GOLFCREST NURSING CENTER
Non profit - Corporation
67 Beds
BENJAMIN LANDA
Data: November 2025
Trust Grade
35/100
#354 of 690 in FL
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Golfcrest Nursing Center in Hollywood, Florida has a Trust Grade of F, indicating significant concerns and poor overall performance. Ranking #354 out of 690 facilities in Florida places it in the bottom half, and at #19 out of 33 in Broward County, only a handful of local options are better. Unfortunately, the facility is worsening, with issues increasing from 5 in 2024 to 9 in 2025. Staffing is a mixed bag; although there is good RN coverage, with more RN presence than 96% of Florida facilities, the staffing turnover is concerning at 74%, significantly higher than the state average of 42%. Additionally, the center has incurred $62,700 in fines, which is higher than 88% of facilities in the state, suggesting compliance issues. Specific incidents include a serious failure to properly manage a resident's tube feeding and multiple concerns regarding food safety protocols, potentially impacting the health of many residents. Overall, while there are some strengths in nursing coverage, the facility's weaknesses are significant and should be carefully considered by families.
- Trust Score
- F
- In Florida
- #354/690
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- $62,700 in fines. Lower than most Florida facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 68 minutes of Registered Nurse (RN) attention daily — more than 97% of Florida nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 22 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 49%
Needs review
5 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 9 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Florida average (3.2)
Meets federal standards, typical of most facilities
Staff Turnover: 74%
28pts above Florida avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $62,700
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: BENJAMIN LANDA
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (74%)
26 points above Florida average of 48%
The Ugly 22 deficiencies on record
1 actual harm
May 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0635
(Tag F0635)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, interview and record review, the facility failed to timely order to obtain and document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, interview and record review, the facility failed to timely order to obtain and document proper admission physician orders for immediate care involving surgical site and Foley catheter care, and for pain medication for a resident; re-assess and document a resident's pain level; and administer routinely ordered medications to a resident, for 1 of 2 sampled residents reviewed for admission orders after surgery, Resident #1.
The findings included:
Review of the facility policy and procedure titled, Pain Observation and Record, provided by the Director of Nursing (DON) reviewed April 