to the facility with multiple diagnoses including diabetes.
6/4/25 - A physicians order was written for R27 to receive Ozempic injections for diabetes every Tuesday. The same day the order was then changed to every Friday.
6/13/25 - A physicians order was written to discontinue R27's Ozempic injection.
6/13/25 - A physicians order was written for R27 to receive Bydureon (a once weekly injection similar to Ozempic) for diabetes every Friday.
6/20/25 12:48 PM - An orders administration note in R27's clinical record written by E20 (RN) unit manager documented Bydureon . medication not available. NP aware may hold until arrival from pharmacy no alterative medication.
6/20/25 - A physicians order was written to discontinue R27's Bydureon injections.
6/21/25 - A physicians order was written for R27 to receive Exenatide injections twice a day for diabetes.
June 2025 - Review of R27's MAR revealed Ozempic was not received on 6/6, and 6/13. Bydureon was not received on 6/20.
6/23/25 1:12 PM - During an interview R27 stated, They are not getting my Ozempic
6/26/25 11:27 AM - E2 (DON) confirmed the facility lacked evidence of delivery of R27's Ozempic from the pharmacy.
6/26/25 12:03 PM - During an interview - E20 (RN) unit manager stated, [R27] comes in has order for Ozempic. The pharmacy ask it to be changed to Bydureon, then they say it's not available so they change again to Exenatide.
6/26/25 1:45 PM - During an interview C1 (QAPharmD) confirmed the findings and stated, We did get an order for the Ozempic then the facility submitted another order with a change. We did not dispense either order. We should have sent the second and that was a miss on the pharmacy part. It was miss-assessed. On 6/13 they discontinued the Ozempic and submitted a new order for the Bydureon and that had been discontinued by the manufacturer. We pharmacist spoke to the facility and we told them we could provide Exenatide.
7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), the exit conference.
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 F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that for one (R164) out of three residents reviewed for nutr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that for one (R164) out of three residents reviewed for nutrition the facility failed to ensure the resident received food that accommodated intolerance's. Findings include:
Review of R164's clinical record revealed:
5/28/25 - R164 was admitted to the facility with multiple diagnoses including gastroesohageal reflux disease (GERD a severe and uncomfortable heart burn) and a feeding tube.
5/28/25 - A physicians order was written for R164 to receive a medication to treat GERD daily.
5/30/25 - A care plan for GERD was created for R164 that included an intervention to avoid foods or beverages that tend to irritate esophageal lining, i.e. alcohol, chocolate, caffeine, acidic or spicy foods, fried or fatty foods. Encourage resident to avoid alcohol, smoking, coffee (even decaffeinated), fatty foods, chocolate, citrus juices, [NAME], tomato products, garlic and onions. Encourage a bland diet.
6/3/25 - An admission MDS assessment documented that R164 was severely cognitively impaired.
6/25/25 12:15 PM - During a dining observation R164 was observed being fed a lunch meal of tomato sauce over pasta and softened garlic bread and tomato juice by E31 (CNA). E31 reported that the only dietary restrictions for R164 were related to texture.
6/26/25 12:09 PM - During a dining observation R164 was observed being fed a lunch meal of E32 sliced steak with onions and peppers over rice by E32 (CNA). The lunch ticket that accompanied R164's meal lacked documentaion regarding avoidance of dietary intolerance's related the the diagnosis of GERD such as tomato, and onions.
6/26/25 12:17 PM - During an interview E34 (FSD) reported the facility has always available options by request such as sandwiches and salads. E34 confirmed the dietary department was unaware of dietary intolerance's related to R164's diagnosis of GERD.
6/26/25 12:32 PM - E33 (RN) assigned to R164 reviewed the GERD care plan with the surveyor and confirmed the lunch that day did not avoid the residents dietary intolerance's related to GERD.
7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), the exit conference.
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 three (R127, R164 and R319) out of thirty-two (32) residents in the investigative sample, the facility failed to ensure the clinical re...
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Based on record review and interview, it was determined that for three (R127, R164 and R319) out of thirty-two (32) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include:
A review of R127's clinical record revealed:
12/3/24 - R127 was admitted to the facility.
12/30/24 - A physician's order for R127 documented morphine sulfate ER (extended release) 15 mg tablet, give 1 tablet by mouth every 12 hours for pain.
1/3/25 9:00 PM - The medication administration record for R127 documented a blank, unsigned value for the morphine sulfate medication to be administered.
1/4/25 9:00 AM - The medication administration record for R127 documented a blank, unsigned value for the morphine sulfate medication to be administered.
7/2/25 - A review of the controlled drug administration record for R127 for the morphine sulfate medication documented that the medication was administered on 1/3/25 at 9:00 PM and on 1/4/25 at 9:00 AM.
7/2/25 11:02 AM - During an interview with E2 (DON), it was determined that E9 (RN) had forgotten to sign off the administration of the morphine sulfate medication in the electronic medication administration record and R127 did not miss any scheduled doses.
2. A review of R319's clinical record revealed:
11/25/24 - R319 was admitted to the facility.
11/25/24 - A physician's order for R319 documented morphine sulfate ER (extended release) 15 mg tablet, give 1 tablet by mouth every 12 hours for pain.
1/3/25 9:00 PM - The medication administration record for R319 documented a blank, unsigned value for the morphine sulfate medication to be administered.
1/4/25 9:00 AM - The medication administration record for R319 documented a blank, unsigned value for the morphine sulfate medication to be administered.
7/2/25 - A review of the backup pharmacy dispensary log documented that 1 tablet of morphine sulfate 15 mg tab was dispensed on 1/3/25 and 1/4/25.
7/2/25 11:02 AM - During an interview with E2 (DON), it was determined that a new blister pack of morphine sulfate 15 mg had been sent to the facility from the pharmacy for R319. Therefore, E9 (RN) had to use the backup pharmacy medication to give to R319. It was confirmed that R319 did not miss any scheduled doses.
3. Review of R164's clinical record revealed:
5/28/25 - R164 was admitted to the facility with a feeding tube.
5/28/25 - A physicians order was written for R164 to receive liquid nutrition for malnutrition if the resident consumes >50 % of a meal.
6/9/25 - A nutritional assessment completed by E30 (RD) documented that R164 was to receive nutrition through the feeding tube when <50% of a meal was consumed. Less than 50% meal consumption was not consistent with the current physicians order.
6/25/25 2:12 PM - During an interview E20 (RN) unit manager confirmed the findings and stated that R164's nutritional assessment had a less than [<] sign documented in error instead of a greater than sign [>] consistent with R164's physicians orders related to nutrition through the feeding tube based on meal intake. E20 provided a copy of R164's hospital discharge records that also indicated the resident was to receive nutrition through the feeding tube with >50% consumption of a meal.
7/2/25 2:30 PM - Findings were reviewed with E1 (NHA), E2, E3 (ADON) during the exit conference.
Jul 2024
25 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 observations, interviews and record review, it was determined that for one (R36) out of three residents reviewed for dignity, the facility failed to promote dignity by not using a privacy bag...
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Based on observations, interviews and record review, it was determined that for one (R36) out of three residents reviewed for dignity, the facility failed to promote dignity by not using a privacy bag for a urinary collection bag. Findings include:
A review of the facility's policy titled Catheter Care last revised 4/2024, documented . 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use .
Review of R36's clinical record revealed:
1/26/24 - R36 was admitted to the facility.
2/22/24 - A care plan documented that R36 has an indwelling catheter for neurogenic bladder.
4/3/24 - A physician's order for foley catheter to straight bag drainage for urinary retention.
7/9/24 - Observations of R36 lying in bed with the catheter collection bag was visible from the hallway and not in a privacy bag at 10:23 AM, 11:14 AM and 1:56 PM.
7/10/24 11:31 AM - An observation of R36's being pushed back to the room in a wheelchair where the catheter collection bag was not in a privacy bag and hooked onto the wheelchair. An interview with E15 stated she brought R36 back from the large therapy room located off R36's unit and located near the main facility entrance. E15 confirmed that the catheter collection bag did not have a privacy cover and immediately got a privacy bag and covered the catheter collection bag.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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 (R143) out of thirty-three 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 (R143) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure care preferences were being honored. Findings include:
Review of R143's clinical record revealed:
4/4/24 - R143 was admitted to the facility.
4/6/24 - An admission MDS revealed that R143 was not assessed for shower or bathing preferences.
4/10/24 - An admission recreation assessment revealed that for R143 it was very important to choose between a tub bath, shower, bed bath or sponge bath.
7/9/24 - R143 was readmitted from hospital.
7/9/24 12:31 PM - A physician's order revealed shower days were Wednesday and Saturday on the 3 -11 shift with skin check on Saturday and to document refusals every Wednesday and Saturday.
7/10/24 12:58 PM - An interview with R143 revealed that the facility did not give R143 a choice of shower day or time. R143 stated that she prefers showers in the morning.
7/17/24 11:00 AM - An interview with E12 (Activities Assistant Director) revealed that the initial recreation assessment is completed upon admission and is shared with the MDS coordinator and nursing to help establish what's important to the resident.
7/17/24 11:15 AM - An interview with E11 (LPN) revealed that shower schedule is based on room assignment.
7/17/24 11:20 AM - An interview with E10 (LPN UM) confirmed that shower scheduled is based on room assignment for day and time.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to have written policies and procedures regarding the visitat...
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Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments that do not have a legal decision maker. Findings include:
Cross refer F602 and F745.
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.
4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.
5/29/24 - E46 (Psychologist) documented in R146's EMR, Her judgment and insight are impaired. At this time, patient is not capable of making her own healthcare decisions.
5/31/24 - The facility made a referral for capacity determination.
6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that R146 did not have capacity to function independently including: activities of daily living, pay her own bills, live alone, take medicine appropriately, give consent for medical procedures and resist scams.
6/3/24 10:06 AM - F4 (male friend) signed R146 out of the facility in the Leave of Absence log. R146 was signed back into the facility at 11:35 AM.
6/4/24- The facility petitioned the Court of Chancery to initiate R146's guardianship process.
According to the Release of Responsibility for Leave of Absence log, R146 was signed out and left the faciity on a leave of absence with unrelated persons on 5/20/24, 5/25/24, 6/3/24, 6/21/24, 6/28/24 and 7/12/24.
7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (R146's other sister) listed as emergency contact #2.
The facility failed to ensure that R146, a resident with severe cognitive impairment, did not leave the facility without her family's consent.
7/12/24 3:13 PM - During an interview, E1 (NHA) stated, We don't have a policy or procedure for residents that have been deemed not to have capacity and don't have a legal guardian or POA (power of attorney).
7/15/24 12:29 PM - During an interview, E38 (NP) stated, There are no special orders that we place when a patient is deemed not to have capacity .
7/16/24 10:10 AM - During an interview, E5 (SW) stated, To my knowledge, there is no policy or precedent regarding when a resident is deemed not to have capacity. I am not aware of any restrictions regarding leaving the facility. I guess you would call her sister. I am not aware of a guardian ad litem.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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 F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for beneficiary notice, the facility failed to provide notification of service changes to R1...
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Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for beneficiary notice, the facility failed to provide notification of service changes to R146's authorized representative. Findings include:
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.
4/12/24 - R146 given a Notice of Medicare Non-Coverage (NOMNC) that advised that R146's effective date of last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Work) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .
7/9/24 1:54 PM - During a telephone interview, F2 (R146's sister) stated that she was not informed about R146's last day of Medicare coverage and was not offered the opportunity to appeal.
7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (R146's other sister) listed as emergency contact #2.
The facility was unable to provide evidence of any attempt to reach either emergency contact for the purpose of receiving the NOMNC notification.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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 Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include:
7/9/24 10:13 AM - An ...
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Based on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include:
7/9/24 10:13 AM - An observation in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled on wall with a stain. Subsequently the same observation occurred on 7/10/24 and 7/11/24.
7/12/23 1:00 PM - An interview with E13 (Maintenance Director) revealed that the facility has a plan to replace all handrails with new design. E13 stated he will cover the broken handrail for safety concerns for the current time until new rails are installed. E13 also stated that maintenance will clean the base boards and wall of the 400 hallway.
7/15/24 9:51 AM - An observation of a handrail in the 300 hallway of Ocean Gardens unit, revealed a broken handrail with jagged edges not covered. The baseboards in 400 hallway were dirty and dusty, and an area where a dark substance was spilled on wall with a stain.
7/15/24 2:17 PM - An interview with E13 confirmed the handrail should have been fixed over the weekend and it will get taken care of today. Also noted the walls and base boards will be cleaned today.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to protect R146 from misappropriation of resident property/fu...
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Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, the facility failed to protect R146 from misappropriation of resident property/funds. Findings include:
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission Minimum Data Set (MDS) assessment documented R146's BIMS score of three, which reflected severe cognitive impairment.
4/12/24 - A Notice of Medicare Non-Coverage (NOMNC) documented that R146's last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .
5/16/24 - According to a signed and dated statement, F2 (R146's sister) provided the facility with R146's identification, bank statement, other documents and R146's checkbook. F2 had E1 (NHA) and E5 (SW Director) sign the document listing all the documents and belongings that F2 handed over to the facility.
5/17/24 11:05 AM - E43 (Business Office manager) documented a note in R146's EMR that stated R146's checkbook and other documents were secured in the facility safe.
5/19/24 3:43 PM - E45 (RN) documented in R146's EMR that a family member called and requested that R146 should not sign anything without her family present.
5/23/24 - E1 (NHA) and E43 (Business Office manager) obtained R146's checkbook from the facility safe and assisted R146 to write two checks- Check #4483 to the facility in the amount of $6435 for April room/Board and another check as deposit for an assisted living facility that R146 was interested in transferring to.
The facility failed to identify that R146 was not cognitively capable of understanding a financial transaction and failed to safeguard R146's property from inappropriate access.
5/29/24 - E46 (Psychologist) documented in R146's EMR, Her judgment and insight are impaired. At this time, pt is not capable of making her own healthcare decisions.
5/31/24 - E43 received an email from the facility Home Office stating that check #4483 was returned for insufficient funds.
5/31/24 - The facility made a referral for capacity determination.
6/3/24 - E39 (MD) completed a Physician Affidavit for Guardianship which documented that R146 does not have capacity.
7/12/24 9:31 AM - During an interview, E44 (SWS) stated, When I was explaining about the insurance, she did not understand. She did not understand what she was signing so she did not sign. She would nod her head in agreement but she did not understand.
7/12/24 9:55 AM - During an interview, E43 stated, Only the NHA and I have access to the safe. The NHA and I took her checkbook to her to write the checks (to [assisted living facility] and to us). That is when we found out the money was gone because the checks bounced . I told the NHA and Social worker was to report it to APS (Adult Protective Services).
The facility was unable to provide evidence that this allegation of missing resident funds was reported to the State agency.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
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 (R130) out of ten residents reviewed for hospitalization, the facility failed to notify R130's family representative and the Ombuds...
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Based on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify R130's family representative and the Ombudsman of R130's transfers to the hospital on 3/15/24 and 3/24/24. Findings include:
10/26/23 - R130 was admitted to the facility's locked dementia unit with diagnoses, including: dementia with agitation.
1/31/24 - R130's quarterly MDS documented a BIMS score as five, which reflected severe cognitive impairment.
3/15/24 - R130 was transferred to the hospital for three episodes of coffee-ground emesis and was diagnosed with a gastrointestinal bleed. R130 returned to the facility on 3/17/24.
3/25/24 - R130 was transferred to the hospital for a syncopal episode. R130 returned to the facility on 3/27/24.
7/17/24- Review of R130's EMR revealed F1 (R130's son) was listed as Emergency contact # 1 and R130 was listed as responsible party.
7/17/24 - Review of R130's Transfer Notices, dated 3/15/24 and 3/25/24, both revealed R130 listed as the responsible party to whom the notice was presented.
In both instances, the facility failed to notify an appropriate resident representative of R130's transfers to the hospital. R130 had a documented and known severe cognitive impairment.
7/17/24 - Review of the March 2024, Ombudsman Admission/ Discharge Notice revealed that R130's name was not listed on the report at any point throughout the month of March 2024 as a transfer to an acute care hospital. Neither transfer (3/15/24 or 3/25/24) was listed on the Ombudsman notification for March 2024.
The facility failed to provide the Office of the Ombudsman notification of R130's 3/15/24 and 3/25/24 transfers to an acute care hospital.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify the family representative of the bed-hold p...
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Based on record review and interview, it was determined that for one (R130) out of ten residents reviewed for hospitalization, the facility failed to notify the family representative of the bed-hold policy. Findings include:
Review of R130's clinical record revealed:
10/26/23 - R130 was admitted to the facility's locked dementia unit with diagnoses including: dementia with agitation.
1/31/24 - R130's quarterly MDS documented a BIMS score of five, which reflected severe cognitive impairment.
3/15/24 - R130 was transferred to the hospital for three episodes of coffee-ground emesis (vomit) and was diagnosed with a gastrointestinal bleed. R130 returned to the facility on 3/17/24.
3/25/24 - R130 was transferred to the hospital for a syncopal (fainting) episode. R130 returned to the facility on 3/27/24.
7/17/24 - Review of R130's EMR revealed F1 (R130's son) was listed as Emergency contact # 1 and R130 was listed as responsible party.
7/17/24 - Review of R130's Bed-hold Policy Notices, dated 3/15/24 and 3/25/24, both revealed R130 listed as the responsible party to whom the notice was presented.
The facility failed to notify an appropriate resident representative of the facility's bed-hold policy for R130's hospitalizations.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
2. Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive i...
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2. Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.
5/8/24 - E38 (NP) ordered a wander guard check placement every shift.
7/3/24 - R146's quarterly MDS documented that R146 did not have a wander/elopement alarm.
7/12/24 9:32 AM - During an interview, E42 (CNA) confirmed that R146 still had a wander guard alarm on her person.
7/12/24 3:42 PM - During an interview, E19 (RNAC) confirmed that R146's 7/3/24 quarterly MDS was modified yesterday to include that R146 did in fact have a wander guard alarm.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
Based on record review and interview, it was determined that for three (R66 and R146) out of thirty-three residents reviewed in the investigative sample, the facility failed to ensure an accurate assessment. Findings include:
1 Review of R66's clinical record revealed:
5/10/18 - R66 was admitted to the facility.
2/17/24 - Section I of the annual MDS revealed the following: No natural teeth or tooth fragment(s) (edentulous): Yes. Obvious or likely cavity or broken natural teeth was not checked.
7/11/24 11:45 AM - In an interview, E20 (CNA) and E21 (CNA) revealed R66 does not complain of pain with eating and does not wear dentures.
7/11/24 11:50 AM - In an interview, it was revealed that R66 does not have dentures. The surveyor noted that R66 has teeth, but they are in disrepair. R66 stated that although dental exams are offered, R66 declines to attend.
7/12/24 3:35 PM - In an interview, E19 (MDS Coordinator) confirmed that the MDS reflected that resident is edentulous (lack of teeth). Surveyor advised that R66 has broken teeth and R66 confirmed she does not have dentures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
3. Review of R98's clinical record revealed:
12/4/20 - R98 had a level l PASARR completed at the hospital with the indication of no level II needed and no suspected or confirmed PASARR conditions.
2/2...
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3. Review of R98's clinical record revealed:
12/4/20 - R98 had a level l PASARR completed at the hospital with the indication of no level II needed and no suspected or confirmed PASARR conditions.
2/2/21 - R98 was admitted to the facility with diagnoses including cerebral infarction and altered mental status.
4/5/21 - R98 had a level l PASARR completed with the indication of no level II needed and no suspected or confirmed PASARR conditions.
2/2/23 - The electronic medical record documented a new diagnoses of unspecified mild dementia with psychotic disturbance and psychotic disorder with delusions were identified.
6/19/23 - The electronic medical record documented a new diagnoses of unspecified dementia with agitation and violent behavior were identified.
6/20/23 - R98 had psychiatry visits on 6/20/23, 7/5/23, 7/11/23, 1/10/24 and 3/6/24.
7/16/24 9:52 AM - During an interview E5 (SW Director) stated the psych nurse practitioner will screen residents weekly and notify him, the unit manager, or the DON if a resident has any behavioral changes. E5 stated once notified, they will initiate a PASARR review. E5 stated that the facility was without a psych nurse practitioner who had a definitive schedule for a long time and some residents got missed.
7/16/23 12:15 - E5 confirmed a Level II PASARR was not submitted for R98 and one should have been submitted for review.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
Based on interview and record review, it was determined that for three (R14, R37 and R98) out of three residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed. Findings include:
A review of the facility's policy titled Resident Assessment - Coordination with PASARR Program last revised 6/18/24, documented . 9. A resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.
1. Review of R14's clinical record revealed:
5/9/21 - R14 had a level I PASARR completed.
6/7/21 - R14 was admitted to the facility with the following diagnoses: major depressive disorder, adjustment disorder with depressed mood, and delusional disorder.
5/31/23 - R14 was diagnosed with the following diagnoses: unspecified dementia with agitation, violent behavior, and moderate major depressive disorder.
7/16/24 09:52 AM - An interview with E5 (SW Director) confirmed that R14 did not have a level II PASARR completed and one was needed.
2. Review of R37's clinical record revealed:
11/4/18 - R37 was admitted to the facility.
11/5/18 - A level l PASARR was completed and revealed . this patient appears to have: Indicators of mental illness, mental retardation/related conditions, but meets physician's exemption criterion .
12/20/18 - A level 1.5 PASARR was completed and revealed The individual does have a documented serious mental illness (SMI) or a mental illness other than SMI but further review of level of impairment, recent treatment history, or other circumstances demonstrates a full level II is not required .
5/12/23 - Unspecified mood (affective) disorder and unspecified dementia, unspecified severity, without behavioral disturbance psychotic disturbance, mood disturbance and anxiety were added to R37's list of diagnoses.
7/11/24 2:28 PM - In an interview, E1 (NHA) confirmed that given the transition with social workers, there were issues with PASARR's not being completed. E1 stated this situation is being audited and this has been ongoing since May.
7/11/24 - A request for a Level II PASARR was completed by E5 (SW Director).
7/16/24 - A Notice of a PASARR Level I Screen Outcome was received from Maximus confirming that a Level II Onsite PASARR was needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, it was determined that for one (R128) out of seven residents reviewed for ADLs, the facility failed to provide mobility from bed to chair. Findings i...
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Based on observation, interview and record review, it was determined that for one (R128) out of seven residents reviewed for ADLs, the facility failed to provide mobility from bed to chair. Findings include:
Cross refer F842.
Review of R128's clinical record revealed:
8/11/23 - R128 was admitted to the facility with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side.
4/23/24 - A physician order documented that R128 was to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.
5/16/24 - A quarterly MDS revealed that R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. R128 required substantial or maximal assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed and was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition.
7/9/24 - An interview with R128 stated, I stay in bed and they don't get me up.
Observations of R128 laying in bed: 7/10/24 at 10:32 AM, 7/10/24 at 11:14 AM, 7/11/24 at 9:35 AM, 7/11/24 at 10:41 AM, 7/11/24 at 12:11 PM, 7/11/24 at 2:56 PM.
7/12/24 9:33 AM - During an interview R128 stated he did not get out of bed at any time on 7/11/24.
7/12/24 2:29 PM - During an interview, E25 (CNA) confirmed that R128 did not get out of bed on 7/11/24 and that R128 did not refuse. E25 stated, we did not ask if he wanted to get up. He usually tells us that he wants to be up. We did not ask, so he did not refuse.
7/12/24 2:31 PM - During an interview, E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.
There was no facility documentation of any refusals by R128 to get out of bed on 7/11/24.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R146) out of ten resident reviewed for hospitalization, th...
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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 (R146) out of ten resident reviewed for hospitalization, the facility failed to ensure that R146's warfarin dosing was managed in accordance with the professional standards of practice. Findings include:
The acceptable time frame to achieve anticoagulation with warfarin typically ranges from 5 to 7 days. However, it's important to note that the full therapeutic effect may take up to a week due to the long half-life of prothrombin (factor II), which is essential for converting fibrinogen to fibrin12. Warfarin inhibits the production of vitamin K-related factors, and its antithrombotic effect gradually becomes evident as prothrombin levels decrease. During this period, concurrent use of more rapidly acting anticoagulants, such as low-molecular-weight heparin (LMWH) or unfractionated heparin, is recommended. National Library of Medicine, Turkish Journal of Hematology 2016
Warfarin Dosing Guideline- .V. Warfarin dosing nonogram (in medicine, a pictorial representation of a complex mathematical formula) for Maintenance therapy (>1 week of warfarin therapy) of non-bleeding patient
Goal INR 2-3 Dosing Adjustments
INR <1.5 - Consider a one-time dose increase of 1.5-2 times daily maintenance dose
-If adjustment to maintenance dose is needed, increase dose by 10-20%
-Repeat INR in 1 week
INR 1.5-1.7 -Consider a one-time dose increase of 1.5 times daily maintenance dose
-If adjustment to maintenance dose needed, increase by 5-15%
- Repeat INR in 2 weeks
INR 1.8-1.9 -No dosage adjustment may be necessary if the last two INRs were in
Range
-Repeat INR within 8 weeks
-Consider a one-time dose increase of 1.5 times daily maintenance dose
-If adjustment to maintenance dose needed, increase dose by 5-10%
-Repeat INR in 2 weeks
(University of New Mexico Health System June 2020)
Review of R109's clinical record revealed:
6/14/24 - R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs.
Due to the risk of blood clots, R109 was medically managed with warfarin for anti-coagulation therapy with the goal INR range of 2.0 to 3.0. (University of New Mexico Health System June 2020)
6/14/24 Friday - E39 (MD) documented in R109's EMR, Warfarin tablet 2 mg (milligram) - give 1 tablet by mouth in the evening every Sat, Sun and Warfarin tablet 2 mg- [NAME] 1.5 tablet (3 mg) by mouth in the evening every Mon, Tues, Wed, Thu, Fri. Total weekly warfarin dosage was 19 mg.
6/15/24 Saturday 11:12 AM - R109's INR was reported as 1.5, which was not at R109's therapeutic goal of 2.0 to 3.0.
The facility lacked evidence of any intervention for this below goal INR level.
6/18/24 Tuesday 12:06 PM - R109's INR was reported as 1.2, which was not R109's therapeutic goal of 2.0 to 3.0.
6/19/24 - E38 (NP) documented in R109's EMR, Warfarin tablet 2 mg- give 1.5 tablets (3 mg) by mouth in the evening every Mon, Tue, Wed, Thu, Fri, Sat, Sun. Total weekly warfarin dosage was 21 mg.
This reflected an increase of 2 mg or 10 % of the total weekly warfarin dosage.
6/21/24 Friday 11:45 AM - R109's INR was reported as 1.3, which was below R109's therapeutic goal of 2.0 to 3.0.
This was day 7 of anti-coagulation therapy in the facility and R109 did not reach the desired goal of INR 2.0 to 3.0.
6/21/24 - E38 (NP) documented in R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Tue, Wed, Thu, Sat. Total weekly warfarin dosage was 24 mg.
This reflected an increase of 3 mg or 14.3 % of the total weekly warfarin dosage.
6/25/24 Tuesday 12:23 PM - R109's INR was reported as 1.7, which was still below R109's desired goal of 2.0 to 3.0.
6/25/24 - E38 (NP) documented in R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Tue, Wed, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Thu, Sat. Total weekly warfarin dosage was 26 mg.
This reflected an increase of 2 mg or 7.7 % of the total weekly warfarin dosage.
6/26/24 - R109 was hospitalized for shortness of breath. During this hospitalization, R109 was treated with lovenox, an heparin injection, to help reach the desired anti-coagulation goal as R109's INR was not at goal upon admission to the hospital.
6/30/24 - R109 was re-admitted to the facility.
6/30/24 - E38 (NP) documented in R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening every Mon, Tue, Wed, Fri, Sun and give 1.5 tablets (3 mg) by mouth at bedtime every Thu, Sat. Total weekly warfarin dosage was 26 mg.
7/2/24 Tuesday 12:10 PM - R109's INR was reported as 1.2, which was not at R109's desired goal of 2.0 to 3.0.
7/3/24 Wednesday - E38 (NP) ordered in R109's EMR, Warfarin tablet 2 mg- give 2 tablets (4 mg) by mouth in the evening. Total weekly warfarin dosage was 28 mg. E45 (NP) also ordered, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime every Wed, Thu for 2 days for a total dose of 5 mg. With the additional 2mg of warfarin, the total weekly dosage was 30 mg.
This one-time dose increase did not meet the professional standard guidelines of a one-time dose increase of 1.5-2 times daily maintenance dose.
This reflected an increase of 4 mg or 15.4 % of the total weekly warfarin dosage.
7/9/24 12:08 PM - R109's INR was reported as 1.4, which was below R109's therapeutic goal of 2.0 to 3.0.
7/9/24 - E38 (NP) ordered in R109's EMR, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime every Tue, Wed, Thu. Give in addition to 2 mg tabs (total dose= 5 mg). Total weekly warfarin dosage was 31 mg.
This reflected an increase of 3 mg or 10.7 % of the total weekly warfarin dosage.
This was day 9 of anti-coagulation therapy in the facility after R109's re-admission to the hospital and R109's INR remained below therapeutic goal of 2.0 to 3.0.
7/12/24 12:33 PM - R109's INR was reported as 1.2, which did not meet R109's therapeutic goal of 2.0 to 3.0.
7/12/24 - E38 (NP) ordered in R109's EMR, Warfarin tablet 1 mg- give 1 tablet (1 mg) by mouth at bedtime. Give in addition to 2 mg tabs (total dose = 5 mg) and Warfarin tablet 2 mg- give 2 tablets by mouth at bedtime. Give in addition to 1 mg tab. Total dose =5mg). Total weekly warfarin dosage was 35 mg.
This reflected an increase of 4 mg or 12.9 % of the total weekly warfarin dosage.
7/15/24 12:34 PM - During an interview, E38 (NP) stated that he looked up the hospital records from the 6/26/24 admission and reviewed the Hematology consult note. I decided not to bridge with lovenox. There was conflicting documentation in the discharge summary regarding whether to bridge or not. I am following the INR and am increasing the dosage with each INR result.
7/16/24 - R109's INR was reported as 1.5, which was below R109's desired goal of 2.0 to 3.0.
This was day 16 of anti-coagulation therapy in the facility after R109's re-admission to the hospital and R109's INR did not reach the therapeutic goal of 2.0 to 3.0.
7/16/24 - E38 (NP) ordered in R109's EMR, Warfarin tablet 2 mg- give 3 tablets (6 mg) by mouth at bedtime. Total weekly warfarin dosage was 42 mg. E45 (NP) also ordered, Warfarin tablet 2 mg- give 4 tablet (8 mg) by mouth at bedtime for 1 day. With the additional of the one-time 8mg dosage, the weekly warfarin dosage was 50 mg.
This reflected an increase of 15 mg or 42.8 % of the total weekly warfarin dosage.
7/18/24 12:14 PM - During a telephone interview, E39 (MD) confirmed that R109's INR goal for anti-coagulation therapy was 2-3. With regard to the timeframe that it was taken to achieve this goal, E39 stated, It has taken too long.
Of note, at the time of the survey team exit, the facility was still unable to provide evidence that R109 was therapeutically anti-coagulated with warfarin.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that for two (R123 and R143) out of three residents reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined that for two (R123 and R143) out of three residents reviewed for bowel and bladder, the facility failed to respond to or provide services to restore bladder continence. Findings include:
1. Review of R123's clinical record revealed:
2/15/24 - R123 was admitted to the facility.
2/20/24 - A bowel and bladder initial assessment revealed that R123 was continent of bowel and bladder.
2/21/24 - An admission MDS assessments revealed that R123 was always continent of bowel and bladder and not indicated for a toileting program.
April 2024 - A review of the April CNA task flow sheet revealed that R123 was incontinent of bladder sixty-five times out of ninety opportunities.
5/21/24 - A quarterly MDS assessment revealed that R123 was frequently incontinent of bladder and always incontinent of bowel and not indicated for a toileting program.
May 2024 - A review of the May CNA task flow sheet revealed that R123 was incontinent of bladder seventy-two times out of ninety opportunities.
June 2024 - A review of the June CNA task flow sheet revealed that R123 was incontinent of bladder eighty-[NAME] times out of ninety opportunities.
July 2024 - A review of the July CNA task flow sheet revealed that R123 was incontinent of bladder twenty-nine times out of thirty-three opportunities.
7/15/24 12:53 PM - An interview with E40 (CNA) confirmed that R123 is usually incontinent and unable to recall if R123 was on a toileting program. E40 stated that R123 was on a different unit previously and was using a urinal. E40 stated she does not offer a urinal or commode to R123.
7/15/24 1:45 PM - An interview with E41 (COTA) confirmed that therapy assessed R123 for use of urinal and bedside commode. E41 confirmed that R123 is able to utilize both adaptive equipment safely.
7/16/24 12:19 PM - An interview with E14 (RN Staff Educator) revealed that the voiding diary gives them an idea of target times to assist the resident with incontinence. Nursing is able to initiate adaptive equipment such as a urinal but therapy has to initiate a commode. E14 confirmed that R123 is not currently using a urinal or commode.
The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R123.
7/16/24 1:20 PM - An interview with E3 (QA), E7 (ADON), and E2 (DON) revealed that R123 was offered a urinal trial starting on 7/15/24.
2. Review of R143's clinical record revealed:
4/4/24 - R143 was admitted to the facility.
4/6/24 - An admission MDS revealed that R143 is occasionally incontinent of bowel and bladder and is not indicated for a toileting program.
April 2024 - A review of the April CNA task flow sheet revealed that R143 was incontinent of bladder fifty-nine out of one hundred and one opportunities.
May 2024 - A review of the May CNA task flow sheet revealed that R143 was incontinent of bladder eighty-three out of one hundred and twenty-six opportunities.
June 2024 - A review of the June CNA task flow sheet revealed that R143 was incontinent of bladder fifty-five out of ninety opportunities.
July 2024 - A review of the July CNA task flow sheet revealed that R143 was incontinent of bladder twenty-eight out of thirty-eight opportunities.
7/5/24 - A voiding diary was completed for R143 from 7/3/24 to 7/5/24. The facility lacked evidence of implementing a plan to restore continence for R143.
7/17/24 10:25 AM - An interview with E20 (CNA) revealed that [R143] is independent and will notify staff if she is incontinent. [R143] is able to clean herself up and I (E20) dont normally have to assist her.
The facility lacked evidence of responding to decreased continence and failed to provide evidence of services to restore continence for R143.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) 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, record review and interview, it was determined that for two (R47 and R121) out of two residents reviewed for respiratory care, the facility failed to provide respiratory care con...
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Based on observation, record review and interview, it was determined that for two (R47 and R121) out of two residents reviewed for respiratory care, the facility failed to provide respiratory care consistent with professional standards of practice. Findings include:
1. Review of R47's clinical record revealed:
5/27/16 - R47 was admitted to the facility with diagnoses including traumatic brain injury and tracheostomy status.
7/7/22 - A physician's order was written for R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *.
5/22/24 - An annual MDS revealed that R47 required tracheostomy care.
7/15/24 9:15 AM - A review of the R47's physician's orders lacked evidence of current tracheostomy size and brand of use.
7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that all tracheostomy orders would be located in the EMR under orders. E27 confirmed R47's size and type of trach was not indiciated in EMR. E27 stated R46 is a size 6 based on the emergency equipment.
7/15/24 10:40 AM - A physician's order for R47 revealed that tracheostomy size #4 shiley was the current tracheostomy size and brand.
7/15/24 2:50 PM - An interview with E32 (RN) stated she was unsure of R47's trach size prior to today.
7/16/24 9:58 AM - An observation of a size #6 and size #4 replacement tracheostomy to be hanging at bed side with emergency equipment.
7/17/24 9:30 AM - An interview with E28 (NP) confirmed R47 should be a shiley #4 trach and that the facility does not have the proper equipment at this time to accommodate a smaller size as the emergency order states.
2. Review of R121's clinical record revealed:
10/27/23 - R121 was admitted to the facility with a diagnosis of acute respiratory failure with hypoxia (deficiency in amount of oxygen reaching body tissues).
11/10/23 - A physicians' order documented continuous oxygen at 2 liters/minute via nasal cannula (tube placed into nostrils to deliver oxygen). Change, date and initial tubing weekly and change humidifier bottle weekly and PRN, every night shift on Saturday.
7/9/24 11:10 AM - During an observation, the oxygen tubing was not labeled with date and initials, this was confirmed with E30 (LPN).
CONCERN
(D)
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, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to ensure that the Physician's orders included trach ...
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Based on interview and record review, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to ensure that the Physician's orders included trach size, type, and accurate emergency orders. Findings include:
Review of R47's clincal record revealed:
5/27/16 - R43 was admitted to the facility.
7/7/22 - A physician's order was written for R47 Emergency Trach Supply list - Items are to be kept in a bag together at bedside/head of bed at all times 1. The same size trach 2. next size smaller trach 3. Ambu bag and mask 3. Sterile lubricant (2 packets) 4. Suction Machine with tubing 5. Suction Catheter 6. Oxygen tank/full 7. sterile gloves 8. Trach Ties *check for expiration dates and replace prn *.
7/15/24 9:15 AM - A review of the R47's physician's orders lacked evidence of current tracheostomy size and brand of use.
7/15/24 10:29 AM - An interview with E27 (LPN UM) revealed that all tracheostomy orders would be located in EMR under orders. E27 confirmed R47's size and type of trach was not indiciated in EMR.
7/15/24 10:40 AM - A physician's order for R47 revealed that tracheostomy size #4 shiley is current tracheostomy size and brand.
7/17/24 11:50 AM - An interview with E28 (NP) confirmed that the emergency order instructions were not accurate for R47's plan of care.
The facility failed to have a current order for R47's tracheostomy that included type and size and failed to have accurate emergency order's,
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on interview and review of the clinical record, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to have nursing staff with the approp...
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Based on interview and review of the clinical record, it was determined that for one (R47) out of two residents reviewed for respiratory care, the facility failed to have nursing staff with the appropriate competencies and skill sets to provide nursing and related services to a resident with a tracheostomy. Findings include:
Review of R47's clinical record revealed:
5/27/16 - R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status.
5/22/24 - An annual MDS revealed that R47 required tracheostomy care.
7/15/24 02:58 PM - An interview with E32 (RN) stated she was unsure of R47's trach size prior to today.
7/17/24 10:30 AM - An interview with E36 (Agency LPN) revealed in an emergency you would insert the smaller size trach if it comes out.
7/17/24 10:45 AM - An interview with E37 (Agency LPN) revealed that E37 was unable to articulate what to do in an emergency with a tracheostomy resident. E37 stated I would call the supervisor for help.
7/17/24 12:30 PM - A review of tracheostomy care competency checklists provided by E14 (Staff Educator RN) revealed that the facility lacked evidence of verifying compentcies with all agency nurses and lacked evidence of all staff being verified for emergency tracheostomy procedures.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, it was determined that the facility failed to provide medically related social se...
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Based on record review and interview, it was determined that for one (R146) out of three residents reviewed for abuse, it was determined that the facility failed to provide medically related social services to R146, who was cognitively impaired and did not have a legal decision maker. Findings include:
Cross refer F582 and F602.
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.
4/1/24 3:09 PM - R146 signed the facility's admission Agreement, which included an authorization form to release financial data. The clauses that identified R146's legal representative and responsible party were left blank in this signed document.
The facility's admission Agreement included information regarding resident's rights, payment obligations, grievance process, advanced directive and other services provided by the facility.
4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.Her sister [F2] was invited to the meeting (care plan meeting) .SW (social work) was unable to get in contact with her sister .The plan is to have [R146] move in with one of her sisters .[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .
4/5/24 - R146's admission Minimum Data Set (MDS) assessment documented a BIMS score of three, which reflected severe cognitive impairment.
4/9/24 9AM - E6 (SW) documented in R146's EMR Update delivered to family and CM (case management) in phone call.
The facility failed to identify that R146 with a BIMS of 3, did not have the cognitive ability to be her own responsible party and was unable to provide evidence of any intervention on behalf of R146 to address the need for a responsible party with R146's two known sisters.
4/12/24 - R146 was given a Notice of Medicare Non-Coverage (NOMNC) that advised that R146's effective date of last day of Medicare coverage was 4/17/24. The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .
4/15/24 10:58 AM - E5 (SW director) documented in R146's EMR, .[R146] received a NOMNC letter with a last cover date of 4/17/24. [R146]'s original discharge plan was to return home alone or to live with one of her sisters. [R146] does not feel like she can live on her own. It was reported to the social services department that she can no longer live with her sister .SW (social work) will work with [R146] and her family to assist with getting her transferred to another facility.
4/17/24 - R146 was cut from Medicare insurance coverage and deemed private pay at the rate of $495 per day, as stated in the admission Agreement, for her stay at the facility.
4/18/24 4:04 PM - E5 (SW Director) documented in R146's EMR, .[R146] was scheduled for discharge today to her sister, [F3]. SW spoke with both of [R146]'s sisters. [F3], she states that her daughter called this morning and left a message on the admission director's voicemail stating that the resident cannot come and live with her. [F3] also wants to be removed from the electronic medical record as a point of contact for [R146]. SW spoke with the resident's other sister, [F2]. She states that she did not know that the resident could not go home with her other sister. [F3] said that she is home with COVID. F3 will revisit the resident coming home to live with her once she is systematic (sic). SW updated the IDT (interdisciplinary team) that [R146] will not be discharged today.
The facility continued to fail to identify a responsible party for R146 and failed to initiate a referral to the medical staff for a capacity determination.
5/19/24 3:43 PM - E45 (RN) documented in R146's EMR that a family member called and requested that R146 should not sign anything without her family present.
According to the Release of Responsibility for Leave of Absence log, R146 was signed out and left the faciity on a leave of absence with unrelated persons on 5/20/24, 5/25/24, 6/3/24, 6/21/24, 6/28/24 and 7/12/24.
The facility failed to verify that the persons had authorization to take R146 out of the building.
5/14/24 1:52 PM - E5 documented in R146's EMR,[R146]'s sister called and stated that she wanted referred (sic) to [assisted living] facility program. SW spoke with [R146] and she agreed with a referral to be sent to [assisted living facility]. SW completed the referral and now awaiting a response from [assisted living facility] to see if they will accept [R146].
5/24/24 9:48 AM- E5 (SW) documented in R146's EMR, [R146] visited [assisted living facility] on Monday with her sister. [R146] had been referred to [assisted living facility] for possible placement. [R146] had been accepted by [assisted living facility]. [R146] provided a deposit for [assisted living facility]. There are other documents that need to be filled out by her sister and the n here. There is no set discharge date for [R146] at this time. IDT team has been made aware.
5/28/24 1:15 PM - E44 (SW) documented in R146's EMR, SW added new contact in PCC (Point Click Care) w/permission of [R146]. Her male friend [F4] xxx-xxx-xxxx.
5/29/24 - E46 (Psychologist) documented in R146's EMR, Her judgment and insight are impaired. At this time, pt is not capable of making her own healthcare decisions.
5/31/24 - The facility made a referral for capacity determination.
This capacity referral was made fifty-six (56) days after the initial BIMS assessment that documented R146 having a severe cognitive impairment.
6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that R146 did not have capacity to function independently including: activities of daily living, pay her own bills, live alone, take medicine appropriately, give consent for medical procedures and resist scams.
6/3/24 10:06 AM - F4 (male friend) signs R146 out of the facility in the Leave of Absence log. R146 was signed back into the facility at 11:35 AM.
6/4/24- The facility petitioned the Court of Chancery to initiate R146's guardianship process.
This petition was initiated one (1) day after R146 was deemed not to have capacity and sixty (60) days after R146 was documented to have a severe cognitive impairment and lacked family/community support.
7/9/24 1:54 PM - During a telephone interview, F2 (R146's sister) stated that she was not informed about R146's last day of Medicare coverage nor was she offered the opportunity to appeal. F2 also confirmed that she was not asked about allowing R146 to go out the facility with unrelated persons.
7/9/24 - The Court of Chancery filed paperwork that appointed C3 (Esquire) as attorney ad litem of R146, a person with an alleged disability and stated the hearing for guardianship would be on August 15, 2024.
7/10/24 10:24 AM - E5 (SW) documented in R146's EMR, [R146]'s care plan meeting was rescheduled until July 23rd at her request. IDT team was made aware of her meeting being rescheduled.
7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (R146's other sister) listed as emergency contact #2.
Ninety-six (96) days after R146 was documented as having severe cognitive impairment and thirty-seven (37) days after R146 was deemed not to have capacity, R146's face sheet continued to document that R146 was her own responsible party.
7/12/24 9:31 AM - During an interview, E44 (SWS) stated, When I was explaining about the insurance, she did not understand. She did not understand what she was signing so she did not sign. She would nod her head in agreement, but she did not understand.
7/12/24 10:54 AM - During an interview, F5 (CSA, female friend), I don't have a contract with [R146]. I just really like her and am keeping touch because I like her. I have taken [R146] to Dairy Queen, my grandson's birthday party, out for lunch. She has met my daughter. I have never taken her to the bank. She does not have any money. I heard [F4] and [F3] were trying to get POA (power of attorney).
7/12/24 11:03 AM - During an interview, E1 (NHA) stated, We were trying to get a Medicaid application together. When we got the bounced check, that was when we became aware that there was a problem. That was in May sometime. No, I did not report it to APS.
7/12/24 1:07 PM - When shown a copy of the facility Release of Responsibility for Leave of Absence log, F5 (CSA, female friend) stated, Yes, that is my chicken scratch (pointing to the dates of 5/20, 5/25, 6/21, 6/28, & 7/12 on the release log). F5 then stated that the signature on 6/3 was F4 (male friend). I remember seeing them here on 6/3; it's my birthday.
7/12/24 3:13 PM - During an interview, E1 (NHA) stated, We don't have a policy or procedure for residents that have been deemed not to have capacity and don't have a legal guardian or POA (power of attorney).
7/15/24 10:15 AM - During a telephone interview, F2 (R146's sister) reported that R146's roommate F7 alleged that F4 came to the facility and had R146 call the bank to have another debit card mailed to R146's apartment and F4 was the person who picked up R146's mail.
7/15/24 11 AM - The surveyor informed the facility of the allegation against F4 who was listed on R146's face sheet as friend.
7/15/24 12:29 PM - During an interview, E38 (NP) stated, There are no special orders that we place when a patient is deemed not to have capacity. We were not aware that [R146] had been financially exploited.
7/15/24 5:30 PM- After inquiry by the surveyor, E2 (DON) filed a complaint with the [local] police regarding R146's returned check #4483 from 5/23/24 for insufficient funds.
7/16/24 10:10 AM - During an interview, E5 (SW) stated, To my knowledge, there is no policy or precedent regarding when a resident is deemed not to have capacity. I am not aware of any restrictions regarding leaving the facility. I guess you would call her sister. I am not aware of a guardian ad litem.
7/16/24 11:42 AM - During an interview, E1 (NHA) stated, The facility petitioned for guardianship on 6/4/24. The referral for capacity was made on 5/31/24. [R14]'s need for a capacity determination was discussed and decided at morning meeting so there are no notes from an IDT meeting about it. If [R146} wants to leave the facility with friends, we allow her to go.
7/18/24 - F4 (male friend) remained listed on R146's face sheet as a friend.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(D)
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 (R128) out of thirty-three (33) residents in the investigative sample, the facility failed to ensure the clinical record contained ...
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Based on record review and interview, it was determined that for one (R128) out of thirty-three (33) residents in the investigative sample, the facility failed to ensure the clinical record contained accurate documentation. Findings include:
Cross refer F676.
Review of R128's clinical record revealed:
8/11/23 - R128 was admitted to the facility.
4/23/24 - R128's physicians orders documented R128 to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.
5/16/24 - A quarterly MDS revealed that R128 was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition.
7/10/24 at 10:32 AM - 7/11/24 at 2:56 PM - Multiple observations of R128 laying in bed.
7/12/24 9:33 AM - During an interview R128 stated he did not get out of bed at any time on 7/11/24.
A review of the treatment administration record (TAR) revealed a checkmark with E8 (LPN)'s initials for the treatment order that states, Resident to be out of bed for a minimum of 2 hours every day - Nursing to document and notify Sister . of refusals every day shift.
7/12/24 2:29 PM - During an interview, E25 (CNA) confirmed that R128 was not out of bed on 7/11/24 and they did not offer to get R128 out of bed.
7/12/24 2:31 PM - During an interview E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.
7/17/24 9:19 AM - During an interview E8 confirmed that the checkmark on the treatment administration record for 7/11/24 means that the task was completed and R128 got out of bed.
There was a lack of facility documentation of any refusals by R128 to get out of bed on 7/11/24.
The facility documented that R128 was out of bed when he was never out of bed on 7/11/24.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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 Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff. Findings include:
7/9/24 12:17 PM - Several pipes in the ceiling a...
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Based on observation and interview, it was determined that the facility failed to maintain a safe and sanitary environment for staff. Findings include:
7/9/24 12:17 PM - Several pipes in the ceiling area of the clean laundry room were dripping onto the floor and into a trash can that had been placed under a portion of the leaking area. All of the leaking pipes had numerous areas of black staining, which appeared fuzzy in some sections. Three wet and stained towels were on the floor under the areas of the leaks.
7/9/24 1:46 PM - During an interview, E50 (Laundry Staff) confirmed the dripping and standing water and stated that the water had been dripping from the pipes and pooling on the floor for several months.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
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
3. Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive ...
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3. Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility.
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.
7/15/24 9:45 AM - A review of R146's care plans revealed the facility lacked evidence of a cognitive impairment care plan with interventions.
7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to R146's cognitive impairment.
4. Review of R109's clinical record revealed:
6/14/24 - R109 was admitted to the facility with diagnoses, including but not limited to, atrial fibrillation (Afib), deep vein thrombosis (DVT) and factor V Leiden heterozygous mutation, an inherited disorder that causes abnormal blood clots in legs or lungs.
7/11/24 10:45 AM - A review of R109's care plan revealed no evidence of a care plan or interventions regarding R109's need for anti-coagulation therapy due to the diagnoses of Afib and DVT.
7/15/24 1:35 PM - During an interview, E3 (QA/IP) confirmed the lack of care plan interventions with regard to R109's need for anti-coagulation therapy.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN), and E7 (ADON) at the exit conference.
Based on interview and record review, it was determined that for four (R123, R143, R146 and R109) out of thirty-three residents in the investigative sample the facility failed to develop and implement a comprehensive resident centered care plan for an identified care area. Findings include:
1. Review of R123's clinical record revealed:
2/15/24 - R123 was admitted to the facility.
2/21/24 - An admission MDS assessment revealed that R123 was always continent of bowel and bladder. The MDS revealed that R123 was not indicated for a toileting program at this time.
5/21/24 - A quarterly MDS assessment revealed that R123 was frequently incontinent of bowel and bladder. The MDS revealed that R123 was not indicated for a toileting program at this time.
7/11/24 9:31 AM - A review of R123's care plan revealed the facility lacked evidence of an incontinence care plan.
7/15/24 10:29 AM - An interview with E27 (LPN UM) confirmed that R123 did not have a care plan for incontinence.
2. Review of 143's clinical record revealed:
4/4/24 - R143 was admitted to the facility.
4/6/24 - An admission MDS assessment revealed that R143 was occasionally incontinent of bowel and bladder. The MDS revealed that R143 was not indicated for a toileting program at this time.
7/11/24 9:42 AM - A review of R143's care plan revealed the facility lacked evidence of an incontinence care plan.
7/15/24 10:29 AM - An interview with E27 (LPN UM) confirmed that R143 did not have a care plan for incontinence.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
5. Review of R47's clinical record revealed:
5/27/16 - R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status.
5/29/16 - A rev...
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5. Review of R47's clinical record revealed:
5/27/16 - R47 was admitted to the facility with the following but not limited to diagnoses traumatic brain injury and tracheostomy status.
5/29/16 - A review of a careplan for R47's impaired breathing mechanic's last updated 7/25/23 revealed that if R47's tracheostomy dislodges to complete the following interventions: 1. notify supervisor 2. call physician and 911 3. Assess respiratory status, if oxygen saturation is below ninety- two percent apply oxygen by ambu bag or by holding oxygen to the stoma site 4. liscense nurse may reattempt to resinsert trach as per policy.
6/1/16 - An admission MDS revealed that R47 required the following respiratory treatments oxygen, suctioning, and tracheostomy care.
5/22/24 - An annual MDS revealed that R47 required tracheostomy care.
7/15/24 10:29 AM- An interview with E27 (LPN UM) confirmed the care plan did not reflect the current needs related to R47's tracheostomy. The care plan did not reflect R47's current tracheostomy size or current emergency needs if tracheostomy dislodges.
6. Review of R68's clinical record revealed:
11/19/21 - R68 was admitted to the facility.
8/16/23 - A care plan revealed that R68 is resistive and non-compliant with treatment and care related to dementia. The interventions included allow flexibility in ADL routine and if resists care to reapproach.
7/18/24 9:50 AM - An interview with E31 (RN UM) revealed R68 only refuses showers and the following interventions are used: to call daughter, change times, change staff, and change approach. E31 confirmed the current interventions are not reflected on the careplan.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
Based on record review and interview, it was determined that for six (R25, R37, R47, R66, R68, and R75) out of thirty-three sampled residents for care plan investigations, the facility failed to ensure
that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and for R66's care plan inaccurately includes dentures. Findings include:
A facility policy entitled Comprehensive Care Plans (revised 4/24) states, The comprehensive care plan will be prepared by the interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. B. A registered nurse with responsible for the resident. c. A nurse aide with responsibility for the resident. d. a member of the food and nutrition staff . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
1. Review of R25's clinical record revealed:
9/21/23 - R25 was admitted to the facility.
9/25/23 - A baseline care plan was e-signed.
7/12/24 - E1 (NHA) provided a copy of a quarterly care plan meeting for 4/23/24 that lacked evidence of input from the Physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, and a food/nutrition services staff. Additionally, the facility lacked evidence that R25 had a quarterly care plan meeting in December, 2023.
2. Review of 37's clinical record revealed:
11/4/18 - R37 was admitted to the facility.
7/12/24 approximately 11:00 AM - E1 (NHA) provided a copy of a Comprehensive Resident Centered Care Plan Conference sheet for a quarterly meeting, which was undated. The facility lacked evidence that the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident and a member of food and nutrition services staff provided input. The surveyor also requested documentation for the three previous care plan meetings including the two quarterly meetings and the annual meeting, but the facility was not able to produce evidence that these meetings occurred.
3. Review of R66's clinical record revealed:
5/10/18 - R66 was admitted to the facility.
7/16/24 untimed - E1 (NHA) provided the surveyor with a Comprehensive Resident Centered Care Plan Conference Sheet for R66's annual care plan meeting on 8/28/23, which lacked evidence of input from the Physician, a nurse aide with responsibility for the resident, and a food/nutrition services staff. The facility lacked evidence that a quarterly care plan meeting was held in November, 2023, February, 2024 or May, 2024. Additionally, R66's care plan inaccurately reflected that R66 has an upper and lower dentures.
7/17/24 2:02 PM - In an interview, E14 (staff educator/acting UM) confirmed that R66's care plan inaccurately reflects that this resident had upper and lower dentures. E14 confirmed that resident has broken teeth but does not use dentures.
4. Review of R75's clinical record revealed:
10/9/18 - R75 was admitted to the facility.
7/15/24 approximately 9:45 AM - E1 (NHA) provided the surveyor with a Comprehensive Resident Centered Care Plan Conference Sheet for an annual care plan meeting on 10/26/23 that lacked evidence of from the Physician, a nurse aide with responsibility for the resident, and a food/nutrition services staff. The quarterly care plan meeting sheet also lacked evidence of input from these three IDT members. Additionally, the facility lacked evidence that R75 had a care plan meeting in August, 2023 or January, 2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
2. Review of R109's clinical record revealed:
6/14/24 - R109 was admitted to the facility.
6/14/24 - E17 (LPN) completed the following admission assessments: Resident Basics/Medical History, Elopement...
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2. Review of R109's clinical record revealed:
6/14/24 - R109 was admitted to the facility.
6/14/24 - E17 (LPN) completed the following admission assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail assessment, Oral/Nutrition assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.
3. Review of R144's clinical record revealed:
3/21/24 - R144 was admitted to the facility.
3/25/24 - Baseline care plan was generated by E9 (LPN).
4. Review of R148's clinical record revealed:
3/21/24 - R148 was admitted to the facility.
3/21/24 - E23 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition Assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.
3/25/24 - The baseline care plan was generated by E9 (LPN).
6/17/24 - R148 was re-admitted to the facility.
6/17/24 - E18 (LPN) completed the follwoing assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition Asessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.
5. Review of R157's clinical record revealed:
6/19/24 - R157 was admitted to the facility.
6/19/24 - E22 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition Assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.
6/20/24 - The baseline care plan was generated by E9 (LPN).
6. Review of R461's clinical record revealed:
6/19/24 - E24 (LPN) completed the following assessments: Resident Basics/Medical History, Elopement Risk Assessment, Pain Assessment, Fall Assessment, Skin Integrity/ Braden Scale, Mobility/Lift/Side Rail Assessment, Oral/Nutrition assessment, Respiratory/Smoking Evaluation, Bowel & Bladder Assessment and IV/Other.
7/17/24 9:19 AM - During an interview, E8 (LPN) stated that she has done admit/readmit screener on the electronic medical record (EMR) for newly admitted residents. The admit/readmit screener was defined as vitals, a skin check and a whole list of questions that we have to ask regarding things like fall and dentures and so on. When asked about the baseline care plan, E8 stated that the unit manager does the care plan.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (corporate RN) and E 7 (ADON) at the exit conference.
Based on record review and interview, it was determined that for six (R25, R37, R47, R66, R68, and R75) out of thirty-three residents in the investigative sample the facility failed to ensure that the required interdisciplinary team (IDT) memebers participated in the care plan meetings and additionally, R66's care plan inaccurately included dentures. Findings include:
State of Delaware Board of Nursing- RN (registered nurse), LPN (licensed practical nurse) and NA (nurses aide)/UAP (unlicensed assistive personnel) Duties 2024 .admission Assessments - RN, admission History Review -RN .Plan of Care: Initial- RN . Updated 4/10/24
1. Review of R160's clinical record revealed:
3/30/24 - R160 was admitted to the facility.
3/30/24 - E8 (LPN) completed the Prestige Admit/Readmit Screener.
4/3/24 - R160's baseline care plan was e-signed by E9 (LPN).
An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission assessment and baseline care plan for R160.
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 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 in...
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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:
7/9/24 11:05 AM - Observation of nourishment refrigerator located at the nurse's station number two (2) revealed a carton of Nutritional Shake that was undated. The instructions on the carton indicate that once opened, any remaining product should be discarded after four (4) days.
7/9/24 11:06 AM - The food storage shelves in the walk-in refrigerator were covered in numerous areas of rust, the floor of the walk-in was wet, and there was some small areas of ice build up in the walk-in freezer.
7/9/24 11:27 AM - During a tour of the kitchen, the surveyor observed E48 (Dining Services Director) and E49 (Assistant Dining Services Director) test the sanitizer level of the solution in two red sanitizing buckets. When E49 tested the sanitizing solution in the bucket from the prep area, the test strip from that bucket indicated that the level of chemical concentration was not at a sufficient level to provide proper sanitization.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
2. Review of R461's clinical record revealed:
6/13/24 12:18 PM - E33 (MD) documented the successful placement of right upper extremity PICC (peripherally inserted central catheter) line.
6/13/24 - R...
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2. Review of R461's clinical record revealed:
6/13/24 12:18 PM - E33 (MD) documented the successful placement of right upper extremity PICC (peripherally inserted central catheter) line.
6/13/24 - R461 was admitted to the facility.
6/13/24 - E34 (NP) ordered Assess PICC line site RUE (right upper extremity) area for any signs of infection and notify MD (medical doctor) every shift in R461's EMR.
6/13/24 - E39 (MD) ordered Enhanced Barrier precautions: related to PICC line and staph infection 1. Gown. 2. Mask 3. Face shield (if splattering expected to occur) 4. Gloves very shift in R461's EMR.
7/2/24 - E28 (NP) ordered piperacillin sod- tazobactam Intravenous solution 4.5 gm - give 4.5 grams IV four times a day related to infection in R461's EMR.
7/15/24 2:09 PM - During medication administration, E35 (LPN) was observed administering R461's 2 PM Piperacillin IVSS dose wearing only gloves, E35 did not have a yellow gown on.
3. Review of R36's clinical record revealed:
1/26/24 - R36 was admitted to the facility.
2/22/24 - A care plan documented that R36 has an indwelling catheter for neurogenic bladder.
4/3/24 - A physician's order for a foley catheter to straight bag drainage for urinary retention.
7/9/24 - Observations of R36's catheter collection bag lying flat on the floor without a privacy bag while R36 was resting in bed at 10:23 AM and 11:14 AM.
7/10/24 11:31 AM - An observation of R36's catheter collection bag was hooked on the wheelchair and the bottom of the collection bag was dragging along the floor while R36 was being pushed in the wheelchair by E15 (COTA). The catheter collection bag did not have a privacy bag cover. An interview with E15 stated she brought R36 back from the large therapy room located off R36's unit and located near the main facility entrance. E15 immediately got a privacy bag, covered the catheter collection bag and hung it off the floor.
7/12/24 9:44 AM - An observation of R36's catheter collection bag was in a privacy bag but touching the floor. E16 (UM) confirmed the catheter collection bag was touching the floor and stated the privacy bag straps are attached to the bed and it is difficult to keep the catheter collection bag off the floor. E16 then manipulated the privacy bag straps and was able to raise the catheter collection bag off the floor.
7/12/24 12:32 PM - An observation of R36's catheter collection bag lying flat on the floor without the privacy bag straps tied to the bed to keep it raised off the floor. An interview with E16 confirmed the catheter collection bag was on the floor. E16 stated she had the collection bag off the floor, the hooks came off the collection bag earlier and she would try something else.
7/12/24 3:05 PM - An interview with E16 revealed that the collection bag was corrected and they used the hooks on the collection bag to attach to the bed frame.
7/16/24 12:47 PM - An interview with E3 (QA/IP) revealed that the privacy bags are being evaluated for functionality and they may order different bags.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
Based on observations, interviews and record review, it was determined that for three (3) (R36, R47 and R461) out of thirty-three (33) reviewed in the investigative sample, the facility failed to ensure a urinary catheter bag was kept off the floor and to ensure staff utilized enhanced barrier precautions (EBP). Findings include:
2023 - A facility policy titled, Enhanced Barrier Precautions- It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced barrier precautions refers to the use of gown and gloves for use (sic) during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) .
Policy Explanation and Compliance Guidelines:
7. High-contact resident care activities include: .
g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes
1. Review of R47's clinical record revealed:
5/27/16 - R47 was admitted to the facility with diagnoses including: traumatic brain injury and tracheostomy status.
5/22/24 - An annual MDS revealed that R47 required tracheostomy care.
5/5/23 - A careplan for R47 revealed enhanced barrier precautions related to presence of tracheostomy last revised on 3/19/24.
7/16/24 1:55 PM - An interview with E3 (QA and IP) confirmed that supplies for enhanced barrier precautions should be stored in plastic containers in the room and extra supplies are stored in the units linen closets.
7/16/24 2:58 PM - An observation of tracheostomy care completed by E8 (LPN Agency) lacked use of enhanced barrier precautions. E8 failed to utilize a gown or face shield during tracheostomy care with R47. R47's room lacked necessary supplies needed for enhanced barrier precautions.
MINOR
(C)
Minor Issue - procedural, no safety impact
QAPI Program
(Tag F0867)
Minor procedural issue · This affected most or all residents
Based on review of facility documentation, review of cited deficiencies from the facility's annual survey of 7/14/23 and staff interview, it was determined that the facility's Quality Assurance and Pe...
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Based on review of facility documentation, review of cited deficiencies from the facility's annual survey of 7/14/23 and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. Findings include:
7/11/24 - A review of the facilities undated policy titled, Medication Regimen Review, lacked information regarding the time frames for a pharmacist response, urgent and non-urgent medication recommendations, or a time frame for a facility response to recommendations.
7/11/24 - A review of the 2567 from Annual and Complaint survey dated 7/14/23 revealed a previous deficiency cited for the facilities MRR policy and lack of time frames for response times.
7/12/24 9:48 AM - An interview with E1 (NHA) confirmed the MRR policy provided was current.
The facility failed to update the MRR policy per the Plan of Correction dated 9/6/23 which indicated the facility would revise and update policy.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA) , E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
Jun 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined that for one (R15) out of four residents reviewed for acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined that for one (R15) out of four residents reviewed for accident hazards, the facility failed to ensure the resident's environment was free of accident hazards. On 6/3/24, while being transported in the facility van, R15 fell from the wheelchair due to improper restraining. R15 was taken to the hospital for treatment of a cut to the forehead. The unsafe facility transport caused R15 harm. Findings include:
An undated facility instruction guide titled Driver/Operator Instruction Guide QRT MAX included: Step 2. Attach lap and shoulder belt. Belt should bear upon the bony structure of the body and should be worn low across the front of the pelvis with the junction between the lap and shoulder belts located near the passenger's hip. Adjust the bets as firmly as possible consistent with user comfort.
A review of R15's clinical record revealed:
11/30/18 - R15 admitted to facility with diagnoses including but not limited to, hemiplegia and hemiparesis affecting the left side.
4/29/24 - A quarterly MDS documented R15 had a documented BIMS score of 13, revealing an intact cognitive state. R15 was documented as requiring moderate assistance to change from sitting to standing position and to transfer from a bed to a wheelchair.
6/3/24 4:57 PM - A hospital history and physical report by P1 (MD) documented that [R15] is a [AGE] year-old male who is wheelchair-bound . Apparently [R15] was traveling in the van and as per records seems like he was unrestrained in his wheelchair in the van. Apparently upon taking a sharp turn [R15] fell out of his wheelchair and in the process bumped his forehead. [R15] was brought to the emergency room as a trauma code. There is a small laceration on the forehead . Status post fall from the wheelchair: Patient has been evaluated by trauma. CT of head, neck, chest abdomen pelvis without any acute findings of trauma. Patient does have a minor scalp laceration and has been evaluated by surgery.
6/4/23 1:25 PM - A nurses note by E9 (Nurse Unit manager) documented that R15 was admitted to [NAME] with symptomatic anemia and a scalp laceration [status post] fall .
6/5/24 12:38 PM - A provider note by E11 (CRNP, APRN-C) documented that . [R15] seen after returning from hospital. He is returning here from an appointment with a specialist, fell out of his wheelchair and sustained a laceration to his forehead. He was taken to the ED. Imaging was negative for any acute injury .
6/5/24 - A wound assessment report by E12 (Wound NP) documented that R15 had a 3.5 cm x 3.5 cm x 0.2 cm laceration to the scalp with the appearance of 75-99% epithelial cells and 1-24% eschar. The treatment was to cleanse with normal saline and apply xeroform or a bordered gauze every day or as needed.
6/6/24 2:39 PM - An observation of R15 revealed a wound dressing to the left forehead and a standard sized wheelchair in the room next to the bed. In an interview with R15, he was unable to recall any specific details of the incident on 6/3/24.
6/6/24 2:58 PM - An interview with E13 (Van Driver) revealed that she was driving R15 to an appointment on 6/3/24 and she secured the hooks to the wheelchair frame and secured the lap belt to the floor anchor then through the wheelchair's armrests and anchored to the floor on the opposite side appropriately. E13 stated that along the way she drove around a roundabout and looked up in the rearview mirror at R15 who had his eyes closed, calm and was slightly hunched over. E13 had driven around a second roundabout and heard a bang. E13 looked over her shoulder and saw R15's whole body on the floor with the lap belt on him. E13 stated that she saw blood on the floor and a cut on R15's head and didn't touch or move R15. E13 stated during her initial training, the maintenance director showed her the lap belt but could not remember being shown the shoulder belt. E13 stated that the shoulder belt doesn't really do anything.
6/6/24 3:20 PM - An observation made with E13 in the same transport van used during the incident when E13 demonstrated where the wheelchair was placed and the position of R15 after the fall. E13 stated R15 was between the right side of the wheelchair and the right sliding passenger door of the van. R15's head was towards the back of the van and his feet were towards the front. E13 stated that R15 must have hit his head on one of the floor anchors.
6/10/24 10:33 AM - An interview with P2 (EMT) revealed that R15 was laying on the floor of the transport van between the wheelchair and the right sliding passenger door of the van. R15's head was towards the back of the van and feet were towards the front of the van. R15 was in a fetal position with an injury to the head that was bleeding. P2 stated that there was no lap belt of any kind on the resident when they arrived and they did not have to unbuckle any belts to remove the resident onto a stretcher.
The facility failed to safely restrain R15 in the transport van which resulted in R15 falling out of the wheelchair where he hit his head and was transported to the hospital.
6/10/24 2:40 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA and IP) and E4 (Regional Consultant) during the exit conference.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review, interview and review of other facility documentation, it was determined that in accordance with accepted professional standards and practices, the facility failed to maintain t...
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Based on record review, interview and review of other facility documentation, it was determined that in accordance with accepted professional standards and practices, the facility failed to maintain the Controlled Drug Count Record report accurately and completely for the month of May 2024. The facility did not accurately reconcile the transfer of controlled drugs from one shift to another. Findings include:
Review of the Controlled Drug Count Record report for the month of May 2024 revealed the following:
5/2/24 - 3:00 PM - 11:00 PM shift lacked evidence that the narcotic count was completed for Nurse Reporting On and there was no entry for Received From Pharmacy (+).
5/3/24 - 11:00 PM - 7:00 AM shift lacked evidence that the narcotic count was completed for Nurse Reporting On.
5/7/24 - Under the 3:00 PM - 7:00 AM shift, the Received from Pharmacy (+) number was scribbled out and it appears that it was initially marked as 0 and then changed to 1.
5/8/24 - Under the 11:00 PM - 7:00 AM shift the following categories were not completed: Completed/Disposed (-), Received from Pharmacy (+) and # Items in Drawer.
5/9/24 - Under the 11:00 PM - 7:00 AM shift, the following categories were not completed: Nurse Reporting ON (11-7), Completed/Disposed (-), Received from Pharmacy (+) and # Items in Drawer.
5/10/24 - No one signed under Nurse Reporting OFF (11-7) or recorded the number of items in the drawer. Additionally, under the 3:00 PM - 11:00 PM shift, someone marked over 0 with a 1, making the entry difficult to decipher. Under 11:00 PM - 7:00 AM shift the following categories were not completed: Completed/Disposed (-), Received from Pharmacy (+) and # Items in Drawer.
5/11/24 - Under the 7:00 AM - 3:00 PM shift, at the beginning of the shift, there were 21 items with nothing received or disposed of, yet it appears that the number of items in the drawer is 20. Under the 3:00 PM - 11:00 PM shift, the number of items in the drawer was written over, making the number difficult to decipher.
5/13/24 - Under the 11:00 PM - 7:00 AM shift, it appears that the number 2 was entered and then written over with a 0, making the entry difficult to decipher.
5/15/24 - Under the 3:00 AM - 11:00 PM shift, the following categories were not completed: Nurse Reporting On 3-11, # Items in Drawer (both oncoming and off going), Completed/Disposed (-), and Received from Pharmacy (+).
6/7/24 1:35 PM - In an interview, E1 (NHA) and E2 (DON) confirmed that the facility did not accurately reconcile the transfer of controlled drugs from one shift to another.
6/10/24 2:40 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA and IP) and E4 (Regional Consultant).
Nov 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review, interview and review of other facility documents, it was determined that for one (R4) out of the nine sampled residents, the facility failed to identify and immediately report ...
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Based on record review, interview and review of other facility documents, it was determined that for one (R4) out of the nine sampled residents, the facility failed to identify and immediately report allegations of physical and/or emotional abuse. Findings include:
The facility's undated Abuse Policy and Procedure documented:
Investigation and Reporting
- Once an allegation of abuse has been made, the supervisor who initially recieves the report must inform the Administrator/Director of Nursing immediately and intimate gathering requested information.
- The Administrator, Director of Nursing or designee shall notify the Department of Health via the Event Reporting System electronically, or by phone in the event of the electronic system being unavailable.
- Reporting requirements in response to allegations of abuse, neglect, exploitation or mistreatment will be made immediately to the Administrator, DON or designee and the State Survey Agency.
- The facility will report these allegations immediately but no later than 2 hours of any allegation which includes injuries of unknown source and misappropriation of resident property if the events that cause the allegation involve abuse or result in serious bodily injury.
- The facility will report no later than 24 hours if the events that cause the allegations did not involve abuse and do not result in serious bodily injury to the Administrator, DON or Designee and state survey agency.
R4's clinical records revealed:
11/11/22 - R4 was admitted to the facility with diagnoses including autism.
9/26/23 4:19 PM - A nurse progress note documented, Resident [R4] reported that another resident [R8] hit him on the left side of his forehead as he was trying to go into his own room. The other resident [R8] was visiting [R4's] roommate at the time of incident .
There was a lack of evidence that the resident to resident altercation/abuse was reported to the State Authority.
11/15/23 9:30 AM - In an interview, E10 (NHA) stated that the incident was not reported to the State because .it did not result in physical any injury.
11/5/23 2:11 PM - A nurse progress note documented, Contacted by nurse [E17] to speak with .sister [F3], who voiced strong concerns about his [R4] safety on this unit, with the roommate whom whom he is placed .
11/6/23 7:24 PM - A nurse progress note documented, Resident [R4] transferred to (room) per family's request due to roommate's aggressive behaviors .
11/15/23 11:48 AM - In an interview, E17 (LPN) stated that she was R4's nurse on the 3-11 shift on 11/5/23. R4's family member came up to the nurses station in the afternoon to tell her that she was worried of R4's new roommate who was bullying [R4] who had autism. E17 stated, I didn't observe the actual bullying incident between [R4] and [R9] but the family member stated that resident [R9] was not letting [R4] in the closet to get his things and stated that [R9] was blocking [R4] from getting near the closet. I notified my Supervisor when I learned about this.
11/15/23 - Review of the State agency incident report data lacked of evidence that the incident of alleged emotional abuse of R4 by R9 was reported to the State.
11/15/23 2:21 PM - In an interview, E18 (RN) stated that he did not initiate an incident report after he was made aware of R4's family's concern over the roommates aggressive behavior towards R4.
11/15/23 2:45 PM - In an interview, E19 (RN) stated that she did not initiate an incident report after she was made aware of R4's family's concern over the roommates behavior towards [R4].
11/16/23 12:07 PM - During an interview, E10 (Corporate Nurse) confirmed that any allegation of abuse must be reported to the State Agency even before the facility investigation. The facility can unsubstantiate the allegation through their investigation, but when the facility first gains knowledge of the allegation of abuse it must immediately report pending investigation.
11/16/23 - Findings were reviewed with E10 (Corporate Nurse), E3 (ADON) and E11 (RN Staff Development) during the Exit Conference beginning at approximately 5:30 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 Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for one (R1) out of four reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to ensure that R1's transfer and discharge requirement was met when he was discharged on 10/31/23 despite requesting a discharge appeal. Findings include:
Cross refer to F623 example 1 and F660
Review of R1's clinical record revealed the following:
4/26/22 - Resident was admitted to the facility.
The facility's document titled, Resident admission Agreement & Reference Guide, revised 3/1/22, documented: VIII. TRANSFER, DISCHARGE AND LATE PAYMENT .A .B .C .D. NON-PAYMENT .The Resident may be discharged after thirty (30) days' notice where: .An appeal of a denial of benefits is not pending .
9/21/23 - A State document titled, Basic Payment Class Assignment revealed that R1 was assessed by P2 (Medicaid Assessment Nurse) and it was determined that R1 did not meet the requirements for nursing home care.
9/26/23 - A State document titled, Notice to Close Your Medical Assistance revealed that R1 will no longer get Medical Assistance payment for the nursing home program with a case closure date of 10/31/23.
10/2/23 - The facility's 30 day discharge notice to R1 revealed that .effective October 31st, 2023 [R1] will be discharged to (hotel and address) .for .reason .Your health has improved sufficiently so you no longer need the services provided by our facility. Pursuant to the Delaware Health and Social Services determination to close your Nursing Home coverage effective 10/31/23 .You have the right to request a fair hearing to appeal this discharge action, as described in accordance with 16 DE Admin code 3102, and 16 DE Code Section 1127 of the Department of Health and Social Services. If you elect to pursue an appeal, your written request must be received by (facility) within thirty (30) days from the date of the discharge notice that is received by you, your family or your legal representative. You must send a copy of your request for an appeal to the Delaware Division of Health Care Quality, and to the Delaware State Long Term Care Ombudsman Office.
10/2/23 5:20 PM - A social worker progress note by E14 (SW) documented that a 30 day notice to termination of Medicaid Services through the State was delivered to R1. E14 reviewed documentation with R1 who verbalized understanding of his rights to appeal and actions that would be required of him. E14 further documented that R1 will consider an appeal.
10/26/23 8:31 AM - An email correspondence from the Sate Agency addressed to E1 (NHA), P3 (State Ombudsman Director), P1 (State Ombudsman), E14 (SW), P6 (Nursing Facility Transition Case Manager) and P5 (Case Management Supervisor) revealed R1's upcoming discharge hearing and for the hearing participants' availability.
10/27/23 1:18 AM - An email correspondence from E1 addressed to the State (DHCQ), P3, P1, E14, P6 and P5 documented, (facility) is withdrawing and rescinding our 30 day notice of discharge to [R1]. Upon advice from legal counsel, he is welcome to stay upon payment of services. My apologies for the confusion.
10/31/23 - A facility Transfer/Discharge notice revealed that, .[R1] requested this voluntary discharge and the discharge is appropriate because [R1's] health has improved sufficiently so [R1] no longer need the services provided by the facility .
11/7/23 1:47 PM - In a telephone interview, P6 stated that R1 appealed his discharge and should have been able to stay until his discharge hearing in December (2023).
11/8/23 9:00 AM - In a telephone interview with R1, he stated that, They [facility] came to me on 10/30/23, the day before I was discharged and told me that I will be discharged because I did not meet the requirements of the State program for nursing home care. They caught me off guard! I didn't realize that they really discharged me and let me go. I submitted an appeal for discharge hearing. They told me they could send me to a hotel or I could still stay here but I have to pay. I don't have money to pay. I don't have a choice. They sent me to a hotel.
11/8/23 11:18 AM - In a telephone interview, P1 stated that the facility rescinded R1's 30 day discharge notice despite R1's pending discharge hearing.
11/9/23 - In an email correspondence with the surveyor, P3 documented that a discharge appeal hearing for R1 was in place and scheduled. P3 further documented that it was not clear if R1 was in agreement with the private pay option that the facility gave him when the facility rescinded the discharge on [DATE].
11/15/23 - A written statement by E1 documented, .October (sic) informed by BOM (Business Office Manager) that we received notice of services ending October 31 .at some point toward the end of the latter point of the month I received legal counsel that a 30 day notice of discharge was not required or applicable, because he was welcome to stay if he had payment for staying .I rescinded the 30 day notice Repealing the 30 day notice made null and void any appeals that may have been outstanding regarding the discharge notice. If there were other appeals to Medicaid, I am unaware and do not have first hand knowledge.
The facility failed to ensure that R1's right to appeal for the discharge and have a hearing was honored when he was discharged on 10/31/23.
11/16/23 2:00 PM - Findings were discussed with E10 (Corporate Nurse).
11/16/23 - Findings were reviewed with E10 (Corporate Nurse), E3 (ADON) and E11 (RN Staff Development) during the Exit Conference beginning at approximately 5:30 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for two (R1 and R2) out of four...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for two (R1 and R2) out of four residents reviewed for discharge, the facility failed to ensure that the notice requirements before discharge were met. For R1, the facility failed to notify the resident and update the notice as soon as practicable when information became available that the 30 day discharge notice dated 10/2/23 was rescinded by the facility on 10/27/23. In addition, the facility failed to communicate to the receiving community case manager necessary information to ensure a safe and effective transition of care. For R2, the facility failed to ensure that a written discharge notice was provided at least 30 days before his discharge on [DATE]. Findings include:
Cross refer to F622 and F660
1. Review of R1's clinical record revealed the following:
4/26/22 - Resident was admitted to the facility.
a. 10/2/23 - R1 was issued a 30 day discharge notice by the facility.
10/27/23 1:18 AM - An email correspondence from E1 (NHA) addressed to the State Agency, P3 (State Ombudsman Director), P1 (State Ombudsman), E14 (SW), P6 (Transition Case Manager) and P5 (Case Management Supervisor) documented, [facility] is withdrawing and rescinding our 30 day notice of discharge to [R1]. Upon advice from legal counsel, he is welcome to stay upon payment of services. My apologies for the confusion.
10/31/23 - R1 was discharged from the facility.
10/31/23 - R1's record lacked evidence that a new 30 day discharge notice was provided.
11/8/23 9:00 AM - In a telephone interview, R1 stated that the day before the facility discharged him (10/30/23), the staff came in the room and told him he will be discharged . R1 further stated, They [facility] caught me off guard! I didn't realize that they really discharged me and let me go. I submitted an appeal for discharge hearing. They told me they could send me to a hotel or I could still stay here but I have to pay. I don't have money to pay. I don't have a choice. They sent me to a hotel.
11/15/23 - A written statement by E1 documented, .I rescinded the 30 day notice and authorized staff to give [R1] option of payment of bill, or option of 3 day stay in hotel, at our expense. Repealing the 30 day notice made null and void any appeals that may have been outstanding regarding the discharge notice .
The facility failed to provide a new 30 day discharge notice to R1 when the original notice dated 10/2/23 was rescinded by the facility on 10/27/23.
11/16/23 2:00 PM - Findings were discussed with E10 (Corporate Nurse).
b. 10/4/23 7:45 PM - A social worker progress note by E14 (SW) documented that an email was sent to P6 (Nursing Facility Transition Case Manager) for assistance with R1's transition back into the community after discharge from the facility scheduled for 10/31/23.
10/31/23 - R1 was discharged to the community.
11/1/23 3:16 PM - An email correspondence from P6 addressed to E1 (NHA), State Agency, P3 (State Ombudsman Director), P1 (State Ombudsman), E14 (SW) and P5 (Case Management Supervisor) documented that P6 received a report that R1 was discharged on 10/31/23 and if someone can tell her what happened and where was R1 discharged to. P6 further documented that R1 appealed his discharge and should have been able to stay until hearing in December (2023).
11/1/23 3:20 PM - An email correspondence from E1 addressed to P6, the State Agency, P3, P1, E14 and P5 revealed that R1's 30 day notice was withdrawn. E1 further documented, However, when presented with the choice of a 30 day bill, the member [R1] chose to discharge. He went to a hotel in (town).
11/7/23 1:50 PM - During an interview, P6 stated that she never received any communication either verbal or written instructions from the facility related to R1's actual discharge on [DATE] despite R1's pending discharge hearing. P6 further stated that she sent an email to the facility when she received a report on 11/1/23 of R1's discharge on [DATE]. P6 also stated that she asked the facility for R1's discharge destination for which the facility only replied with He went to a hotel in (town).
The facility failed to communicate the following to the community case management provider:
- All special instructions or precautions for ongoing care;
- Comprehensive care plan goals;
- All the necessary information, including a copy of the the resident's discharge summary and any other documentation, as applicable to ensure a safe and effective transition of care. Specifically, R1's discharge location was not communicated to the case management provider.
11/16/23 2:00 PM - Findings were discussed with E10 (Corporate Nurse).
2. 9/14/23 - R2 was readmitted to the facility.
11/1/23 - R2's discharge MDS documented that R2 had a planned discharge to home/community.
11/6/23 - Review of R2's records lacked evidence that a 30 day discharge notice in writing was provided to R2.
11/8/23 11:30 AM - In an interview, P1 (State Ombudsman) stated that she was at the facility on 10/30/23. P1 also stated that she was present in that meeting with E1 (NHA) and R2 discussing about R2's discharge circumstance. P1 stated that she asked R2 if his discharge was voluntary to which R2 confirmed and agreed. P1 stated that R2 did not have 30 days discharge notice prior to his actual discharge on [DATE].
11/9/23 12:26 PM - In an interview, P7 (Case Manager) stated that she was at the facility on 10/24/23 and was told by E1 (NHA) that E1 and E22 (BOM) had scheduled a meeting with R2 for that day to discuss the Medicaid fraud with him as during a financial review they had located funds of his that he had not disclosed to the facility. P7 also stated that she was on the phone for that meeting, and added, They gave him the option of discharging on 11/1/23 or being charged with Medicaid fraud. [R2] was discharged on 11/1/23 and did not have a 30 day discharge notice.
11/15/23 - A written statement by E1 (NHA) documented, No 30 day notice required .(Facility) did not discharge (R2), he chose to leave voluntarily .
The facility failed to ensure that a written discharge notice was provided at least 30 days before his discharge on [DATE].
11/16/23 2:00 PM - Findings were discussed with E10 (Corporate Nurse).
11/16/23 - Findings were reviewed with E10 (Corporate Nurse), E3 (ADON) and E11 (RN Staff Development) during the Exit Conference beginning at approximately 5:30 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
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for one (R1) out of four reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of other facility documents, it was determined that for one (R1) out of four residents reviewed for discharge, the facility failed to develop and implement a discharge plan to include identified specific needs and goals for a safe discharge to the community when R1 was issued a 30 day discharge notice on 10/2/23. In addition, the facility lacked communication with the community transition case manager. Findings include:
Cross Refer to F622 and F623 example #1
R1's clinical record revealed:
4/26/22 - Resident was admitted to the facility.
9/21/23 - A social worker progress note by E14 (SW) revealed that a meeting was held with P2 (Medicaid Assessment Nurse), E3 (ADON/UM), E23 (Therapy Manager), E24 (Restorative Nurse) and P4 (Case Manager) regarding R1 not meeting the required criteria to receive further NFLOC (Nursing Facility Level of Care) Medicaid benefits in the nursing home and that the last day of covered payment was set for 10/31/23.
10/2/23 - R1 was issued a 30 day discharge notice by the facility.
10/4/23 7:45 PM - A social worker progress note documented that an email was sent to P6 (Nursing Facility Transition Case Manager) for assistance with R1's transition back into the community after discharge from the facility scheduled on 10/31/23.
Review of R1's clinical records lacked evidence of discharge planning from 10/5/23 through 10/27/23.
10/27/23 1:18 AM - An email correspondence from E1 addressed to State Agency, P3 (State Ombudsman Director), P1 (State Ombudsman), E14 (SW), P6 (Transition Case Manager) and P5 (Case Management Supervisor) documented, (facility) is withdrawing and rescinding our 30 day notice of discharge to [R1]. Upon advice from legal counsel, he is welcome to stay upon payment of services .
10/31/23 - R1's discharge MDS assessment revealed an unplanned type of discharge to home/community.
Further review of R1's clinical records from 10/5/23 through 10/31/23 lacked evidence that the facility notified P6 of the change in R1's discharge circumstance and P6's response to the change when R1's 30 day discharge notice was rescinded on 10/27/23, 4 days before his actual discharge on [DATE].
11/7/23 1:55 PM - During a telephone interview, P6 stated that P4 had a meeting with the facility nursing staff, E14 and P2 (Medicaid Assessment Nurse) to discuss R1's level of care determination. P4 related to P6 that R1 was going to be discharged to the community and will be needing assistance with community services. P6 further stated that she saw R1 while at the facility on 10/9/23 and learned that R1 appealed the discharge notice. P6 stated that, On 11/1/23, I found out about his 10/31/23 actual discharge through our computer generated discharge list and not from the facility. I reported this to my supervisor and we were worried because we did not know the discharge status of [R1]. We did not know where to find him. We tried calling all the contact persons in [R1's] profile until one of his brothers answered the phone and told us that he [R1] was staying in the hotel and provided the address. I went to the hotel and assessed [R1]. He had no food, no money and no phone. I had to go to (store) to buy him food and a prepaid phone so we can contact him. I also had to find transportation and placement for him as his hotel stay was good only for 3 days. I saw him on a Thursday and he had to check out on Saturday. I had to pay out of my pocket for his transportation as his transfer to another temporary housing happened on a weekend and this was not pre-planned. We were not given a heads up that the facility was discharging him on 10/31/23 despite an appeal for a fair hearing. The facility should have coordinated and collaborated with us to ensure [R1's] safe smooth transition to the community.
11/7/23 2:44 PM - In a telephone interview, P4 stated that, .On 11/1/23 I gathered from a system generated facility/hospital census report the information that [R1] was discharged from [facility] on 10/31/23. I went ahead and checked the facility electronic health record and verified that [R1] was indeed discharged on 10/31/23. I thought he has an open appeal for the 30 days and the nursing home will not discharge him until a decision was made. Nobody from the facility reached out to me nor called me to inform that the facility was going to discharge the resident on 10/31/23.
11/15/23 - A written statement by E1 documented, .informed by BOM (Business Office Manager) that we received notice of services ending October 31 I rescinded the 30 day notice and authorized staff to give [R1] option of payment of bill, or option of 3 day stay in hotel, at our expense .Repealing the 30 day notice made null and void any appeals that may have been outstanding regarding the discharge notice .Was informed he [R1] chose the hotel stay. (Facility) set up transportation and did all usual preparations and procedures for a discharge to community, as reflected in extensive social work and nursing notes in chart.
Review of R1's comprehensive care plan lacked evidence that a discharge care planning process was developed. In addition, R1's clinical records revealed a physician's Discharge summary dated [DATE], however, the facility lacked evidence of collaboration with the interdisciplinary team and community case management provider.
11/16/23 2:00 PM - Findings were discussed with E10 (Corporate Nurse).
11/16/23 - Findings were reviewed with E10 (Corporate Nurse), E3 (ADON) and E11 (RN Staff Development) during the Exit Conference beginning at approximately 5:30 PM.
Jul 2023
22 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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The following was reviewed in R195's record:
5/30/18 - R195 was admitted to facility with diagnoses including a stroke affect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The following was reviewed in R195's record:
5/30/18 - R195 was admitted to facility with diagnoses including a stroke affecting the left dominant side, difficulty swallowing, and need for assistance with personal care.
5/31/18 - R195's Baseline Care Plan under Assistance with ADL's stated, Nursing staff to provide care as needed related to deficits to ensure ADL care is being met.
1/31/20 - A Grievance Written Decision signed by E15 (former NHA) stated, Orders added to clarify resident needs assistance with feeding for every meal and to remove dietary trays upon completion of feeding. Staff to review voiding diary in accordance with toileting plan and to check/change resident prior to meals being offered to resident. Based on . findings . grievance was confirmed.
12/16/20 2:12 PM - A Grievance email from F2 (R195's stepdaughter) to E15 (former NHA) stated, Good afternoon (E15), My mother (F3) just had a facetime with her husband (R195) who is my stepfather . She called me very upset. (R195) was lying in bed eating lunch with only an undershirt on. He is suppose (sic) to be up in his wheelchair for all meals due to aspiration risk and dressed in an undershirt, shirt and flannel day pants everyday .
The facility was unable to provide any evidence of a written response to this Grievance by R195's family.
9/11/21 - R195's quarterly MDS (Minimum Data Set) assessment documented R195 as an extensive, two person assistance (assist) for bed mobility, transfer, dressing and toilet use, and extensive, one person assist for eating and personal hygiene.
11/9/21 - A Family Grievance by F2 documented concern that R195 . was not dressed and no teeth in at 11 AM.
11/9/21 - E6's (NP) verbal order stated, Ensure resident is OOB (out of bed) for all meals with dentures in place. Soak dentures overnight two times a day.
11/9/21 - R195's Care Plan was updated under Nutritional problem to Encourage OOB for all meals.
11/16/21 - A Grievance Written decision signed by E14 (another former NHA) on 11/17/21 stated, The CNA that was assigned to R195 works for an agency and 'isn't here often.' She was not aware of the visitation schedule and was educated on the spot where to locate the sheet from this point on. She had provided incontinent care to him (R195) but he was still in a gown until able to provide full bath and dressing, acknowledged that his dentures were not in. She was also educated on the spot regarding ensuring dentures are provided at meals. E2 (DON) spoke to stepdaughter (F2) and notified her of all . Based on . findings . grievance was confirmed.
1/14/22 - R195's quarterly MDS assessment documented R195 as an extensive, two plus person assist for transfers and toilet use, and extensive, one person assist for bed mobility, dressing, eating and personal hygiene.
2/15/22 - A Family Grievance by F3 (R195's wife) documented on 2/14/22 (R195) still in bed at 11:55 AM and he was not shaved plus hair a mess, food was all over him and in bed (sic). The room was a mess. Food was not double portions, there was no gravy or soup which is suppose (sic) to be at every meal.
2/15/22- A Grievance Written Decision signed by E14 stated, (F3) had concerns about room cleanliness, food portion size, food items not being present, resident not being out of bed in a timely manner . Based on . findings . grievance was confirmed.
11/10/22- A Grievance email from F2 stated, Good Morning, I was in and visited with my stepfather (R195) last PM and wanted to report a few things. I also took photos which I have attached. I discovered mouse droppings on his nightstand. His meal ticket did not state what the meal was and he only received mashed potatoes, meat and ½ cup mandarin oranges. No vegetable or soup. The meal issues have been previously reported several times. I did report the mouse droppings issue to the nurse on duty, showed her and asked for a resident concern form to be filed. She stated she was contacting the supervisor on duty but I never heard anything further. I expect a resident concern report to be filed for the mouse and dietary issues with a timely action and resolution reported back to me and my mother (F3). As you are aware my mother is out of the country . I can be reached on my cell (phone number) .
The facility was unable to provide any evidence of a written response to this Grievance by R195's family.
12/12/22 - R195's quarterly MDS assessment documented R195 as an extensive, two plus person assist for bed mobility, transfers, and toilet use and extensive and a one person assist for dressing, eating and personal hygiene.
7/11/23 11:59 AM - During an interview, E1 (NHA) stated, Previously the backup battery (for Hoyer lifts) was in maintenance and if the Hoyer battery was dead, the staff would have to go to maintenance to get the replacement battery. Now they have extra back up batteries available on the floors. E1 confirmed that this change was initiated during her time as NHA. E1 has been the facility's NHA since April 2023.
7/11/23 1:48 PM - During a telephone interview, F2 (stepdaughter) stated, There were more issues with getting R195 out of bed on weekends. Staff would report that the Hoyer lift battery was dead and they could not get to the replacement. F2 stated, After complaining to the State, the Ombudsman got involved. There was a meeting scheduled at the facility for 11/17/2022 that the facility Administration, my mom (F3), myself, the Ombudsman (C3) and a representative from (name), R195's insurance company, to discuss our care concerns. The then Administrator (E22) did not even show up.
7/12/23 10:50 AM - During an interview, E1 (NHA) stated, The facility does not have documentation for the 2021 grievances, as they only keep grievance documentation from survey to survey.
7/12/23 12:22 PM - During a telephone interview, E3 (R195's wife) stated, I was afraid for his safety. I got to the point where I was considering withholding his portion of the monthly bill ($3000) because the care was that bad.
7/12/23 1:25 PM - E1 (NHA) confirmed that on weekends, the Nursing Supervisor had the key to the Maintenance Office and that they would need to get the replacement battery for the Hoyer lift for staff.
7/13/23 11:43 AM - E1 stated, We found grievances back to 2010.
7/13/23 1:34 PM - E1 confirmed the facility was unable to provide Grievance Written Decision statements for 12/16/20 and 11/10/22. E2 (DON) confirmed that the facility was not able to provide notes regarding the 11/17/22 meeting with R195's family, Ombudsman (C3) and insurance Representative. E2 stated he recalled that the then Administrator (E22) had car trouble that day and was unable to attend the meeting.
7/14/23 10:30 AM- Findings were reviewed during the Exit Conference with E1, E2, and E3 (ADON).
Based on record review and interview, it was determined that the facility failed to take immediate action to resolve a resident grievance for one (R40) out of one resident reviewed for missing personal belongings. Additionally, the facility failed to make prompt efforts to permanently resolve multiple concerns repeatedly brought forth by R195's family. The facility also failed to consistently issue written grievance decisions to R195 and his family in response to their grievances. Findings include:
The facility policy on grievances, last updated January 2023, indicated, A family member may voice grievances. Grievances may be voiced in the following forums: Verbal complaint to a staff member. The staff member receiving the grievance will record the specifics on the . grievance form . The facility will make prompt efforts to resolve grievances.
1. During an interview on 7/7/23 at 10:57 AM, F4, relative of R40, stated R40's Coat is still missing and we paid over $100.00 for it. I told them about it months ago and they said they would look for it, but there was nothing that they could do. I still have the receipt and everything.
7/7/23 - Review of R40's clinical record revealed a personal possessions list that documented, 1 coat black with fur signed by E24 (CNA) and dated 12/20/17.
During an interview on 7/10/23 at 10:54 AM, E5 (SW) stated that she was unaware that R40 had a missing coat. E6 stated, I just started that unit in December, but I never heard anything about that. I don't have information about that.
During an interview on 7/10/23 at 11:26 AM, E1 (NHA) denied knowledge of R40's missing coat and stated,We replace lost items, I haven't heard anything about this.
During an interview on 7/10/23 at 11:39 AM, E12 (RN) stated that R40's family reported the residents missing coat to E12 Six months ago, during the winter months. When it wasn't located, I told her that if it wasn't labeled, the facility is not responsible. I told her we can have laundry look to see, it wasn't labeled so I told her it couldn't be replaced. E12 confirmed that she did not complete a written grievance at that time.
7/10/23 12:35 PM - A social work progress note documented, This worker contacts [resident] Guardian for resident to resolve issue relative to loss of a coat at Atlantic [NAME]. This worker offers to replace the value of the coat per instruction of [E1(NHA)]. Guardian very pleased with offer and will actually bring a receipt for the coat.
During an interview on 7/11/23 at 9:42 AM, E1 (NHA) confirmed the facility did not have evidence of a written grievance nor a prompt response/resolution for R40's missing coat that was reported several months prior. E1 confirmed the facility was resolving the grievance that day with reimbursement.
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 interview and record review, it was determined that for one (R32) out of eight residents reviewed for abuse, facility staff failed to immediately report an allegation of abuse to the Administ...
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Based on interview and record review, it was determined that for one (R32) out of eight residents reviewed for abuse, facility staff failed to immediately report an allegation of abuse to the Administrator and the State Agency within two hours. Findings include:
Cross refer F610
The facility policy titled Abuse Policy and Procedure, revised 1/2023, stated, once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing immediately and initiate gathering requested information. An investigation must be directed by the Administrator or designee immediately.
Review of R32's clinical record revealed:
8/20/21 - R32 was admitted to the facility.
7/5/23 9:25 AM - An interview with R32 revealed an allegation of abuse by a staff member (CNA - [E10]). R32 alleged that E10 punched him in the stomach during care.
7/5/23 3:15 PM - An allegation of abuse was reported to E1 (NHA) and E2 (DON) by the Surveyor.
7/5/23 4:51 PM - An incident report was submitted to the State Agency for an allegation of abuse for R32.
7/10/23 12:48 PM - An interview with E1 revealed that the allegation of abuse (for R32) occurred several months prior and that documentation of a formal investigation does not exist. E1 stated the current investigation did not reveal any evidence of abuse and that E10 was able to return to work.
The facility failed to identify an allegation of abuse and lacked evidence of reporting the allegation of abuse to the State Agency within designated timeframe.
7/12/23 1:20 PM - An interview with E12 (Unit Manager) revealed that the allegation of abuse was reported to her and it was investigated. E12 stated that an incident report to notify leadership or initiating a report to the State Agency was not completed. R32 was physically assessed after the allegation revealing no injuries. E12 interviewed E10 (CNA)and R32 and determined that the allegation was not abuse.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview, record review, and review of other facility documentation as indicated, it was determined that for one (R32) out of eight residents reviewed for abuse, the facility failed to have ...
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Based on interview, record review, and review of other facility documentation as indicated, it was determined that for one (R32) out of eight residents reviewed for abuse, the facility failed to have evidence of a thorough investigation of an allegation of abuse. Findings include:
Cross refer F609
Review of R32's clinical record revealed:
8/20/21 - R32 was admitted to the facility.
7/5/23 9:25 AM - An interview with R32 revealed an allegation of abuse by a staff member (CNA - [E10]). R32 alleged that he was punched in the stomach during care.
7/5/23 3:15 PM - An allegation of abuse was reported to E1 (NHA) and E2 (DON) by the Surveyor.
7/5/23 4:51 PM - An incident report was submitted to the State Agency for an allegation of abuse for R32.
7/10/23 12:48 PM - An interview with E1 revealed that the allegation of abuse from (R32) occurred on or around March/ April (2023) timeframe. The facility failed to report or investigate the allegation of abuse. E1 stated the current investigation did not reveal any evidence of abuse and that E10 was able to return to work.
7/12/23 1:20 PM - An interview with E12 (Unit Manager) confirmed that the allegation of abuse was reported to her and was investigated, however, there was no investigation on record. E12 stated that an incident report to notify leadership or initiating a report to the State Agency was not completed. R32 was physically assessed after the allegation revealing no injuries, however, no record reveals this. E12 stated she interviewed E10 and R32 and she determined that the allegation was not abuse.
The facility lacked evidence of a thorough investigation at the time of the allegation of abuse.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.
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 record review and interview, it was determined that for one (R597) out of three residents reviewed for discharge, the facility failed to provide evidence of the required documentation, includ...
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Based on record review and interview, it was determined that for one (R597) out of three residents reviewed for discharge, the facility failed to provide evidence of the required documentation, including an interagency transfer sheet with Physician orders and Physical Therapy (PT) recommendations for R597's transfer to another facility on 12/20/22. Findings include:
Cross refer F677
Review of R597's clinical record revealed:
12/18/22 - R597 was admitted to the facility with diagnoses including a right femur (thigh bone) fracture with surgical repair and the need for assistance with personal care.
12/18/22 - R597's Baseline Care Plan documented R597 at risk for developing complications related to needing assistance with ADL's related to: poor motivation, weakness . CNA Intervention- Functional status as per therapy recommendations.
The Baseline Care Plan did not specifically address R597's functional status for her ongoing care related to bed mobility, toilet use and hygiene.
12/21/22 - R597 was transferred to another rehabilitation facility at her request.
12/21/22 10:39 AM - E6's (Nurse Practitioner/NP) Progress Note documented R597's Assessment/Plan as Unspecified fracture of right femur . WBAT (weight bear as tolerated) to RLE (right lower extremity) .
The 12/21/22 Progress Note written by E6 only referenced R597's transfer as an addendum on 1/6/23. There were no special instructions regarding R597's care.
12/22/22 - R597's admission MDS (Minimum Data Set) assessment documented bed mobility and toilet use as extensive two plus person assistance and personal hygiene as extensive one person assistance.
12/23/22 - E5 (Social Worker) documented R597's BIMS (Brief Interview for Mental Status) score as 15 in the MDS assessment, which reflected normal cognition.
1/6/23 11:15 AM - E6's (NP) addendum to the 12/21/22 Progress Note stated, Patient discharged to another facility on 12/21/2022 per patient preference.
7/7/23 10:41 AM - During an interview, E1 (NHA) stated, We did not keep a copy of the interfacility transfer sheet for R597's transfer to another facility on 12/21/2022. E2 (DON) stated, But we would have sent a copy of the face sheet, care plan, H&P (admission history and physical) and current orders. We would also send a copy of the Advance Directive if there was one.
7/14/23 10:30 AM - The findings were reviewed during the Exit Conference with E1, E2 and E3 (ADON).
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 (R599) out of three residents reviewed for discharge, the facility failed to provide written notice to R599's resident representati...
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Based on record review and interview, it was determined that for one (R599) out of three residents reviewed for discharge, the facility failed to provide written notice to R599's resident representative regarding the resident's discharge. Findings include:
Review of R599's clinical record revealed:
4/12/22 - R599 was admitted to the facility for rehabilitation.
4/29/22 - A Physician Discharge Summary stated the discharge date was 4/29/22.
R599's clinical record lacked evidence that R599 and their representative were provided with a written discharge notice that included:
The reason for transfer or discharge;
The effective date of transfer or discharge;
The location to which the resident is transferred or discharged ;
A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.
7/12/23 1:06 PM - An interview with E13 (Unit Manager) confirmed there was no documentation in the clinical record that showed R599's resident representative was notified prior to discharge.
In the aforementioned note, the lack of notification of discharge resulted in the resident remaining at the facility as private pay until 5/2/22.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed fol...
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Based on interview and record review, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed ensure that a referral for a PASARR screening was completed following new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include:
The facility policy on PASARR, last updated October 1, 2022, indicated that the Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or related condition will be referred promptly to the State authority for a review.
Review of R16's clinical record revealed;
8/9/21 - A level I PASARR screening was completed for R16 that determined no level II PASARR was required and that R16 did not have a diagnosis of dementia or any mental health diagnoses.
8/11/21- R16 was admitted to the facility with multiple diagnoses listed including delusional disorder, unspecified mood disorder and anxiety.
8/18/21- An admission MDS assessment documented R16 as severely cognitively impaired with active diagnoses that included non-Alzheimers dementia, depression and psychotic disorder.
10/7/21- A level I PASARR was completed for R16 and diagnoses of depressive disorder, anxiety and dementia were determined. A level II PASARR was not required. The PASARR did not list R16's diagnosis of a psychotic disorder.
During an interview on 7/10/23 at 10:56 AM, E5 (SW) confirmed that R16 did not receive any PASARR referrals after the 10/7/21 PASARR was completed.
Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) at the exit conference on 7/14/23 at 9:45 AM.
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 record review and interview, it was determined that for one (R118) of two sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) Level I, the facility failed to hav...
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Based on record review and interview, it was determined that for one (R118) of two sampled residents reviewed for Preadmission Screening and Resident Review (PASRR) Level I, the facility failed to have a currently dated PASRR Screening. Findings include:
Review of R118's clinical record revealed:
3/26/23 - R118 was admitted to the facility.
3/24/23 - A review of the Initial PASARR revealed it was completed on 3/24/23 and was approved for a 60 day short term convalescence admission. The PASARR also revealed if the short term stay surpassed the expiration date, a new screening would have to be initiated by the Provider for completion.
7/7/23 - A review of R118's electronic medical record revealed a PASARR was completed on 3/24/23 to determine placement in a medical facility for a short term convalescence admission.
7/7/23 1:10 PM - An interview with E5 (Social Worker) confirmed that a PASARR was not completed for R118 after the 60 day expiration.
The facility failed to maintain a current PASARR screening for R118.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
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 F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review, it was determined that for one (R194) out of twenty six residents reviewed for comprehensive care planning, the facility failed to develop and implement a baseline care plan fo...
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Based on record review, it was determined that for one (R194) out of twenty six residents reviewed for comprehensive care planning, the facility failed to develop and implement a baseline care plan for R194 that provided effective and person-centered care that met professional standards of care regarding R194's left fibula and ankle fractures and LLE (left lower extremity) surgical incision care. Findings include:
6/24/22 - R194 was admitted to the facility with diagnoses including: left fibula (lower leg bone) and ankle fractures, dementia and need for assistance with personal care.
6/25/22 - R194's Baseline Care Plan documented four areas: Potential Nutritional problem, at risk for falls, at risk for chronic, acute breakthrough pain and at risk for developing complications related to needing assistance with ADL's related to fracture. The Interventions/Task sections of these areas failed to address R194's principle medical problem, her fractured left fibula and ankle and the requisite assessment of the limb and incision as a professional standard of care.
7/14/23 10:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON).
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 two (R7 and R32) out of twenty six residentssampled, the facility failed to develop and implement a comprehensive person-centered care p...
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Based on record review and interview it was determined that for two (R7 and R32) out of twenty six residentssampled, the facility failed to develop and implement a comprehensive person-centered care plan. Findings include:
1. 8/2/21 - R7 was admitted to the facility.
7/5/23 1:25 PM - During an interview, R7 stated she feels chained to the bed.
7/7/23 approximately 8:50 AM - An interview with E17 (Rehabilitation Director) revealed that R7 was receiving PT, but she often refused to get out of bed, although R7 will usually do bed exercises.
7/7/23 approximately 11:06 AM - An interview with E16 (Unit Manager) confirmed that the resident prefers to stay in bed and typically refuses to get out of bed.
7/7/23 untimed - A review of the care plan revealed there was no specific care plan for refusal of care or getting out of bed.
7/10/23 approximately 1:30 PM - An interview with E18 (Activities Director) and E19 (Assistant Activities Director) both said that R7 has not been out of bed in years.
7/11/23 approximately 1:40 PM - An interview with E5 (SW) stated it was R7's preference to not get out of bed.
7/12/23 1:11 PM - An interview with E2 (DON) stated that he has only seen R7 out of bed a handful of times over the past few years.
7/12/23 2:02 PM - An interview with E16 (Unit Manager) confirmed there was no care plan for refusal of care and/or getting out of bed, but she will look into it.
2. Review of R32's clinical record revealed:
8/20/21 - R32 was admitted to the facility.
8/23/21 - A comprehensive care plan was initiated for R32.
7/5/23 - An interview with R32 revealed that R32 has dentures, but is unable to wear them related to a loose fitting bottom plate. The interview further revealed that R32 has not seen a Dentist or had dental services since admission.
7/10/23 9:57 AM - An interview with R4 (Medical Records) revealed that R32 has not seen an outside Dentist or the in house Dental Provider.
7/10/23 10:14 AM - A review of facility communication with regard to the in house Dental Provider revealed that R32 was offered dental services on 2/9/23 and R32's decisionmaker refused services.
7/10/23 11:01 AM - A review of R32's careplan initiated on 8/23/21 revealed no evidence of the resident's use of dentures or dental services.
The facility failed to develop and implement a comprehensive person-centered care plan.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference on 7/14/23 at 9:45 AM.
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 one (R32) out of twenty six sampled residents for care plans, the facility failed to ensure that the required interdisciplinary team (I...
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Based on record review and interview, it was determined that for one (R32) out of twenty six sampled residents for care plans, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings. Findings include:
Review of R32's clinical record revealed:
8/20/21 - R32 was admitted to the facility.
5/31/22 10:00 AM - A review of R32's comprehensive resident centered care plan conference notes revealed the following attendees were present: Unit Manager, Social Worker and R32.
3/30/23 - A review of Care Plan meeting notes revealed the following attendees were present: R32, Unit Manager, R32's decisionmaker and the Admissions Director.
The facility lacked evidence that the post-admission care plan conference attendees included: Physician input, Food and Nutrition Services staff input and CNA (Certified Nursing Aide) input with responsibility for the resident.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
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 (R595) out of three residents reviewed for discharge, the facility failed to develop and implement an effective discharge planning ...
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Based on record review and interview, it was determined that for one (R595) out of three residents reviewed for discharge, the facility failed to develop and implement an effective discharge planning process that focused on R595's discharge goals and effectively prepared her to transition to post discharge care as evidenced by failure to communicate arrangements for home health nursing, physical therapy (PT) and occupational therapy (OT) to R595 and her family. Findings include:
1/25/23 - R595 was admitted to the facility with diagnosis including: a stroke with left sided paralysis, heart failure, end-stage kidney failure on hemodialysis and a seizure disorder.
2/1/23 - R595 had a documented BIMS score of 9, which reflected moderate cognitive impairment.
2/24/23 - R595 was discharged home with family was documented on the discharge paperwork (referred to as Transition booklet). The transition booklet documented that R595 required follow-up medical care with C1 (Primary Care NP), but did not supply contact information for this Provider and required home health care services of PT, OT and Nursing from a local home health care agency, but the facility did not supply any contact information or the frequency of the services.
7/6/23 2:05 PM - During an interview, E5 (Social Worker) stated, R595's discharge was at the resident's initiation and R595's family was not happy about it as R595's family thought she should stay as a long-term care resident. E5 confirmed that she did not discuss the pending discharge with R595's family, despite R595 having moderate cognitive impairment.
7/6/23 2:20 PM - During an interview, E1 (NHA) stated, The Transition booklet should have all the discharge information, except the medication list. In theory the names and phone numbers of the home health agencies are supposed to be in the booklet, but currently the Social Work department consists of one person in a three man job, so sometimes not all the information is there.
7/7/23 1:23 PM - During a telephone interview with F1 (R595's daughter), F1 stated that the building did not supply in the discharge paperwork the contact information regarding the home health care agency and did not contact R595's dialysis transportation to alert them that she was being discharged , which left the family scrambling to obtain transport to R595's dialysis session on Monday. Fi stated, My Mom has been in and out of facilities over the years. I know how this should be done. They did not do it right.
7/12/23 10:47 AM- During an interview, E1 (NHA) stated, We don't normally arrange dialysis transportation for established dialysis residents as long as the resident previously had transportation arranged and a dialysis chair time from before this admission.
7/14/23 10:30 AM- The findings were reviewed during the Exit Conference with E1, E2 (DON), and E3 (ADON).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
2. Review of R195's clinical record revealed:
5/30/18 - R195 was admitted to the facility with diagnoses including: a stroke affecting the left dominant side, difficulty swallowing and need for assist...
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2. Review of R195's clinical record revealed:
5/30/18 - R195 was admitted to the facility with diagnoses including: a stroke affecting the left dominant side, difficulty swallowing and need for assistance with personal care.
5/31/18 - R195's Baseline Care Plan under Assistance with ADL's stated, Nursing staff to provide care as needed related to deficits to ensure ADL care is being met.
12/14/20 - R195's quarterly MDS (Minimum Data Set) assessment documented R195 as an extensive, two plus person assist for transfers and toilet use, limited one person assistance (assist) for eating and extensive, one person assist for bed mobility, dressing, and personal hygiene.
12/16/20 2:12 PM - A Grievance email from F2 (R195's stepdaughter) to E15 (NHA) stated, Good afternoon E15 (former NHA), My mother (F3) just had a facetime with her husband (R195) who is my stepfather . She called me very upset. R195 was lying in bed eating lunch with only an undershirt on. He is suppose (sic) to be up in his wheelchair for all meals due to aspiration risk and dressed in an undershirt, shirt and flannel day pants everyday .
The facility was unable to provide evidence of an investigation into this grooming/ mobility allegation.
9/11/21 - R195's quarterly MDS assessment documented R195 as an extensive, two plus person assist for bed mobility, transfers, dressing and toilet use and extensive one person assist for eating and personal hygiene.
11/9/21 - A Family Grievance Report by F2 documented concern that R195 .was not dressed and no teeth in at 11 AM.
11/9/21 - E6's verbal order stated, Ensure resident is OOB (out of bed) for all meals with dentures in place. Soak dentures overnight two times a day.
11/9/21 - R195's Care Plan was updated under Nutritional problem and stated, Encourage OOB (out of bed) for all meals.
The facility confirmed R195's family concern by obtaining a medical order to have dentures in and to get R195 out of bed for meals.
1/14/22 - R195's quarterly MDS assessment documented R195 as extensive, two plus person assist for transfers and toilet use and an extensive one person assist for bed mobility, dressing, eating and personal hygiene.
2/15/22 - A Family Grievance Report by F3 (R195's wife) documented on 2/14/22 resident (R195) still in bed at 11:55 AM and he was not shaved plus hair a mess, food was all over him and in bed (sic). The room was a mess. Food was not double portions, there was no gravy or soup which is suppose (sic) to be at every meal.
The facility confirmed R195's wife's allegation of nutritional issues and mobility regarding R195's care.
11/10/22 8:16 AM - A Grievance email from F2 to E8 (ADON) and E22 (a different former NHA) stated, Good Morning, I (F2) was in and visited with my stepfather (R195) last PM and wanted to report a few things . His meal ticket did not state what the meal was and he only received mashed potatoes, meat and ½ cup mandarin oranges. No vegetable or soup. The meal issues have been previously reported several times .
12/13/22 - R195 was discharged /transferred to another facility at the family's request.
3. Review of R597's clinical record revealed:
12/18/22- R597 was admitted to the facility with diagnoses including a right femur (thigh bone) fracture with surgical repair and the need for assistance with personal care.
12/18/22 - R597's Baseline Care Plan documented .at risk for developing complications related to needing assist with ADL's related to: poor motivation, weakness . CNA Intervention - Functional status as per therapy recommendations.
12/21/22 - E8 (ADON) obtained E7's (CNA) Witness Statement via telephone and documented E7 as stating, She (R597) didn't ring the bell during the night. I thought she was independent and didn't ask her about the bathroom. I walked by her room several time throughout my shift. I didn't go in the room at all and did not give her water. The hallway has a lot of bell ringers so I was by her room a lot. She was sleeping on top of the sheets.
12/21/22 - E9's (LPN) Witness Statement documented 07:45 AM. As I was making rounds before my Medpass after 11-7/7-3 report, I went to resident (R597), noted her crying & had her personal cell phone speaker phone with facility message. Noted resident was fully dressed lying on top of her blanket. R597 stated that she was never changed into bedclothes, offered water or checked on all night. Noted resident's pants and bed linen under her were soaked with pee. I immediately notified ADON (E13 - Unit Manager) was not here yet. I found her 7-3 caregiver and she immediately went to her to get her straightened up. She wanted to notify or speak to unit manager.
12/21/22 - E11's (CNA) Witness Statement documented R597 was really wet. She was not happy. She said that no one changed her all night and they didn't even cover her up.
12/22/22 - R597's admission MDS assessment documented bed mobility and toilet use as extensive two plus person assist and personal hygiene as extensive one person assist.
12/23/22- E5 (Social Worker) documented R597's BIMS score as 15 in the MDS assessment, which reflected normal cognition.
1/2/23- E7 (CNA) was terminated from employment at the facility for Failure to complete assigned tasks.
7/14/23 10:30 AM- The findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON).
Based on observation and interview, it was determined that for three (R47, R195 and R597) out of seven residents reviewed for ADL, the facility failed to ensure ADLs were provided to dependent residents. Findings include:
1. Review of R47's clinical record revealed;
3/1/23 - R47's care plan for ADL's related to needing assistance, cognitive impairment and weakness included the intervention for staff to provide care to R47 as needed related to deficits to ensure ADL care is being met.
5/23/23 - A quarterly MDS assessment documented that R47 was moderately cognitively impaired and required extensive assistance of one staff member for completion of hygiene which includes shaving.
R47 was observed with facial hair unkempt on the following dates:
7/5/23 10:57 AM
7/6/23 9:45 AM
7/10/23 9:26 AM.
7/10/23 - Review of 30 days of CNA documentation for completion of resident care revealed hygiene was documented as completed for R47.
During an interview on 7/10/23 at 11:30 AM, E25 (CNA) confirmed that R47's facial hair was unkempt and that the resident was not offered a shave.
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 observations, interview and record review, it was determined that for one (R67) out of one sampled resident reviewed for respiratory care, the facility lacked evidence that R67's nebulizer re...
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Based on observations, interview and record review, it was determined that for one (R67) out of one sampled resident reviewed for respiratory care, the facility lacked evidence that R67's nebulizer reservoir and tubing were labled with a date of use and were stored in a sanitary manner. Findings include:
Review of R67's clinical record revealed:
6/10/21 - R67 was admitted to the facility with COPD (Chronic Obstructive Pulmonary Disease).
5/12/2023 - A Physician's order for R67 included to administer a nebulizer treatment every four hours for shortness of breath or wheezing related to COPD.
5/13/23 - A Physician's order for R67 included to administer a nebulizer treatment once a day related to chronic sinusitis (inflammation of the nasal passage cavities).
7/5/23 12:10 PM - During a random observation during screening, R67's nebulizer reservoir and tubing were noted to be on his bedside table covered with clothing and a pair of shoes next to it. The nebulizer equipment was not contained to keep it sanitary. In addition, the equipment was not labeled with a date to discern when it had last been changed.
7/5/23 12:23 PM - During an observation and interview, E27 (LPN) confirmed that the nebulizer tubing and reservoir were not labeled and were not contained to remain sanitary. E9 stated that the equipment should have been placed in a plastic bag.
7/14/23 - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference beginning at 9:45 AM.
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 (R16) out of two residents reviewed for PASARR, the facility failed to ensure that PRN orders for psychotropic drugs were limited t...
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Based on record review and interview, it was determined that for one (R16) out of two residents reviewed for PASARR, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days. Findings include:
The facility policy on psychotropic medications last updated October 2022, indicated, A psychotropic drug is any drug that affects brain activities . include but not limited to antianxiety [medications]. If the attending physician or prescribing practitioner believe it is important for the PRN to be extended beyond 14 days, they shall document their rationale in the residents medical record and indicate the duration for the PRN order.
Review of R16's clinical record revealed:
6/1/23 - A hospice nursing note documented Recommendations: per hospice when patient unable to swallow, antianxiety medication every morning and evening as needed for anxiety.
6/2/23 - A Physicians order was written by R16's Attending Physician for R16 to receive an antianxiety medication every 12 hours as needed with no stop date.
During an interview on 7/10/23 at 11:44 AM, E23 (RN) confirmed that Typically psychotropic have a 14 day limit and we check, but this was recommended by hospice. The facility did not provide evidence of a rationale for the extension nor a duration documented by R16's Attending Physician.
Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference on 7/14/23 at 9:45 AM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that for two (R32 and R118) out of four sampled residents for dental services, the facility failed to assist the resident in obtaining routine d...
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Based on interview and record review, it was determined that for two (R32 and R118) out of four sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services. Findings include:
Cross refer F656
The facilities policy titled, Dental Services, revised 10/2022, indicated The dental needs of each resident are identified through the physical assessment and MDS assessment process and addressed in each resident's plan of care.
1. Review of R32's clinical record revealed:
8/20/21 - R32 was admitted to the facility.
8/21/21 - Review of the care plan initiated 8/21/21 revealed no evidence of R32 having a care plan related to dentures or dental needs.
5/28/22 - Review of the MDS (Minimum Data Set) assessment documented that R32 had broken teeth or loosely fitting full or partial dentures.
5/28/23 - Review of the MDS assessment documented that R32 does not have broken teeth or loosely fitting full or partial dentures.
7/5/23 9:33 AM - An interview with R32 revealed that R32 has dentures that do not fit, resulting in R32 not wearing dentures due to the lower plate not fitting properly. R32 stated he has not seen the Dentist regarding his dentures.
7/10/23 9:57 AM - An interview with E4 (Medical Records) confirmed that R32 had not been scheduled with the facilities Dentist or an outside Dentist. E4 stated the scheduler was calling to set up an appointment for R32 today.
7/10/23 10:30 AM - Review of an email with the facility Dentist revealed that R32 was offered a dental appointment on 2/9/23 and R32's decisionmaker declined the visit.
The facility failed to offer dental services from 8/20/21 to 2/9/23.
2. Review of R118's clinical record revealed:
3/23/23 - R118 was admitted to the facility.
3/31/23 - Review of the admission MDS assessment revealed that R118 had obvious or broken natural teeth.
7/6/23 9:43 AM - An interview with R118 revealed broken natural teeth and the need to see the Dentist.
7/10/23 9:57 AM - An interview with E4 (Medical Records) confirmed that R118 had not been scheduled with the facilities Dentist or an outside Dentist. E4 stated the scheduler was calling to set an appointment for R118 today.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include:
7/13/23 10:15 AM - Du...
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Based on observation and interview, it was determined that for one out of five resident units, the facility failed to provide a clean and homelike environment. Findings include:
7/13/23 10:15 AM - During an observation and interview on the 400 unit, E28 (Corporate) confirmed the extensive amount of dust and dirt on the baseboards, under the air conditioners in the halls, disrepair of the paint on the walls and that there was no molding or flooring next to the air conditioner in front of the 400 unit nurses' station.
7/13/23 10:40 - During the interview with E26 (ESD), stated that the condition of the facility was unacceptable.
7/14/23 - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference, beginning at 9:45 AM.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on record review, it was determined that the facility failed to provide R194 care and treatment in accordance with professional standards of care regarding her LLE (left lower extremity) surgica...
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Based on record review, it was determined that the facility failed to provide R194 care and treatment in accordance with professional standards of care regarding her LLE (left lower extremity) surgical incision as evidenced by failure to assess, initiate orders and provide care until 7/18/22, which was 24 days after R194's admission to the facility. Findings include:
Review of R194's record revealed the following:
6/24/22 - R194 was admitted to the facility with diagnoses including: left fibula (lower leg) fracture, dementia and need for assistance with personal care. Discharge Instructions from the hospital included: Follow-ups for After discharge . (name of MD), Specialty Orthopedic Surgery, Why: 1-2 weeks If you have a boot or splint, wear the boot or splint as told by your doctor. Take it off only as told by your doctor.
6/25/22, 6/26/22, 6/27/22 - E9 (LPN) documented in Prestige Daily Skilled Note no skin conditions on Section 1 Standard and did not fill in the box for Skin in Section 2 Systems.
For three days' worth of assessments, E9 failed to acknowledge the presence of R194's LLE surgical incisions.
6/27/22 - E34's (MD) admission History and Physical documented Patient had a fall and presented to the hospital, found to have a left distal fibula fracture and transverse medial malleolus (ankle) fracture . underwent ORIF (open reduction and internal fixation(surgery).
The facility used a Prestige Daily Skilled Note to docuement daily assessments. On the following dates (16 days) staff documented no skin conditions, often wrote skin is warm and dry and failed to document under the Surgical Wound subsection on 6/28, 6/29, 6/30, 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, 7/8, 7/9, 7/10, 7/11, 7/12 and 7/13/22.
A total of seven nurses (E9, E36, E37, E38, E39, E41 and E42) documented inaccurate assessments.
6/29/22 - C4's (Consultant Wound Care NP) Skin/Wound Note documented Comprehensive skin and wound evaluation for new admission to facility Exam: Dermatologic- Wound(s) present; Please see wound assessment below. Wounds- Pt (patient) has surgical site to left ankle See TA (Tissue Analytics) documentation for full wound assessment details. Plan: Wound Plan of care . RN to return later to assess area and notify PCP of any concerns . recommend extensive wound care to site .
There was no follow up documentation by the RN regarding R194's wound. Additionally, there was no documentation regarding R194's LLE wound using the Tissue Analytics documentation program at this time.
7/7/22 - E40 (LPN) documented in Prestige Daily Skilled Note no skin conditions on Section 1 Standard and Section 2 Systems documented skin is warm and dry . and in the Surgical Wound subsection documented Surgical wound noted.
This was the first documentation by nursing staff acknowledging the LLE surgical incisions. The next time the wound was acknowledged was 7/14/22.
7/15/22 - E6 (NP) ordered Doxycycline Monohydrate 100mg by mouth two times a day for Ortho (Orthopedic) infection LLE X (times) 7days.
7/18/22 - E6's (NP) Progress Note documented . Physical exam .Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: Closed left ankle fracture . Per ortho- had follow-up on 7/15/22. S/P (status post) L (left) ankle ORIF. Possible infection. Recommend Doxycycline X 7 day course (started 7/15/22) . Continue local wound care . Encounter for other specified surgical aftercare, . had Ortho appt 7/15/22, possible infection. Started on Doxycycline . continues on currently .
7/18/22 - E35 (NP) ordered Treatment- left medial and anterior ankle- cleanse are with NSS (normal saline solution)/wound cleanser, apply xeroform (medicated mesh dressing) and cover with dry dressing. Notify wound care /provider for worsening wound. As needed for wound care AND every shift.
The order on 7/18/22 was the first medical order acknowledging R194's LLE surgical incisions.
7/18/22 - E9 (LPN) documented in Prestige Daily Skilled Note no skin conditions in Section 1 Standard and did not fill in the box for Skin in Section 2 Systems.
7/19/22 - E37 (RN) documented in Prestige Daily Skilled Note no skin conditions in Section 1 Standard and Section 2 Systems documented skin is warm and dry . and in the Surgical Wound subsection documented Surgical wound noted- Right foot.
E37 (RN) acknowledged the presence of a surgical wound; however R194's surgical incision was on her left leg, not her right leg as E37 documented.
7/20/22 9:03 AM - C4 (Consultant Wound Care NP) documented Tissue Analytics wound measurements for left lateral and medial ankle wounds.
This is the first and only documentation of wound measurements using the tissue Analytics program in R194's medical record.
7/10/23 3:33 PM During a phone interview, F5 (R194's granddaughter) stated, I visited my grandmom almost everyday after work. I asked several times different nurses about the dressing on her leg and changing it. My grandmom was a diabetic. F5 stated, I was told 'no instructions were sent from the hospital.'
7/14/23 10:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on record review, it was determined that the facility failed to ensure that the physician reviewed R194's total program of care at each visit, including assessments of the left lower extremity (...
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Based on record review, it was determined that the facility failed to ensure that the physician reviewed R194's total program of care at each visit, including assessments of the left lower extremity (LLE) as evidenced by the lack of orders for assessment and care for the LLE surgical incision until 7/15/22, 21 days after R194's admission. Despite multiple Provider visits, the Physician/NP notes lacked first-hand assessments or interventions for R194's LLE incision. Findings include:
6/24/22 - R194 was admitted to the facility with diagnoses including: left fibula (lower leg bone) and ankle fractures, dementia and need for assistance with personal care. Discharge Instructions from the hospital included: Follow-ups for After discharge . (name of MD), Specialty Orthopedic Surgery, Why: 1-2 weeks . If you have a boot or splint, wear the boot or splint as told by your doctor. Take it off only as told by your doctor.
6/27/22 - E34's (MD) admission History and Physical documented . Patient had a fall and presented to the hospital, found to have a left distal fibula fracture and transverse medial malleolus (ankle) fracture . underwent ORIF (open reduction and internal fixation [surgery]) . Physical exam . Skin: see nursing admit note . Assessment/Plan: Closed left ankle fracture, S/P ORIF- NWB, some pain as expected .
6/29/22 - C4's (Consultant Wound Care NP) Skin/Wound Note documented .Comprehensive skin and wound evaluation for new admission to facility . Exam: Dermatologic - Wound(s) present; Please see wound assessment below. Wounds - Pt has surgical site to left ankle See TA (Tissue Analytics) documentation for full wound assessment details. Plan: Wound Plan of care . RN to return later to assess area and notify PCP (Primary Care Physician or Provider) of any concerns . recommend extensive wound care to site .
There was no follow up documentation by the RN (bedside nurse as referenced in the above note) regarding R194's wound. Additionally, there was no note regarding R194's LLE wound using the Tissue Analytics documentation program at this time. Lastly, there was no explicit wound care recommendations or orders written to coincide with this note.
7/1/22 - E6's (NP) Progress Note documented . Physical exam . Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: Closed left ankle fracture - left distal fibula fracture and transverse medial malleolus fracture. Now S/P ORIF procedure 6/15/22. Remains NWB, has LLE cam brace/boot in place. Some intermittent pain as expected, pain meds help .
7/5/22 - E6's (NP) Progress Note documented . Physical exam . Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: Encounter for other specified surgical aftercare, S/P ORIF to LLE ankle. WCT (Wound Care Team) following. Nursing to monitor ongoing, treatment as ordered/recommended. LLE distal neurovascular exam intact on exam today.
7/6/22 - E6's (NP) Progress Note documented . Assessment/Plan: Encounter for other specified surgical aftercare, S/P ORIF to LLE ankle. WCT following. Nursing to monitor ongoing, treatment as ordered/recommended. LLE distal neurovascular exam intact.
This progress note lacked documentation of the Skin system under the Review of Systems and Physical Exam section.
7/12/22 - E6's (NP) Progress Note documented . Physical exam . Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: Left . fibula and . malleolus fracture . has follow-up with Ortho 7/15/22 . Encounter for other specified surgical aftercare, S/P ORIF to LLE ankle. WCT following. Nursing to monitor ongoing, treatment as ordered/recommended. LLE distal neurovascular exam intact.
7/15/22 - E6's (NP) Progress Note documented . Physical exam . Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: .WCT following . Nursing to monitor ongoing, treatment as ordered/recommended. LLE distal neurovascular exam intact.
7/15/22 - R194's Ortho Consultation Findings note documented . S/P L (left) ankle ORIF, poss (possible) infection, recommend doxycycline (antibiotic). F/U (follow-up) with (MD name) next Tuesday . Local wound care .
7/15/22 - E6 (NP) ordered Doxycycline Monohydrate (antibiotic) 100mg by mouth two times a day for Ortho infection LLE times 7days.
7/18/22 - E35 (NP) ordered Treatment - left medial and anterior ankle - cleanse area with NSS/wound cleanser, apply xeroform (a type of wound dressing) and cover with dry dressing. Notify wound care/provider for worsening wound. As needed for wound care AND every shift.
The order on 7/18/22 was the first order acknowledging R194's LLE surgical incision in the medical orders.
7/18/22 - E6's (NP) Progress Note documented .Physical exam . Skin: Warm, dry. Limited Exam. See nursing notes and skin/wound care notes . Assessment/Plan: Closed left ankle fracture . malleolus fracture . Per ortho - had follow-up on 7/15/22. S/P L ankle ORIF. Possible infection. Recommend Doxycycline X 7 day course (started 7/15/22) . Continue local wound care . Encounter for other specified surgical aftercare . had Ortho appt 7/15/22, possible infection. Started on Doxycycline of which patient continues on currently .
7/20/22 9:03 AM - C4 (Consultant Wound Care NP) documented Tissue Analytics wound measurements for the left lateral and medial ankle wounds.
This is the first and only documentation of wound measurements using the tissue Analytics documentation program in R194's medical record.
7/14/23 10:30 AM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (DON), and E3 (ADON).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation and interview, it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of Kitchen operation. Findings include:
7/5/23...
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Based on observation and interview, it was determined that the facility failed to ensure that a qualified person in charge was present during all hours of Kitchen operation. Findings include:
7/5/23 11:05 AM - During an observation and interview, E32 (Regional Dining Consultant) and E33 (Assistant Dining Services Manager), disclosed that no members in the facility's food service department possessed valid Food Protection Manager certificates from an Accredited Food Safety Program.
7/5/23 3:22 PM - Findings were confirmed with E32 and E33.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, it was determined that the facility failed to prevent the occurrence of mold in high moisture areas, ensure safe storage of food and provide the sanitizing solution...
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Based on observation and interview, it was determined that the facility failed to prevent the occurrence of mold in high moisture areas, ensure safe storage of food and provide the sanitizing solution required for disinfecting food preparation surfaces. Findings include:
7/5/23 9:25 AM - During a tour of the kitchen, no red sanitizer buckets containing sanitizing solution were available in the kitchen for disinfecting food preparation surfaces.
7/5/23 9:32 AM - During a kitchen tour, an improperly covered tray of sliced ham and turkey, a partially covered container of leftovers and a tray of sliced cheese and bread with the plastic film cover peeled up at the corner exposing the contents to moisture and other debris were observed in the walk-in refrigerator.
7/5/23 1:08 PM - During a tour of the kitchen, numerous areas of black spotted staining, which appeared to be mold, were observed on the kitchen ceiling directly above the water pipes that hang several inches below the ceiling.
7/5/23 3:22 PM - Findings were confirmed with E32 (Regional Dining Consultant) and E33 (Assistant Dining Services Manager).
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0924
(Tag F0924)
Could have caused harm · This affected multiple residents
Based on observation and interview, it was determined that in one out of five units, the facility failed to ensure that a handrail in a resident corridor was firmly affixed to the wall. Findings inclu...
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Based on observation and interview, it was determined that in one out of five units, the facility failed to ensure that a handrail in a resident corridor was firmly affixed to the wall. Findings include:
7/5/23 10:43 AM - During an observation and interview, E27 (LPN) revealed to the Surveyor that a handrail approximately four feet long, on the 400 unit, next to the linen room, was loose and about to fall off. The end closest to the unit could easily be pulled away from the wall.
7/5/23 10:50 AM - During an observation and interview, E26 (ESD) confirmed that the handrail was broken and could easily be pulled away from the wall.
7/5/23 11:24 AM - During an observation and interview, E29 (Maintenance) confirmed that the handrail could just pop right off when residents attempted to utilize it.
7/5/23 11:25 AM - During an interview, R36 (RN) stated that she observed other residents use the handrail and one end would fall off the wall. The interview occurred with E29 present.
7/10/23 2:26 PM - During an observation and interview, E1 (NHA) confirmed that the handrail was firmly secure to the wall.
7/14/23 - Findings were reviewed with E1, E2 (DON) and E3 (ADON) at the exit conference beginning at 9:45 AM.
MINOR
(C)
Minor Issue - procedural, no safety impact
Drug Regimen Review
(Tag F0756)
Minor procedural issue · This affected most or all residents
Based on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for diffe...
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Based on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process. Findings include:
7/7/23 11:52 AM - Review of the facilities undated policy titled, Medication Regimen Review, lacked information regarding the time frames for a pharmacist response, urgent and non-urgent medication recommendations, or a time frame for a facility response to recommendations.
7/14/23 - An interview during exit conference with E2 (DON) confirmed the MRR policy did not meet the expected requirements.
7/14/23 9:45 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.
Sept 2021
23 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on record review, interview, and observation, it was determined that the facility failed to provide quarterly statements of personal funds accounts for one (R126) out of four residents reviewed ...
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Based on record review, interview, and observation, it was determined that the facility failed to provide quarterly statements of personal funds accounts for one (R126) out of four residents reviewed for personal funds. Findings include:
Review of R126's clinical record revealed:
5/17/19 - R126 was admitted to the facility.
9/7/21 - A quarterly MDS (Minimum Data Set) assessment stated that R126 had a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact.
9/23/21 1:45 PM - During an interview, R126 stated that she has not received any statements for her personal funds that the facility manages. She knows she can get money out, but she has no idea how much money is in her account.
9/29/21 1:35 PM - During an interview, E1 (NHA) stated that R126 must know how much money is in her account because she withdraws money.
9/29/21 4:00 PM - During an interview with E35 (Business Manager) and R126 in her room, B35 showed R126 her personal fund account statements. R126 denied ever receiving these statements and did not understand how she had so much money in her account. R126 said because she is now bed bound when she needs spending money, she asks the activity staff to get money for her out of her account. E35 explained to R126 the funds she now has (e.g., stimulus checks received) and requested to contact her directly when she needs spending money.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
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 observation, interview, and record review, it was determined that the facility failed to immediately consult with the resident's physician for one (R126) out of six (6) residents reviewed for...
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Based on observation, interview, and record review, it was determined that the facility failed to immediately consult with the resident's physician for one (R126) out of six (6) residents reviewed for unnecessary medications. The facility failed to immediately consult R126's physician when she developed a nosebleed that required nursing intervention on 9/22/21 at 5:15 PM. R126 was on an anticoagulant (increases the risk of bleeding) drug that was decreased by half the dose after the physician was notified of the nosebleed by the surveyor. Findings include:
The facility's policy titled Notification of Change (undated), provided by E3 (Corporate Clinical Consultant), included, The charge nurse, unit manager or nursing supervisor will notify the physician when .there is a significant change in the resident's physical, mental or psychosocial status .the licensed nurse will record in the resident's medical record any changes in the resident's condition and the notification of the physician, family member and/or responsible party.
Review of R126's clinical record revealed:
5/17/19 - R126 was admitted to the facility.
5/17/19 (last revised 7/3/19) - A care plan was initiated that R126 has a potential for alteration in hematological (bleeding) status related to anticoagulant side effects and included interventions to monitor for side effects.
5/17/19 through 9/29/21 - A review of MDS assessments revealed that R126 had been receiving an anticoagulant medication (med) since 9/17/19.
8/31/21 - Physicians' orders (after R126's most recent readmission to the facility) included to give:
- An anticoagulant med by mouth two times a day.
- A low dose Aspirin (can increase risk of bleeding) once a day.
8/31/21 - An order notification was documented in the EMR warning of a potential severe level interaction that stated the use of [the anticoagulant med] with Aspirin may increase the risk of bleeding.
9/22/21 5:15 PM - When the Surveyor entered R126's room she was observed in bed having an active nosebleed of bright red blood and holding bloody tissues on her nostrils. E13 (LPN) was notified of the nosebleed then entered the room to assess and assist R126. When asked, R126 stated she does take anticoagulants.
9/23/21 8:45 AM - During an interview with the nurse assigned to R126 for day shift, E57 (RN) stated that she was not informed of R126's nosebleed.
9/23/21 1:45 PM - During an interview, R126 stated that last night's nosebleed stopped after being assisted by E13. In addition, she stated that she has had other nosebleeds, but not recently.
9/29/21 8:30 AM - During an interview and observation, E19 (interim ADON) confirmed that there was no documentation in the EMR that R126 had a nosebleed on 9/22/21 or that the physician was notified. E19 reviewed and confirmed that the Doctor's Book did not have a message regarding the nosebleed.
9/29/21 9:10 AM - During an interview, E16 (NP) and E17 (Physician) confirmed they were not notified of the nosebleed and that they would have wanted to be notified because R126 was on anticoagulants. E16 checked and confirmed that the on-call medical group was not notified.
9/29/21 1:00 PM - During an interview, E15 (NP) confirmed she was not notified of the nosebleed and that she spoke with E18 (Medical Director) who was also not notified.
9/29/21 - Physicians' orders included to decrease the anticoagulant dose in half and to stop the Aspirin.
The facility failed to follow the standard of care to notify the physician and to document in the medical record R126's nosebleed. When on anticoagulants, evidence of bleeding, such as nosebleeds, blood in the urine, and red or tarry (black tar like) stools, warrant a call to the physician. (CapPharmacology)
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
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 observations and interview, it was determined that for one (rehabilitation- rehab) out of four units, the facility failed to secure the residents Protected Health Information (PHI). Findings ...
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Based on observations and interview, it was determined that for one (rehabilitation- rehab) out of four units, the facility failed to secure the residents Protected Health Information (PHI). Findings include:
9/24/21 11:36 AM - A list of resident names, care issues, and diagnoses was observed on the top of an unattended medicine cart during a random observation in the rehab unit. An interview with E4 (RN) confirmed that she was aware that residents' PHI should not be left out in view. E4 then turned the information face down so it could not be viewed.
9/28/21 3:04 PM - A list of resident names, care issues, and diagnoses was observed on the top of an unattended medicine cart during another random observation on the rehab unit. An interview with E4 (RN) again confirmed that she was aware that residents' PHI should not be left out in view. E4 then turned the information face down so it could not be viewed.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
3. 9/23/21 12:31 PM - During an interview, R33 complained that six of her nightgowns that she had when she was on Station 2 have been missing for several months (she said that she was moved to a room ...
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3. 9/23/21 12:31 PM - During an interview, R33 complained that six of her nightgowns that she had when she was on Station 2 have been missing for several months (she said that she was moved to a room on Station 1 a couple of weeks ago). R33 added that she told several CNAs (on Station 2 who then told the laundry staff) and the laundry staff visited her and told her they were looking for them.
March 2020 - September 2021 - Review of all grievances provided by social services involving lost personal items found no grievance about R33's lost items.
9/29/21 11:30 AM - During a follow-up interview, R33 stated that the facility did not find any of her nightgowns.
9/29/21 12:45 PM - During an interview, E36 (Housekeeping Manager) stated she had talked with R33 several times and tried to find her nightgowns. E36 stated most of the time residents' personal clothing is lost because the nursing staff do not make sure items are labeled with the residents' names. When asked if she did a grievance, E36 said no since the social workers are the ones who do them.
9/30/21 10:29 AM - During an interview, E1 (NHA) stated that she was doing the grievance now for R33's lost nightgowns.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
Based on interview and review of other facility documentation, it was determined that, for two (R33 and R56) out of three residents sampled for personal property, the facility failed to have initiate a grievance when lost laundry items were not located. Additionally, the facility's grievance policy did not include a process for anonymous reporting. Findings include:
1. The facility policy entitled Grievance and Concerns / Complaint (revised 9/15/21) included the process for submitting a grievance or complaint. Grievance forms are available on each nursing unit, the Reception Desk and each Social Services office . Should a staff member overhear, or be the recipient of a complaint voiced by a resident, his/her representative, or other interested family member . the staff member should encourage and assist . to file a written concern with the facility . If the resident is incapable of obtaining and completing a form . the staff member should immediately notify social service representative . assist with the completion of the form if the social service representative is not available . The policy did not include the process for filing a grievance anonymously.
9/24/21 3:01 PM - During an interview with E31 (SW), when asked where residents would get grievance forms and the location of the drop box, E31 did not know, she would ask the person who handled grievances.
9/24/21 3:25 PM - During a follow-up interview, E31 said the resident would get the form from us and we would put it in. When asked how a resident could do a grievance anonymously, E31 did not know the answer and stated that she would find out.
9/24/21 3:34 PM - During an interview, E31 said the forms are at the nursing stations and E31 did not identify how a grievance could be submitted anonymously, other than sliding it under the social services door.
2. 9/22/21 6:00 PM - 6:45 PM - During an interview, FM1 (Family Member of R8) expressed concern over the loss of numerous clothing items (20 pairs of underwear, three pairs of sneakers, four pairs of slippers and all of her pants and tops) along with three comforters. FM1 explained that this occurred just prior to COVID hitting, around March of 2020. FM1 added that R8's name was on all of her items and that FM1 went to the laundry room several times to look for the items. FM1 stated she was told by staff that R8 threw items in the trash or toilet. FM1 added that she discussed the issue with E45 (former NHA) and met with him.
March 2020 - September 2021 - Review of all grievances provided by Social Services involving lost personal items found no grievance about R8's lost items.
9/28/21 approximately 4:05 PM - During an interview with E3 (CCC and former DON) to discuss the lost items, E3 stated, I seem to remember the 20 pairs of underwear.
9/29/21 4:45 PM - During an interview, E30 (SW) stated a former SW took care of grievances at that time. E30 indicated she would look into it when the Surveyor stated that R8's grievance was not in the pile of grievances provided to the Surveyors.
9/30/21 10:29 AM - During an interview, E1 (NHA) stated that she was doing the grievance now. The Surveyor informed E1 that E3 was aware of the issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on record review and interview it was determined that, for one (R56) out of four residents sampled for dementia, the facility failed to identify a significant change of condition on the 7/22/21 ...
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Based on record review and interview it was determined that, for one (R56) out of four residents sampled for dementia, the facility failed to identify a significant change of condition on the 7/22/21 quarterly MDS assessment. Findings include:
1/15/21 - R56 was admitted to the facility with dementia.
4/24/21 - The quarterly MDS assessment revealed R56's BIMS score was 12 (moderate cognitive impairment), was understood and could understand others, had behaviors four to six days a week, was frequently incontinent of urine, occasionally incontinent of bowel and denied having pain.
7/22/21 - The quarterly MDS assessment showed that R56 had severe cognitive impairment (score 3), was less able to understand others and less able to be understood, had no behaviors, was now always incontinent of urine and frequently incontinent of bowel.
The facility failed to identify the change (decline) in three or more areas, and, thus, did not complete a significant change assessment.
9/29/21 10:32 - During an interview the Surveyor reviewed the findings with E27 (RNAC) who said she would look into it.
9/30/21 8:40 AM - During an interview, E33 (RNAC) stated R56's change was not acute, it was disease progression. The Surveyor explained that there were declines in many areas indicating a decline and that a significant change MDS assessment would prompt a close review of care interventions R56 needed.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
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, it was determined that for one (R102) out of four residents sampled for pressure ulcers, the facility failed to develop a comprehensive care plan that included turning, reposit...
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Based on record review, it was determined that for one (R102) out of four residents sampled for pressure ulcers, the facility failed to develop a comprehensive care plan that included turning, repositioning, and offloading heels to prevent pressure injuries. Findings include:
8/18/21 - A physician order was written to turn and reposition R102 and to encourage offloading of heels while in bed.
8/19/21 - A nursing admission note by E4 (RN) revealed mushy heels and no other skin issues.
8/20/21- An admission nursing progress note revealed a pink blanchable buttock.
8/25/21 1:30 PM - A skin/wound note by E41 (CNP wound care) documented, No open wounds on today's skin assessment; please keep patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure to any bony prominence (bony area on body that increases pressure on skin) by adhering to turn protocols and floating heels (positioning feet so heels do not touch surfaces, to prevent pressure) as applicable.
8/25/21 - R102's care plan to prevent pressure injuries failed to include turning and repositioning and encouraging offloading of heels.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
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, observation and interview it was determined that, for two (R8 and R102) out of eight residents investigated for ADLs and respiratory care, the facility failed to revise their c...
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Based on record review, observation and interview it was determined that, for two (R8 and R102) out of eight residents investigated for ADLs and respiratory care, the facility failed to revise their care plans to reflect the residents' current condition. Findings include:
1. Review of R8's clinical record revealed:
10/2/15 - A care plan for ADLs (revised 6/17/21) included the intervention for nursing staff to provide care as needed related to deficits to ensure ADL needs are being met.
9/13/21 - An annual MDS assessment documented R8 as having severe cognitive impairment and R8 needed physical assistance with bathing and limited assistance with both personal hygiene and toilet use.
September 2021 - Review of CNA documentation revealed the tasks were not updated to reflect the level of assistance needed. Bathing/shower was listed as supervision and both personal hygiene and toileting were listed as independent.
September 23, 24, 27, 28 and 29, 2021 - Observations showed that R8 received assistance with bathing prior to breakfast which were later recorded on the CNA documentation as providing extensive assistance each day.
9/30/21 8:20 AM - During an interview with E55 (MDS), the discrepancy of the CNA tasks for bathing, hygiene and toileting compared to the MDS assesment was discussed. The Surveyor explained that a floating or agency aide would not know the degree of help that R8 needed. E55 confirmed that the degree of assistance included on the tasks were not reflective of R8's MDS assessment.
2. The following were revealed in R102's clinical record:
8/25/21 - R102's care plan did not include the use of oxygen.
8/31/21 9:29 PM - A skilled nursing note revealed that R102 was on oxygen.
9/2/21 6:18 PM - A care plan meeting note did not address the addition of oxygen.
9/2/21 10:06 PM - A skilled nursing note documented R102 was on oxygen at 2 liters.
9/27/21 3:53 PM - An interview with E20 (UM) confirmed that R102's care plan was not updated when oxygen was started.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (Corporate Clinical Consultant).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that for one (R65) out of one resident reviewed for constipation the facility failed to implement the bowel protocol. R65 had no assessment or i...
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Based on interview and record review, it was determined that for one (R65) out of one resident reviewed for constipation the facility failed to implement the bowel protocol. R65 had no assessment or interventions for not having a bowel movement in eight days. Findings include:
The undated facility bowel protocol states: If no bowel movement (BM) for three days, give Milk of Magnesia [laxative], if no results follow with Bisacodyl [laxative] tablets or suppository, if no BM after Bisacodyl, follow with Fleet's enema. If no results after enema, notify the provider.
7/28/21 - R65 was admitted for rehabilitation.
A record review of physician orders for R65 revealed:
7/28/21 1:13 PM - A Physician's order was written for Milk of Magnesia thirty milliliters for no BM for three days.
7/28/21 1:13 PM - A Physician's order was written for Bisacodyl tablets or suppository every twenty four hours if Milk of Magnesia was not effective.
7/29/21 1:13 PM - A Physician's order was written for a Fleet's enema every day if Bisacodyl not effective and call MD if no results.
September 2021 review of CNA documentation noted no documented bowel movement for eight days, from 9/17/21-9/24/21.
9/24/21 8:48 AM - During a random observation of R65 during breakfast, R65 was holding a basin and breakfast was on the table at the bedside, uneaten. R65 stated, I'm sick to my stomach and can't eat. On interview, R65 stated to the Surveyor that she had only one BM since her admission to the facility.
9/24/21 9:57 AM - In an interview with E20 (UM) and E65, E20 was unable to explain why R65 had not had a BM for eight days. E20 stated that a report was run every day that identified the residents who had not had a BM for three days and R65 was not identified on this report. E20 then asked R65 when she last had a BM and R65 was unable to state when she last moved her bowels. E20 listened to R65's bowel sounds and confirmed they were present. E20 stated that she will call the provider about the findings.
9/24/21 10:15 AM - During an interview, E22 (LPN) stated that R65 had a BM a few days ago. E22 was unable to confirm with the CNA that R65 had a bowel movement. E20 went to report the findings to the provider.
9/24/21 10:30 AM - During an interview, E20 (UM) stated that she spoke to the doctor and x-rays were ordered to determine R65's bowel status.
9/24/21 1:25 PM - During an interview, E20 (UM) stated that the results of the x-rays were negative for bowel impaction.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON), and E3 (CCC).
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 observation, record review and interview it was determined that, for one (R56) out of five residents investigated for pressure ulcers, the facility failed to ensure measures to prevent pressu...
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Based on observation, record review and interview it was determined that, for one (R56) out of five residents investigated for pressure ulcers, the facility failed to ensure measures to prevent pressure ulcers (sore area of skin that develops when blood supply to it is cut off due to pressure from sitting or laying too long) were implemented. Findings include:
Cross Refer F677, Example 2
Review of R56's clinical record revealed:
1/15/21 - R56 was admitted to the facility with dementia.
1/21/21 - A care plan for being at risk for the development of pressure ulcers included the intervention to turn and reposition every two hours.
7/22/21 - The quarterly MDS assessment documented R56 needed extensive assistance in turning/sitting up in bed and was always incontinent of urine (unable to control urine from leaving the bladder).
9/22/21 8:05 AM - 1:45 PM - R56 was in her wheelchair in the hallway by Station 3's nursing station. R56 occasionally attempted to stand, without her buttocks lifting off of the wheelchair cushion. Every time R56 tried to stand, she was directed to Sit down.
9/23/21 8:30 AM - 1:00 PM - While in her wheelchair from breakfast until after lunch, R56 periodically tried to stand, without lifting her buttocks off of the wheelchair cushion. Due to her severe cognitive impairment, when staff asked what she needed, R56 was not able to state what she wanted and R56 was told to Sit down.
9/24/21 7:50 AM - 12:15 PM - R56 attempted to stand multiple times from her wheelchair, but could not lift her buttocks off of the wheelchair cushion. At 12:15 PM, E7 (RN, UM) asked the aide to take R56 to the bathroom and to use the sit to stand lift since R56 was weak and did not walk.
9/28/21 10:32 AM - During an interview with E3 (CCC) to review concerns about R56, the Surveyor presented E3 with a written list, including the prolonged hours in the wheelchair and lack of incontinence care.
9/29/21 9:35 AM - E3 returned the written list with the observations highlighted in yellow and offered no explanation.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, interview and review of other facility and State Agency documentation, it was determined that, for two (R73 and R79) out of three current residents investigated fo...
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Based on observation, record review, interview and review of other facility and State Agency documentation, it was determined that, for two (R73 and R79) out of three current residents investigated for accident hazards the facility failed to adequately monitor R73 to prevent elopement and failed to implement fall precaution interventions for R79. Findings include:
1. Review of R73's clinical record revealed:
2/2/21 - R73 was admitted to the facility with dementia from alcohol abuse and had a history of brain surgery. R73 threatened to leave the facility, but his family talked him into staying.
2/2/21 - Physicians' orders included a wanderguard bracelet which should activate an alarm when R73 got close to sensors located at exit doors in the facility.
2/3/21 - A care plan for elopement risk was initiated and included the use of the wanderguard.
5/10/21 - The quarterly MDS assessment identified that R73 had moderate cognitive impairment (decisions poor, cues / supervision required) with a score of 8 (moderate score range 8-12).
7/26/21 - A Psychology note documented some verbal aggression and sometimes seeking to exit (the facility).
8/2/21 - A Psychology note documented that R73 was preoccupied with leaving, and needed redirection and distraction from his obsessive thoughts.
8/10/21 - The quarterly MDS assessment documented that R73 was able to walk and had severe cognitive impairment with a score of 6 (severe score range 0-7).
8/17/21 - Review of facility information reported to the State Agency included that when [R73] was not in his room or on the unit, a search was conducted. [R73] was last seen in his room approximately 30 minutes prior when being given his medications. [R73] was located outside of the facility by the nurse and was safely returned inside the facility. A full body assessment was completed with no abnormalities. Vital signs stable. Resident was offered dinner in his room with no complaints. [R73] was placed on 15 minute checks at this time and the NP and sister were notified. The facility's conclusion was that the rug might have slid in/under the door when a visitor's scooter entered the building which deactivated the wanderguard alarm.
8/19/21 - A psychology note documented that [R73] was sorry he eloped to a liquor store. R73 was now in the locked unit.
8/20/21 - 9/15/21 - Review of the State Agency investigation found that R73 left the facility out the front door at 5:48 PM, crossed the four-lane highway and went to the store to buy beer. Shortly after 5:15 PM, several employees held the front door open for a visitor on a scooter who was having difficulty getting into the building. E45 (former NHA) identified that when the front door remained open for an extended period of time, the wanderguard alarm would not go off. Facility video of the front door showed the door was open a little after the visitor on the scooter entered the facility's front door. No one saw R73 leave the facility. R73 was found across the street and was driven back to the facility at approximately 6:30 PM with a bag containing three beers. The wanderguard alarm activated when R73 passed the wanderguard sensors upon his return.
9/27/21 7:40 AM - During an interview, E46 (Front Desk) stated that the facility updates the residents on the elopement list every three to four days. E46 added that residents usually have on a wanderguard that triggers the alarm and the door to lock.
9/28/21 9:26 AM - During an interview, the Surveyor asked E3 (CCC) for R73's elopement investigation packet with statements, root cause analysis and anything done since the elopement. The information received did not include interventions/changes put in place after the elopement.
9/28/21 approximately 10:25 AM - During an interview while E48 (Maintenance) was at the keypad inside the front door which was uncovered with wires visible, when asked if he was fixing the door so that the wanderguard alarm would ring if the door remained open for an extended time, E48 acknowledged that the inside keypad was broken and that the wanderguard sensors were separate. There was no response about the deactivation of the wanderguard alarm when the front door remained open.
9/30/21 6:20 PM - During an interview, E47 (Front Desk) acknowledged that there is a posting at the front desk with pictures of residents on the elopement list.
2. The following was reviewed in R79's clinical record:
11/4/2018 - R79 was admitted to the facility with dementia.
11/5/2018 - R79's fall care plan was initiated and current interventions as of 9/2021 included:
-Dycem (a rubber mat that prevents sliding) to wheelchair.
-Hipsters (a brief with hip protection pads to cushion the hips in the event of a fall and to reduce the risk of hip fracture) on at all times.
-Non-skip strips next to bed.
-Non-slip socks, slippers or shoes at all times.
6/18/2021 - R79's Fall risk assessment documented that R79 was at high risk for falling.
8/10/2021 - A quarterly MDS assessment documented that R79 was moderately cognitively impaired and required assistance for transfers.
9/28/2021 1:00 PM - During an observation and interview with E40 (CNA) and R79, R79, E40 confirmed the aforementioned care plan interventions were not in place. R79 stated that she never had Dycem in her wheel chair, hipsters, or non-skid strips next to her bed. R79 was noted not to have hipsters on. R79 reported that she had non-slip socks, but the surveyor and E40 noted R79's bare feet and her non-slip socks were tucked into her wheelchair. E40 stated that she would have to look in the electronic medical record to see if the interventions were in the task documentation of R79's chart.
9/29/2021 - During an interview at approximately 9:30 AM, E40 (CNA) reported that she went to the therapy department right away after the observation and interview on 9/28/2021 and secured Dycem for R79's wheelchair.
9/30/2021 2:35 PM - During an observation, non-skid strips were noted to be in place on the floor next to R79's bed.
The facility failed to implement R79's care planned fall risk interventions.
These findings were reviewed during the exit conference on 9/30/2021, beginning at 5:04 PM, with E1 (NHA), E2(Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview it was determined that, for two (R56 and R77) out of four residents investigat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview it was determined that, for two (R56 and R77) out of four residents investigated for dementia, the facility failed to ensure the comprehensive care plans included resident symptoms, interventions to ensure consistent staff response and had measurable goals. Findings include:
Cross Refer, F758, Example 1
1. Review of R56's clinical record revealed:
1/15/21 - R56 was admitted to the facility with dementia and psychosis (loss of touch with reality).
Care plans were initiated for different aspects of R56's dementia:
- 1/28/21: bowel incontinence with the goal to be continent during the daytime with an intervention to take R56 to the toilet at the same time each day (no time frame specified).
- 2/26/21: paranoia related to accusatory statements for staff providing ADL care. The goal to have fewer episodes of paranoia was not measurable.
- 3/2/21: antipsychotic medication related to psychosis. R56 had been taking the medication since admission on [DATE].
4/1/21 - A Psychiatric NP note included that R56 had paranoid delusions (false beliefs) and dementia with behaviors.
4/24/21 and 7/22/21 - A quarterly MDS assessments documented R56 had both delusions and hallucinations.
5/10/21 - A Psychiatric NP note documented R56 was diagnosed with major depression with psychotic features and paranoid delusions.
9/2421 10:30 AM - During a random observation, E56 was seated in the hallway near the nursing station and was talking to someone not visible to the Surveyor (hallucination).
9/27/21 - During an observation, E2 (RN, UM) was heard talking to E18 (Physician) in the presence of the Surveyor. E7 described in detail, R56's delusions that involved the CIA (Central Intelligence Agency) entering her room by the stairwell in her closet and killing her dog.
The facility failed to include the resident's specific hallucinations and delusions in her comprehensive care plan, along with staff interventions for a consistent response.
9/29/21 at approximately 9:20 AM - During an interview, E3 (CCC) stated that the care plans would be updated.
2. Review of R77's clinical record revealed:
11/2/20 - R77 was admitted to the facility with dementia associated with alcoholism.
1/5/21 - A care plan for aggression was initiated (revised 8/16/21) with a goal to decrease behaviors, which was not measurable. All interventions were from January, 2021.
Progress Notes documented R77's behaviors about calling and/or going home:
- 2/11/21: impulsive behaviors regarding calling wife.
- 2/14/21: up most of night pacing asking when was his wife was coming to get him.
- 2/14/21: in the daytime, called 911 to go home.
- 2/15/21: non-stop calling wife to beg her to get him.
- 2/23/21: called home several times.
- 2/25/21: called home frequently.
- 4/24/21: calling home nonstop.
6/4/21 - A care plan for using Seroquel (an antipsychotic medication) related to verbal aggression included the goal that verbal and physical aggression would decrease. The goal was not measurable.
R77's care plans for aggression for Seroquel use were not revised or individualized to include R77's frequent calls to his wife at home and how staff should respond for consistency.
9/29/21 at approximately 9:20 AM - During an interview, E3 (CCC) stated that the care plans would be updated.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
2. September 2021 - Review of Bay Terrace's Back Hall medication cart's controlled drug count record revealed incomplete entries including no nurse initials, items completed/disposed of, items receive...
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2. September 2021 - Review of Bay Terrace's Back Hall medication cart's controlled drug count record revealed incomplete entries including no nurse initials, items completed/disposed of, items received from the pharmacy and/or the total number of items in the drawer to verify that the count was correct:
- Day to evening shift: September, 6, 11, 21 and 28.
- Evening to night shift: September 1, 2, 3, 4, 6, 7, 8, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 24*, 25 and 26. *The 9/24/21 entry recorded there were no (zero) items in the locked drawer when 14 were present on the evening to night count.
- Night to day shift: September 22.
9/29/21 at approximately 10:35 AM - During an interview, the Surveyor showed E7 (RN, UM) and E3 (Corporate Clinical Consultant) the controlled drug count record from the back hall with incomplete entries, including nurse initials and missing amounts of controlled medication. E7 added that some of the staff may have worked a double and would verify with the schedules and get back to the Surveyor.
9/30/21 6:00 PM - No additional information was provided by the end of the exit conference.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
Based on record review, observation, and staff interview, it was determined that for two (Beach Cove Unit, South Cart and Bay Terrace, Back Hall Cart) out of four medication carts inspected, the facility failed to accurately reconcile the transfer of controlled drugs from one shift to another. Findings include:
8/21/21 (date of last revision) -The facility policy for Controlled Substances stated, in reference to shift change controlled substance count, that Controlled Substances will be counted shift to shift between the oncoming nurse and the off going nurse .The oncoming nurse with the off going nurse will verify that each individual medication card, liquid bottle/vials, boxes are counted, and the total documented accurately on the Narcotic Count Sign in Sheet .Any discrepancies will be reported to the Unit manager /Supervisor /ADON /DON immediately for investigation to determine the cause and identify any responsible parties .
1. 9/28/21 4:00 PM - During a narcotic count of Beach Cove Unit's South Cart with E32 (RN), it was discovered that the Controlled Meds Count Record sign in sheet was incorrectly signed by the oncoming nurse and the off going nurse for the past three shifts. In addition, while E32 was observed signing his initials to indicate the count was correct in the block for the nurse reporting on the 11-7 night shift (but he was reporting on the 3 -11 evening shift), he stated that he just needed to initial one spot before this form was checked. When asked to explain where he should have initialed when he verified the count was correct with the 7 - 3 day shift nurse, he scribbled over the entire block to cover his initials and said, This sheet is completed wrong.
9/28/21 4:30 PM - During an interview and review of the form, E19 (ADON) confirmed that the Controlled Meds Count Record sign in sheet was incorrectly signed by the oncoming nurse and the off going nurse for the past three shifts, and that she would call each nurse to have them correct the sheet and to verify that the count was correct.
9/29/21 12:30 PM - During an interview, E19 (ADON) stated that she had to restart a new Controlled Meds Count Record sign in sheet and was still waiting for some of the nurses to resign the new sheet.
CONCERN
(D)
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 two (R33 and R73) out of nine residents sampled for accidents and personal property and one (R20) out of one resident sampled for dial...
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Based on record review and interview, it was determined that, for two (R33 and R73) out of nine residents sampled for accidents and personal property and one (R20) out of one resident sampled for dialyisis, the facility failed to ensure accurate and complete records. Findings include:
Cross Refer F689, Example 1
1. Review of R73's clinical record revealed:
2/2/21 - R73 was admitted to the facility with dementia.
8/2/21 - An elopement risk evaluation, completed in preparation for the next quarterly MDS assessment, documented that R73 had eloped, which did not occur until 8/17/21.
8/10/21 - The quarterly MDS assessment was completed.
8/17/21 - R73 eloped from the facility and was not located for approximately 30 minutes.
9/29/21 1:05 PM - During an interview, E3 (CCC) provided printed copies of the elopement risk evaluations and confirmed the error.
2. Review of R33's clinical record revealed:
6/19/21 - R33 was admitted to the facility for rehabilitation.
6/19/21 - A Treatment Limitations/DNR Order Form was completed by E58 (RN, Supervisor) and was co-signed by E2 (Interim DON), but was not signed by a medical practitioner. This form indicated that R33 was a DNR (do not resuscitate), RN may pronounce, and a DNI (do not intubate- put in a breathing tube).
6/19/21 7:50 PM - E58 (RN, Supervisor) documented in the eMAR (electronic medication administration record), Talked with daughter stated she was a DNR status. Second witness talked with daughter, DNR order signed.
6/19/21 - A physician's order was written for DNR, RN may pronounce, and DNI.
9/23/21 12:30 PM - During an interview, E19 (ADON) provided a copy of E33's Treatment Limitations/DNR Order Form and confirmed that it was just signed by a medical practitioner (E16 NP) today after the surveyor requested a copy. In addition, the form did not include the signature of the responsible party/resident.
9/24/21 9:30 AM - During an interview with E2 (Interim DON) and E3 (CCC), E3 stated that the facility no longer uses the Treatment Limitations/DNR Order Form as an order; therefore, it is not required that it be signed by a medical practitioner. E3 added that all code status orders must be ordered in the EMR (electronic medical record), not on paper. E2 (Interim DON) stated that he and E58 (RN, Supervisor) spoke to R33's daughter on 6/19/21 on the phone and confirmed that R33 was a DNR.
The facility placed a Treatment Limitations/DNR Order Form on the resident's chart that did not indicate who the nurses spoke with to confirm R33's code status. E58 documented in the eMAR, not in the EMR progress notes that she spoke with R33's daughter to confirm the code status. The interdisciplinary team would not look for this information in the eMAR.
3. 6/6/19 - R20 was admitted to the facility with end stage kidney disease.
3/8/21 9:00 AM - A physician's order included: Dialysis on Monday, Wednesday and Friday.
3/8/21 3:00 PM - A physician's order included: Record post dialysis weight from (dialysis) treatment book every evening shift every Monday, Wednesday and Friday.
9/27/21 9:14 AM - R20 was noted to have a dialysis communication record binder that is sent with R20 on her dialysis days. There was a section of the dialysis communication sheets that had noted by facility for post dialysis review to initial. The post dialysis sheets in the communication book were blank on numerous instances.
9/27/21 9:51 AM - During an interview, E24 (Wound Nurse) confirmed that the space for noted by facility in the dialysis communication book was not initialed on a significant amount of the sheets. E24 reported that the post-dialysis weights are recorded in R20's medication administration record (MAR) which confirms that they had been reviewed.
Review of R20's medical record revealed that R20's post dialysis weights were not documented in the MAR on 7/14, 7/28 and 8/6/21 for practitioners to review. In addition, the noted by staff line on the communication sheets in R20's dialysis communication book were not initialed as noted by the facility on the dates in question as well.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview, it was determined that, for two (R73 and R77) out of five residents sampled for immunizations, the facility failed to offer the pneumonia vaccination. Findings in...
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Based on record review and interview, it was determined that, for two (R73 and R77) out of five residents sampled for immunizations, the facility failed to offer the pneumonia vaccination. Findings include:
1. Review of R73's medical record revealed:
2/2/21 - R73 was admitted to the facility with dementia.
There was no evidence in the eMAR, consents or immunization section of the clinical record that the pneumonia vaccination was ever offered, declined or accepted.
9/28/21 at 10:33 AM - During an interview with E3 (CCC), the Surveyor requested information about R73's immunization status for the pneumonia vaccination.
9/29/21 at approximately 9:35 AM - During an interview with E6 (RN, QAPI) and E3, E6 stated that R73 would receive his pneumonia vaccination today.
2. Review of R77's clinical record revealed:
11/20/20 - R77 was admitted to the facility.
There was no evidence in the eMAR, consents or immunization section of the medical record that the pneumonia vaccination was offered, declined or accepted.
9/28/21 at 10:33 AM - During an interview with E3 (CCC) the surveyor requested information about R77's pneumonia immunization status.
9/29/21 at approximately 9:35 AM - During an interview with E6 (RN, QAPI) and E3, E6 stated that R77 received his pneumonia vaccination the day prior after obtaining permission from R77's responsible party.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview it was determined that the facility failed to ensure a sanitary and comfortabl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview it was determined that the facility failed to ensure a sanitary and comfortable environment for residents and families. Findings include:
Observations during the survey revealed:
1. 9/22/21 11:37 AM - The entire resident room floor was sticky from the doorway and into the bathroom. The frame around the wall-mounted bathroom call light was broken.
9/22/21 at 6:05 PM - During an interview, FM1 (R8's family member) stated that R8's floor has always been dirty, when I would visit three times a week. FM1 added, I would clean it myself and not say anything.
9/23/21 9:08 AM - A random observation of R102's bathroom revealed a loose towel rack. E56 (CNA) confirmed it was loose and will place a maintenance request to fix it. There was also a large amount of water between the air conditioner and R102's bed, appearing to be coming from the air conditioner. E56 got some towels to absorb the water and confirmed that this will be included in the work order.
9/23/21 8:10 AM - After the floor was cleaned by housekeeping, the floor still appeared dirty when observed from the doorway.
9/23/21 before lunch - During an interview, E53 (Housekeeper) stated that she usually would clean the room when staff were assisting R8 in the bathroom to avoid R8 yelling to get out of the room. When the surveyor described that the floor still looked dirty from the doorway the other day, E33 added that the floor may need to be stripped and redone.
2. 9/23/21 8:57 AM - An observation in room [ROOM NUMBER] revealed a black substance on the floor behind the toilet and along the wall where resident shoes were stored. The bathroom had a foul odor that was not urine or bowel movement. The odor permeated through the KN95 mask worn by the Surveyor. Additionally, the floor in front of the lounge chair was cracked and indented.
9/29/21 2:00 PM - The environmental findings were reviewed with E1 (NHA), E37 (Maintenance Director), and E38 (Regional Director of Operations).
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on record review, interview and review of other facility documentation, it was determined that the facility failed to ensure that Resident Council grievances were promptly acted upon and that th...
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Based on record review, interview and review of other facility documentation, it was determined that the facility failed to ensure that Resident Council grievances were promptly acted upon and that the facility response was communicated to the Council. Findings include:
Cross-refer F804
The Resident Council meeting minutes for June, July, and August 2021 were reviewed for resident concerns.
6/22/21 - The Resident Council had concerns that laundry was taking more than three days to label and return laundry.
7/27/21 - The facility response to the laundry concern was that the facility was still working on a resolution to the issue.
7/27/21 2:00 PM - During the Resident Council meeting, concerns were raised that rooms were not being cleaned and paper items were not being restocked in resident rooms. R75 had concerns that staff were unprofessional, call bells were not being answered and follow up's to requests was poor. A resident who wished to remain anonymous, stated staff were talking on their cell phones in resident rooms. Several residents also had concerns that they had pests (mice and bugs) in their rooms.
8/24/21 - Facility responses to the July Resident Council meeting concerns:
- Laundry issue was due to limited laundry staff, because laundry staff were now helping housekeeping clean and stock resident rooms.
- Staff education was ongoing concerning call bell responses and professionalism.
- Pest resolution was ongoing and follow up from the facility listed the dates that pest control was in the facility.
8/24/21 2:00 PM - A Resident Council meeting was held where concerns were raised about call bell wait times, face masks not being worn properly, and not getting water at night.
- No follow up to these concerns were noted in the resident minutes as of 9/22/21.
9/24/21 1:25 PM to 3:00 PM- During a Resident Council meeting held with residents (R15, R31, R71, R75, R81, R124, R137, R143) the attendees stated the facility did not always act on the Resident Council concerns. The food was often unpalatable, pests were seen in rooms, including mice and bugs. Laundry was often slow and misplaced items. There were concerns that staff members were unprofessional, did not answer call bells timely and often had a bad attitude.
9/27/21 4:00 PM - In an interview, R15 (Resident Council President) confirmed that the facility follow-up on Council concerns was inconsistent. R15 stated that he still sees mice in his room, as well as black bugs in his shower. R15 stated that he spoke with E5 (Dietary Manager) about food concerns and that it would improve for a time, then in a month or so they (food concerns) would come up again. R15 also stated that staff members are still unprofessional and stated that especially at the change of shift, he could hear them yelling at each other and talking loudly about their personal business in the hall outside of his room.
The facility failed to consistently communicate responses to Resident Council grievances.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview it was determined that, for three (R50, R56,and R59) out of five residents reviewed for activities of daily living, the facility failed to provide inc...
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Based on observation, record review and interview it was determined that, for three (R50, R56,and R59) out of five residents reviewed for activities of daily living, the facility failed to provide incontinence care, hand hygiene and hair brushing for residents unable to do so on their own. Findings include:
1. The following was reviewed in R59's clinical record:
4/23/20 - R59 was admitted to the facility with a left below the knee amputation.
7/23/21 - A quarterly MDS assessment documented that R59 was cognitively intact, required extensive assist for his care, and was incontinent of urine.
9/22/21 8:40 AM - During an interview, R59 reported that on the night shift he rang his call bell and told the CNA that responded to his call bell that he was wet, and that his shirt, his pad and the bed were all wet. R59 stated that the CNA changed his incontinence brief, but did not change his clothing or the bed linen. R59 lifted up his blankets for the surveyor to see and R59's bed was soaked from one side to the other beneath the resident.
9/27/21 8:21 AM - During an interview, R59 stated that he was wet through to his bed last night. R59's bed was unmade, the mattress was airing out, and appeared to be wet. During an interview, E40 (CNA) confirmed that R59's bed was soaked this morning. R59's roommate, R100 stated that the last time an aide was in to change R59 was about 2 or 3 o'clock this morning. R100 is cognitively intact.
9/29/21 12:23 PM During an interview, E40 (CNA) reported that she had looked at R59's bladder incontinence record and her conclusion was that the resident did not get care for the 11 PM to 7 AM shift. E40 stated that the days she has been R59's aide, 9/27-9/29/21, R59 has been wet all the way through to the bed every day. E40 stated that even if R59 is a heavy wetter, R59 should not have been that wet if the last rounds for incontinence care were provided.
A review of R59's urinary incontinence record revealed that 10 entries were blank and lacked evidence that incontinence care was provided on the following dates and shifts:
-Day shift 9/5, 9/11, and 9/13/21.
-Evening shift 9/16/21.
-Night shift 9/11, 9/15, 9/16, 9/19, 9/20, and 9/21/21.
The facility lacked evidence that R59's need for urinary incontinence care was completed on the aforementioned dates.
Cross Refer F637 and F686
2. Review of R56's clinical record revealed:
1/15/21 - R56 was admitted to the facility with dementia.
1/21/21 - A care plan for being at risk for pressure ulcers (a sore area of skin that develops when blood supply to it is cut off due to pressure from laying or sitting in the same position) included the intervention to perform incontinence care every two to three hours and as needed.
7/22/21 - R56's quarterly MDS assessment identified that R56 had severe cognitive impairment and was always incontinent of urine.
9/22/21 - 9/24/21 - Observations revealed the facility failed to provide incontinence care every two to three hours according to R56's care plan and failed to provide hand hygiene before meals.
- 9/22/21 8:05 AM - 1:45 PM: R56 was seated in a wheelchair in the hallway at Station 3's nursing station. R56 ate breakfast and lunch in the same location. At 1:45 PM when the Surveyor left the area, R56 had not received incontinence care or hand hygiene since being up in the wheelchair from before breakfast.
- 9/23/21 8:30 AM - 1:00 PM: R56 ate breakfast and lunch while in the hallway by Station 3's nursing station in her wheelchair. When the Surveyor left the area at 1:00 PM, R56 had not received incontinence care or hand hygiene.
- 9/24/21 7:50 AM - 12:05 PM: While seated in her wheelchair in the hallway by the Station 3 nursing station, R56 ate breakfast and lunch and remained there without incontinence care until E7 (RN, UM) asked the aide to take her to the bathroom and use the sit to stand [lift].
9/28/21 10:32 AM - During an interview with E3 (Corporate Clinical Consultant), the Surveyor provided a written list of identified concerns, including the aforementioned observations.
9/29/21 9:35 AM - During an interview, E3 returned the written list with the observations marked with a yellow highlighter, but offered no explanation.
3. Review of R50's clinical record revealed:
3/22/21 - R50 was readmitted to the facility after having a stroke that left her without the ability to use her right arm/hand and difficulty speaking.
6/5/12 A care plan for ADL deficit due to late effects of a stroke (last reviewed 8/23/21) included that R50 required total assistance with personal hygiene care (including washing hair) and required one staff participation with showering. The goal was for R50 to complete all personal care tasks (excluding showering and hair care) with no more than set up assistance.
September 2021 - Review of CNA documentation tasks, however, included that R50 was independent with personal hygiene, which was not reflective of R50's ability to brush her hair.
9/23/21 8:59 AM - During an observation, R50's hair was part way down her back below her shoulders and in a pony tail using a rubberband. R50's hair below the rubberband was tangled and matted.
9/24/21 10:10 AM - R50 was observed sitting in her wheelchair in the activity room awaiting her turn to receive nail care from CNA students. R50's hair remained the same, tangled and matted.
9/28/21 9:48 AM - While seated in her doorway, R50's hair remained tangled and matted below the pony tail. When asked if staff ever brushed her hair, she replied, No. When asked if she could brush any part of her hair, she said, No. When asked if she would want to have her hair brushed, R50 said, Yes.
9/29/21 9:50 AM - During an interview with E27 (MDS Coordinator), CNA tasks and lack of interventions addressing R50's hair brushing were reviewed. E27 said she would take care of it.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, it was determined that, for four (R8, R56, R73 and R77) out of six residents reviewed for unnecessary psychotropic medications and/or for elopement, ...
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Based on record review, observation and interview, it was determined that, for four (R8, R56, R73 and R77) out of six residents reviewed for unnecessary psychotropic medications and/or for elopement, the facility failed to monitor for adverse effects and/or specific resident behaviors for the psychotropic medications ordered and they failed to provide evidence that a quarterly GDR (gradual dose reduction) meeting was conducted. Additionally, the Antipsychotic Medication Use policy did not include all of the needed requirements. Findings include:
An undated and untitled facility policy received by E2 (Interim DON) on 9/29/21 at 11:43 AM was identified as the Psychotropic Medication policy. The policy included that PRN (as needed) orders for psychotropics . should have limitations or [an] identified, or clinical rationale if not . A behavior monitoring sheet will be initiated with the new behaviors identified. The Abnormal Involuntary Movement Symptoms (AIMS) assessment would be done per the standards of practice.
1. 6/15/21 - A facility policy entitled Antipsychotic Medication Use included that residents will not receive PRN doses of psychotropic medications unless the medication is necessary to treat a specific condition that is documented in the clinical record. The policy did not include the 14 day limit for PRN antipsychotics and the required evaluation by the provider prior to being reordered.
9/28/21 9:22 AM - During an interview, E3 (CCC) stated the policy would be reviewed when informed about the missing time limits and the need for evaluation when orders were to be reordered.
2. Review of R56's clinical record revealed:
1/15/21 - R56 was admitted to the facility with dementia and psychosis (loss of touch with reality) and had been taking Ability (antipsychotic) prior to admission.
1/15/21 - admission physicians' orders included Abilify for an unspecified mood disorder.
There was no evidence in the record that an AIMS (Abnormal Involuntary Movement Scale) was performed as a baseline to assess for uncontrolled body movements when R56 was admitted on antipsychotic medication.
2/26/21 - A care plan for paranoia was initiated for accusatory statements regarding staff providing ADL care. An intervention included two staff to enter her room for R56's care needs.
3/2/21 - A care plan was initiated for R56 taking Abilify for psychosis with monitoring for targeted behaviors of inappropriate response to verbal communication, including accusatory statements. R56 had been taking this medication since her 1/15/21 admission.
March, 2021 - The Pharmacist Consultant identified the need to clarify the physician's diagnosis of depressive mood disorder for the antipsychotic Abilify. The physician wrote to change the diagnosis to depression with psychosis on 3/4/21. However, the diagnosis on the 3/20/21 order for Abilify remained unspecified mood disorder.
4/1/21 - A Psychiatric NP note documented R56 had paranoid delusions (false beliefs).
6/3/21 - The AIMS assessment was conducted, as well as an entry for monitoring for adverse side effects of the antipsychotic was added to the eMAR for nurses to record any adverse effects, nearly five months after R56 was admitted to the facility on Abilify.
9/24/21 10:30 AM - During a random observation R56 was seen talking to someone not visible to the Surveyor.
9/27/21 8:30 AM - During a random observation, E7 (RN, UM) was heard talking to E18 (Physician) in the presence of the Surveyor. E7 described the details of R56's delusions including that the CIA (Central Intelligence Agency) was in her closet and they killed her dog.
There was no evidence that the facility monitored for delusions and/or hallucinations (hearing, seeing or feeling something that is not visible, heard or felt) even after delusions were identified in April by the Psychiatric NP.
9/28/21 1030 AM - During an interview with E3 (CCC), the Surveyor presented a list of concerns identified, including that the AIMS and adverse effects were not monitored until nearly 5 months after R56 was admitted on an antipsychotic and that behavior monitoring did not include delusions and/or hallucinations. E3 stated she would look into the issues.
9/29/21 at approximately 9:20 AM- During an interview, E3 stated that the delusions and hallucinations would be added for behavior monitoring. In regard to the AIMS, E3 stated that she spoke with the Psychiatric NP who claimed she documented by exception (only putting the abnormal findings) and that since no mention of abnormal movements was in the 2/5/21 NP note, then R56 did not have any. Review of the copy of the NP note provided showed numerous entries of normal findings including No elopement attempts; appetite baseline; no consistently interrupted sleep pattern; compliance with medication administration indicating that charting was not done by exception.
9/30/21 11:43 AM - E2 (Interim DON) presented the Surveyor with a copy of the Psychotropic Medication policy and said it was from E3. The policy was requested several days prior. The Surveyor pointed out that the policy had no title or date and looked like it was just typed. E3 offered no explanation.
3. Review of R73's clinical record revealed:
2/2/21 - R73 was admitted to the facility with dementia from alcohol abuse and had a history of brain surgery.
a. 2/2/21 - Physicians' orders included a medication for anxiety (Ativan) to be given once a day as needed (PRN) for seven days.
2/10/21 - Physicians' orders included Ativan to be given every 8 hours PRN for aggression, agitation. This order did not have an end date.
Psychotropic medications ordered PRN should have an end date after evaluation by a physician for the continued need after the initial order that should be limited to a maximum of 14 days.
9/23/21 6:45 PM- The Ativan order was rewritten with a stop date of 14 days the day after the Surveyors arrived at the facility.
b. April 2021 - September 2021 - Review of R73's eMAR documentation and nursing notes revealed 43 times the PRN Ativan was administered without an adequate indication:
- No behavior was identified for 24 administrations: April 9; May 10, 27 and 30; June 5, 9, 12, 20, 21 and 27; July 7, 8, 10, 15 and 21; August 6, 10, 15, 29 and 31; September 2, 5, 12, and 20.
- The letter 'a' was documented for 19 administrations: April 1, 6, 14, 15, 19, 28 and 29; May 5, 19, 24 and 26; June 1, 15, 16, 22 and 23; July 6, 9 and 14.
7/14/21 10:10 PM - A nursing note documented that R73 continued to be agitated about going home. [Ativan] does help to calm him, but does not completely disarm him. Engaging him in conversations about life experiences is a great distraction, taking his mind off of going home. Unfortunately, staff does not have time to constantly engage him this way.
It was unclear if the 'a' written as the reason for the administration of PRN Ativan was aggression or agitation, which was why the medication was ordered.
c. 4/7/21 - Review of the eMAR documentation and nursing notes revealed Ativan PRN was administered at 10:57 AM and 6:01 PM, approximately 7 hours apart. This was an hour early as the medication was ordered every 8 hours PRN.
There was no evidence in the record that the provider was contacted prior to the early administration of the PRN medication.
9/28/21 9:33 AM - During an interview, E14 (LPN) confirmed that behaviors should be documented when administering a PRN medication and if giving a PRN medication early, the provider should be contacted.
d. 7/23/21 - Physicians' orders included an antipsychotic (Risperdal).
There was no evidence that an AIMS assessment was conducted prior to the start of the antipsychotic to serve as a baseline for abnormal body movements, a potential side effect of this type of medication. An AIMS assessment was done 9/28/21, over two months after the antipsychotic was initiated.
e. 8/6/21 - Physicians' orders included an anticonvulsant (Klonopin) which can be used to prevent seizures or to treat mental disorders. The indication for this medication was psychosis.
During the survey, there was no evidence in the record that the facility monitored for adverse effects of Klonopin until the surveyor asked about the monitoring.
9/28/21 1:52 PM - During an interview with E3 (CCC) the surveyor reviewed and presented E3 with a written list of the aforementioned findings about R73's psychotropic medications. E3 stated she would look into it.
9/28/21 3:53 PM - During an interview with E32 (RN), the nurse who wrote 'a' for the behavior and administered the Ativan an hour early, when asked what the 'a' meant, E32 said anxiety. The surveyor was unclear if the 'a' was for aggression or agitation for which the medication was ordered. E32 stated, I will do better [indicating writing resident behaviors].
9/29/21 9:35 AM - E3 returned the written list with the findings that were addressed highlighted in yellow. The AIMS assessment was completed 9/28/21 and adverse actions of Klonopin and Risperdal were added to the eMAR for nurses to document.
4. Review of R77's clinical record revealed:
11/2/20 - R77 was admitted to the facility with dementia.
2/17/21 - Physicians' orders included an antipsychotic (Seroquel) twice a day for major depression with psychosis.
There was no evidence in the record that an AIMS assessment was performed to serve as a baseline for abnormal body movements.
5/4/21 - An AIMS assessment was completed, nearly three months after the antipsychotic was started.
9/28/21 10:32 AM - During an interview, the Surveyor informed E3 (CCC) about the findings regarding R77's psychotropic medications and provided a written list of the identified concerns.
9/29/21 9:35 AM - During an interview, E3 returned the written list and confirmed the AIMS was performed on 5/4/21.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
3. 9/22/21 1:15 PM - During an inspection of the medication storage room on Seaside Way (Station 4) with E27 (RNAC). The following was observed:
- A medication for nausea and vomiting expired 6/21/21....
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3. 9/22/21 1:15 PM - During an inspection of the medication storage room on Seaside Way (Station 4) with E27 (RNAC). The following was observed:
- A medication for nausea and vomiting expired 6/21/21.
- An open and undated vial of medication was found in the refridgerator without an expiration date.
- An open vial of Insulin was found in the refrigerator without an expiration date.
- An open Insulin Pen with an open date of 8/4/21 (Insulin expires 28 days after opening).
- Two bottles of sterile salt water in an overhead cabinet with an expiration date of 6/2020.
9/22/21 1:30 PM - E27 removed the above items from the medication room and stated these would be destroyed.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON), and E3 (Corporate Clinical Consultant).
Based on observation and interview, it was determined that for three (Stations 1, 3 and 4) out of three medication rooms inspected, the facility failed to ensure that medications were labeled with the resident name, expired medications were removed and refrigerated drugs and biologicals were stored under proper temperature controls. Findings include:
1. Medication refrigerator temperatures on Beach Cove Unit (Station 1):
Review of an undated pharmacy policy, provided by E1 (NHA), titled Storage of Medications included, Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 [degrees] C (36 [degrees] F) and 8 [degrees] C (46 [degrees] F) with a thermometer to allow temperature monitoring .The Facility should maintain a temperature log in the storage area to record temperatures at least once a day .
2/27/12 - The facility form entitled Temperature Log, found on the outside of the Beach Cove's (Station 1) medication refrigerator, stated, Medication refrigerator is checked BID (two times a day) .If refrigerator temp [temperature] falls below 36 [degrees] or goes above 46 [degrees] inform the unit manager and/or supervisor immediately so corrective action may be taken.
9/22/21 8:30 AM - During an inspection of the Beach Cove's Medication Room with E27 (RNAC), it was discovered that the medication refrigerator temperature was not checked on nine (43%) out of 21 days reviewed in September 2021. This finding was immediately confirmed by E27.
2. 9/22/21 9:15 AM - Inspection of the treatment cart in the medication room on Bay Terrace (Station 3) revealed:
- top drawer labeled 'FRONT' had an open tube of zinc oxide (skin protection cream) that had been partially used without resident identification.
- top drawer labeled 'BACK' with a tube of a wound gel with about half of the gel used without resident identification.
9/22/21 approximately 11:20 AM - During an interview, E7 (RN, UM) stated that stock meds should be labeled with resident information after opening.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
e. 9/29/21 11:50 AM - 12:15 PM - During a random observation, E31 (SW) was seen at Station 3 nursing station interacting with residents in the common area while wearing a black cloth mask.
3. Accordin...
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e. 9/29/21 11:50 AM - 12:15 PM - During a random observation, E31 (SW) was seen at Station 3 nursing station interacting with residents in the common area while wearing a black cloth mask.
3. According to the CDC, source control referred to well-fitting masks to cover the person's mouth and nose to prevent the spread of respiratory secretions when they breathe, talk, sneeze or cough. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html (Accessed 10/4/21)
During random observations throughout the survey numerous clinical staff were seen wearing their facemasks inappropriately, with either their nose and/or mouth exposed:
a. 9/22/21 9:45 AM - E34 (CNA) was observed walking from the South Hall of Station 1 into the nursing station with her facemask under her chin and her nose and mouth exposed.
9/22/21 10:00 AM - E34 (CNA) was observed sitting at the nursing station charting and talking to other staff with her facemask under her chin and her nose and mouth exposed. When the Surveyor said Your mask should be covering your nose and mouth, E34 pulled the mask up to cover her nose and mouth.
b. 9/24/21 4:45 PM - E11 (CNA) was observed wearing her mask at the nursing station on Station 3 with her nose exposed. After the Surveyor asked E11 her name, E11 walked into the room where the charts were stored, retrieved her identification badge, then returned to the station with her nose still exposed.
c. 9/28/21 3:38 PM - E11 (CNA) was observed walking from Station 1 toward the dining room with her nose exposed. Her mask only covered her mouth.
d. 9/30/21 6:15 PM - E12 (RN) was observed at the medication cart on Station 2 with his mask pulled down under his chin. When the surveyor said, I see your nose, E12 quickly pulled up the mask to cover his nose and mouth.
9/29/21 8:20 AM - During an interview, E18 (Medical Director) expressed concern over the number of staff not wearing their facemasks appropriately as compared to another nursing home E18 visits.
4. The Centers for Disease Control and Prevention (CDC) identified when hand hygiene should be performed by healthcare providers in healthcare settings. Alcohol-based hand sanitizer would be indicated after touching a patient or the patient's immediate environment; after contact with blood, body fluids [including saliva] or contaminated surfaces. https://www.cdc.gov/handhygiene/providers/index.html (Accessed 10/4/21)
9/23/21 9:03 AM - 9:20 AM - During a random observation of supervised smoking, E10 (Restorative Aide) failed to follow standard precautions on several occasions:
- E10 took a used cigarette butt with bare hands from R120 (from Station 4) after it was in his mouth. After placing the cigarette butt in the waste container, E10 did not perform hand hygiene.
- E10 took a used cigarette butt from R139 (from Station 1) with bare hands. With the contaminated hand from the used cigarette butt, E10 touched her own shirt and crossed her arms, contaminating her other arm.
- E10 took another used cigarette from both R120 and R139 with bare hands to place in the waste container.
- Without performing hand hygiene [with contaminated hands], E10 picked up the red plastic tackle box containing the smoking supplies, pressed the numbers on the keypad to unlock the door and held the door open for residents to return into the building. E10 walked down the hallway to return the smoking tackle box to its storage place, then used alcohol based hand sanitizer.
Cross Refer F677, Example 2
5. 9/22/21 8:05 AM - 12:30 PM: During an observation, R56 ate breakfast, then began to use colored pencils to color cards. R56 was served her lunch and was not assisted in performing hand hygiene. R56 used her contaminated fingers to assist in getting food from her fork into her mouth.
9/23/21 8:30 AM - 12:30 PM: During an observation, R56 was finishing breakfast then began to color in a coloring book. When lunch was served, R56 was not assisted in performing hand hygiene. R56 used her contaminated fingers to assist in getting food from her fork into her mouth.
9/24/21: During a Resident Council meeting held between 1:30 PM - 3:00 PM, when asked if staff encouraged or assisted with hand hygiene before meals, the attendees unanimously said no.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
Based on observation, record review and interview it was determined that the facility failed to ensure that infection control practices were implemented and maintained to prevent the spread of communicable disease, including COVID-19. Findings include:
1. The following was reviewed in R105's clinical record:
8/3/2019 - R105 was admitted to the facility with a brain injury that required a tracheostomy (also known as a trach, a breathing tube inserted through the front of the neck) to breath.
A facility policy entitled Tracheostomy Care, last revised 6/2021, included:
General Guidelines
1. Aseptic (sterile) technique must be used during tracheostomy tube changes, either reusable or disposable.
Procedure Guidelines
1. Check Physician order.
2. Explain procedure to resident.
3. Wash hands.
4. Put exam gloves on both hands.
5. Remove old dressings (and the disposable inner cannula (a changeable replacement tube).
6. Remove gloves.
7. Wash hands.
8. Open tracheostomy cleaning kit.
9. Set up supplies on sterile field.
10. Open up supplies maintaining a sterile field.
11. Put on sterile gloves.
12. (Perform the cleaning procedure for the tracheostomy).
13. Remove gloves and discard into the appropriate receptacle.
14. Wash hands.
10/28/20 - A physician order included: Trach Care: Clean Inner Cannula, Cleanse area around the trach & neck every shift and as needed.
8/26/21 - A quarterly MDS assessment documented that R105 was dependent on staff for care.
9/27/21 10:55 AM - During an observation of tracheostomy care with E9 (LPN) on Station 2, it was noted that:
- E9 put on clean gloves in R105's room without performing handwashing first.
- E9 removed the gloves and exited the room and said she forgot something. E9 did not perform hand washing after removing the gloves.
-E9 returned to the room with a pulse ox (an instrument to check a person's oxygen level) and put on clean gloves without first performing handwashing.
-E9 opened a sterile supply container to suction R105's tracheostomy to remove any excess mucous from it and set up the sterile field. E9 did not perform handwashing before putting on the sterile gloves from the suction kit. E9 suctioned R105's tracheostomy.
-E9 opened a sterile tracheostomy care kit and set up the supplies to perform the trach cleaning procedure and then removed the clean gloves. E9 put on the sterile gloves from the kit without first performing handwashing.
-E9 performed R105's tracheostomy cleansing procedure and removed the sterile gloves. E9 exited the room without performing handwashing prior to leaving the room.
-E9 came back to R105's room with a pen in her hand to date the peroxide solution used during the cleansing procedure. E9 left the room again and returned with cleaning wipes.
-E9 put on clean gloves to wipe the table down. E9 finished cleaning the table and removed her gloves. E9 did not perform handwashing prior to leaving R105s room.
9/27/2021 11:20 AM - During an interview, E9 confirmed that she did not perform handwashing at the required times during the procedure.
2. The following observations were made during the survey of staff wearing cloth facemasks in the clinical areas instead of surgical masks:
a. 9/24/2021 1:20 PM - E28 (RN) wore a cloth mask while administering medications on Station 2. E28 confirmed that the mask was cloth.
b. 9/28/2021 08:03 AM - E28 (RN) was at the medication cart wearing a cloth mask that was not covering her nose. The observation of the cloth mask and improper use was verified by two surveyors.
c. 9/28/2021 9:05 AM - E29 (CNA) was performing patient care on Station 2 while wearing a cloth mask.
d. 9/28/2021 12:31 PM - E31 (SW) was talking with R59 in the hall by the Station 2 nursing station wearing a cloth mask.
9/28/2021 12:41 PM - During an interview, E29 (CNA) confirmed that he wore a cloth mask earlier in the day.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, facility contract reviews and interviews, it was determined that the facility failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, facility contract reviews and interviews, it was determined that the facility failed to provide appropriate interventions to manage the presence of pests and to have an effective pest control program on three (Station 1, 2 and 3) out of four resident care units. Findings include:
Cross refer F565.
1. Flies
9/22/21 2:39 PM - During an observation, a fly was noted on R140 during a resident interview (room [ROOM NUMBER]-1).
9/22/21 3:32 PM - During an observation and interview a fly was noted on R92 (room [ROOM NUMBER]-1). R92 stated that he had a fly swatter. R92 reported that they (the flies) come in the room a lot when the food is brought into the room and that they go away sometimes after the food is gone. R92 added that they are bad sometimes.
9/22/21 4:59 PM - During an interview, R75 (room [ROOM NUMBER]-2) stated, There are flies everywhere around here and mosquitoes in the day room. Two flies were observed landing on R75's overbed table and on his sheets.
9/23/21 10:00 AM - During an observation, a fly was noted flying around and landing on R79 (room [ROOM NUMBER]-2) and her bed.
9/23/21 1:18 PM - During an observation a fly landed on R1's (room [ROOM NUMBER]-1) table.
9/23/21 2:11 PM - During an interview, R31 (room [ROOM NUMBER]-2) stated, I have to keep a fly swatter next to me because there are so many! The other day when I came back in my room, I found four flies had gotten under the cover of my lunch plate. A fly was observed flying around the room during the interview.
9/28/21 10:00 AM - During an interview, E1 (NHA) stated that the facility has tried several pest control companies and provided copies of invoices. In addition, E1 said that the facility started a process improvement plan in July 2021 for mice in the facility, but they continue to have an infestation.
2. Mice
9/22/21 10:00 AM - During an interview, R78 (room [ROOM NUMBER]P) stated, If you sit here in the hall by the nursing station you will see them run across the hall. They even get in my bed.
9/22/21 12:05 PM - During an observation, mouse droppings were seen in two areas along the wall near furniture in (room [ROOM NUMBER]-1) R29's room and were confirmed by E50 (CNA) and E51 (LPN).
9/22/21 12:15 PM - During an observation, mouse droppings were seen in the closet in (room [ROOM NUMBER]-2) R137's room and was confirmed by E50 (CNA).
9/22/21 1:00 PM - During an interview, R124 (room [ROOM NUMBER]-1) stated, We have a lot of mice. Not long ago, there was even one climbing up the curtain between our beds.
9/22/21 1:10 PM - During an interview, R143 (room [ROOM NUMBER]-2) stated, The nurses found a dead baby mouse in a box that was on my floor with cough drops.
9/23/21 8:30 AM - During an interview, R53 (room [ROOM NUMBER]-2) stated, There was just a mouse in here the other night. Mouse droppings were observed along the wall next to her dresser and was confirmed by R14 (UM).
9/23/21 2:37 PM - During an interview, R74 (room [ROOM NUMBER]-1) stated, A little mouse stuck his head out of the bathroom door last night and we stared at each other. When I moved toward him, he ran away.
9/27/21 4:00 PM - E15 (room [ROOM NUMBER]P) stated during an interview that he had a mouse that came into his room regularly. R15 also stated he has seen black bugs in the shower.
9/28/21 at 9:15 AM - While seated in the chart room on Station 1 (Beach Cove), the Surveyor saw a mouse run from behind the refrigerator, across the floor in front of the printer cabinet and disappear behind the file cabinet. The Surveyor looked behind the file cabinet and did not see the mouse, but noticed a small space between the bottom of the built-in wood chart rack and the baseboard.
9/28/21 9:24 AM - During an interview, the Surveyor informed E3 (CCC) about the mouse and E3 said she would let them [maintenance] know to take care of it.
9/28/21 9:36 AM - During an interview with E48 (Maintenance), the Surveyor described the path the mouse took. E48 looked behind the file cabinet and said he will take care of it.
9/29/21 2:00 PM - During an interview, E52 (Housekeeper) stated, Just this morning a mouse was caught in a sticky trap in room [ROOM NUMBER] and a mouse was seen in room [ROOM NUMBER]. Mice have been a big problem for at least six months.
9/29/21 2:00 PM - The above findings were reviewed in a meeting with E1 (NHA), E37 (Maintenance Director) and E38 (Regional Director of Operations).
3. The following were observed during the food service audit between 10:45 AM through 1:00 PM:
- The loading bay door had holes, making it an entry source for rodents;
- The dry storage room was not kept clean with food present on the floor, making it a food source for rodents;
- The condensation from the walk-in refrigerator was pooling in the dry storage room, making it a source of water for rodents;
- Dumpster lids were left open which can attract pests;
- Observed multiple holes on the doors to the outside, making it an entry source for pests.
Kitchen findings were reviewed and confirmed on 9/22/21 at approximately 1:00 PM with E5 (FSD).
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
Based on record review and interview, it was determined that, for four (R3, R8, R56 and R77) out of five residents reviewed for unnecessary medications, the facility failed to ensure irregularities id...
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Based on record review and interview, it was determined that, for four (R3, R8, R56 and R77) out of five residents reviewed for unnecessary medications, the facility failed to ensure irregularities identified by the pharmacist were reviewed by the physician. Additionally, the Facility's Drug Regimen Review policy did not contain the necessary requirements. Findings include:
1. Review of the facility policy entitled Drug Regimen Review (last reviewed 6/15/21) revealed the policy failed to include:
- Time frames for the different steps in the process (time frame for pharmacist to inform the facility of irregularities and time frame for the physician to review the irregularities).
- Steps the pharmacist must take when an irregularity requiring urgent action to protect the resident was identified.
- If there was to be no change in the medication when the pharmacist made a recommendation, the attending physician should document the rationale in the resident's medical record.
9/28/21 9:22 AM - During an interview, E3 (CCC) was informed about the missing requirements in the policy and stated that the policy would be reviewed.
2. Review of R8's clinical record revealed:
12/2/15 - R8 was admitted to the facility with dementia.
September 2020 - August 2021 - Drug regimen review reports revealed the following:
- January 2021: original unable to be located, reprinted with no irregularities.
- March 2021: no physician response to evaluate Seroquel with a psychosis diagnosis.
- April 2021: no physician response to Seroquel with dementia diagnosis and the need to be evaluated.
- May 2021: no irregularity; no physician response.
9/27/21 9:24 AM - During an interview, E3 provided copies of the drug regimen reviews and added that these were all that could be located.
3. Review of R56's clinical record revealed:
1/15/21 - R56 was admitted to the facility with dementia.
January 2021 - August 2021 - Drug regimen reports revealed the May 2021 was missing.
9/27/21 9:24 AM - During an interview, E3 provided copies of the drug regimen reviews and added that these were all that could be located.
4. Review of R77's clinical record revealed:
11/3/2020 - R77 was admitted to he facility with dementia.
December 2020 - August 2021 - Drug regimen reports revealed the following Pharmacist recommendations:
- January 2021: missing, no evidence the review was completed.
- April 2021: no physician response to evaluate the diagnosis of Seroquel [antipsychotic] with major depressive disorder with psychotic symptoms.
- May 2021: missing, no evidence the review was completed.
9/27/21 9:24 AM - During an interview, E3 provided copies of the drug regimen reviews and added that these were all that could be located.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. 9/22/21 8:45 AM - During an inspection of the nourishment refrigerator in Station 3's (Bay Terrace) medication room, the foll...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. 9/22/21 8:45 AM - During an inspection of the nourishment refrigerator in Station 3's (Bay Terrace) medication room, the following was discovered:
- small bag from a local store containing sliced apples and filled with air making the bag tight, with an expiration date of 9/6/21.
- plastic container of yogurt with an expiration date of 7/29/21.
- unlabeled peanut butter sandwiches, (5 half sandwiches and 1 whole) with several half sandwiches not sealed and open to air.
- undated thickened juice boxes that had been opened with a shelf life of seven days after opening (one apple and one cranberry).
- 2 undated pitchers of iced tea.
- 1 undated pitcher of cranberry juice.
- 3 plastic containers of unlabeled homemade food (pink container with ready-to-eat fruit and a white container)
- unlabeled half of a water bottle containing frozen and an unlabeled store-bought frozen meal in the freezer.
9/22/21 11:10 AM - During a random observation, E54 (CNA) was seen in the chart room eating her lunch from the pink container with the clear container of fruit nearby.
9/22/21 at approximately 11:20 AM - During an interview, E7 (RN, UM) confirmed and threw away the sandwiches, apples, and yogurt and stated, I don't know who they belong to no names on them. E7 discarded the undated thickened juice boxes, frozen bottle of yellow liquid in freezer and an unlabeled frozen meal. When the surveyor explained about the staff food and pointed out that E54 was eating hers, E7 said, I've been asking for another refrigerator.
5. During the a follow-up tour of the facility kitchen between 10:45 AM to 1:00 PM on 9/22/21, the surveyor(s) observed the following:
- Walk-in refrigerator:
* raw hotdogs were held above ready-to-eat foods in the walk-in refrigerator; E5 (Food Service Director) was not aware that raw hotdogs were considered potentially hazardous foods.
* walk-in refrigerator vent was dusty.
* desserts were partially covered with small lids and were not completely covered.
* condensation (water) dripping on the floor.
* wet cardboard used as shelving, many were stained with food.
* shelving was rusty, making it difficult to clean.
- Dry storage:
* unlabeled bulk storage containers with white powder substance stored in black trash bags, the bags were showing signs of wear and were not clean to the touch.
* bulk storage containers had scoops left inside of the containers.
* floor was not clean.
- Ice machine:
* not properly maintained.
* ice scoop not properly stored.
- Dish washing machine area hose leaking.
- Fume hood was greasy and dusty.
- Hand sink with no splash guard by the kitchen microwave.
- All hand washing sinks were draining poorly.
- Required hand washing signs were not present at the hand washing station.
- Loading bay area was extremely dirty.
Findings were reviewed with E5 on 9/22/21 at approximately 1:00 PM.
These findings were reviewed during the exit conference on 9/30/21, beginning at 5:04 PM, with E1 (NHA), E2 (Interim DON) and E3 (CCC).
Based on observation, interview, and review of other facility documentation, it was determined that for two (1 and 3) out of four resident care units and inspection of the main kitchen, the facility failed store, prepare and serve food in accordance with professional standards for food service safety . Findings include:
7/26/21 (date of last revision) -The facility policy for Use and storage of Food Brought to the Residents by Visitors stated, .Food brought into the facility by residents and family members/visitors, or resident representatives will be stored according to the type .Any expired or unlabeled food will be discarded .
1. 9/22/21 9:00 AM - During an inspection of the Beach Cove (Station 1) Unit's Medication Room with E27 (RNAC), it was discovered that the nutrition refrigerator temperature was not checked on nine (43%) out of 21 days reviewed in September 2021.
The contents inside the aforementioned refrigerator included:
- three opened bottles of expired salad dressing.
- expired box of juice.
- unlabeled opened packages of both sliced and shredded cheese.
- opened unlabeled jar of mayonnaise.
- opened soda and a pre-packaged lunch dated 5/29/21.
- multiple sticky stains throughout the inside of the refrigerator.
- freezer contained an unlabeled and undated fast-food milkshake, two cups of ice cream, and a fast-food cup of orange soda. There were splattered brown stains inside the freezer and no thermometer.
These findings were immediately confirmed by E27 who stated that she will clean out this refrigerator.
2. 9/22/21 10:30 AM - During an inspection of the nutrition refrigerator in the nursing station on the Beach Cove (Station 1) Unit, it was discovered that the nutrition refrigerator temperature was not checked on 14 (67%) out of 21days reviewed in September 2021. When the refrigerator door was opened there was a foul smell. The contents inside the refrigerator included:
- an unlabeled opened milk carton.
- an unlabeled opened plastic bottle of soda.
- an unlabeled plastic cup of mayonnaise.
- a frozen microwavable dinner with a used by date of 8/11/21.
- an unlabeled opened plastic to go container of fresh cut fruit partially full.
- an unlabeled [NAME] jar half filled with an unidentifiable green substance.
- three half peanut butter and jelly sandwiches in plastic wrap, but undated.
- three half peanut butter and jelly sandwiches dated to use by 9/7/21.
- a to-go salad in a plastic container with an expiration date of 9/20/21.
- an unlabeled slice of cheesecake in a plastic container.
- an unlabeled deli sub in a stained white bag.
- a facility bag lunch for a dialysis resident dated 8/10/21.
- an almost empty bottle of catsup labeled with a resident name, but no date.
- two expired styrofoam cups of food (one dated 9/9/21 and one dated 8/9/21).
- multiple sticky stains on the inside bottom of the refrigerator and the door.
9/22/21 11:00 AM - During an interview and observation, E33 (RNAC) confirmed these findings and cleaned out the refrigerator.
4. During the initial and follow-up tours of the facility kitchen between 7:46 AM and 9:13 AM on 9/22/21, the surveyor(s) observed the following:
- Seven (7) opened containers of thickened juice with no open by or use by date noted on the containers, which have a shelf life of seven (7) days after opening.
- A large plastic container containing shredded carrots with plastic wrap loosely draped over the opening of the container, permitting possible contamination from dust, debris, and soiled water.
- A large tray labeled mac and cheese dated 9/14/21. Delaware Food Code 3-501.17 requires all prepared food to be discarded after seven (7) days. The day of preparation is counted as day 1.
- The required signage was missing from the handwashing sink adjacent to the oven.
- There was no red bucket with sanitizing solution available for food preparation surface disinfection.
- Water droplets were dripping from the ceiling resulting in a wet floor in the walk-in refrigerator.
9/27/21 10:34 AM- Findings were reviewed with E1 (NHA) and E5 (Dietary Director).
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Delaware facilities.
Concerns
- • 81 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Ocean Grove Post Acute's CMS Rating?
CMS assigns OCEAN GROVE POST ACUTE an overall rating of 2 out of 5 stars, which is considered 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 Ocean Grove Post Acute Staffed?
Detailed staffing data for OCEAN GROVE POST ACUTE is not available in the current CMS dataset.
What Have Inspectors Found at Ocean Grove Post Acute?
State health inspectors documented 81 deficiencies at OCEAN GROVE POST ACUTE during 2021 to 2025. These included: 79 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Ocean Grove Post Acute?
OCEAN GROVE POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES, a chain that manages multiple nursing homes. With 181 certified beds and approximately 0 residents (about 0% occupancy), it is a mid-sized facility located in MILLSBORO, Delaware.
How Does Ocean Grove Post Acute Compare to Other Delaware Nursing Homes?
Compared to the 100 nursing homes in Delaware, OCEAN GROVE POST ACUTE's overall rating (2 stars) is below the state average of 3.3 and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Ocean Grove Post Acute?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Ocean Grove Post Acute Safe?
Based on CMS inspection data, OCEAN GROVE POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Delaware. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Ocean Grove Post Acute Stick Around?
OCEAN GROVE POST ACUTE has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Ocean Grove Post Acute Ever Fined?
OCEAN GROVE POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Ocean Grove Post Acute on Any Federal Watch List?
OCEAN GROVE POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.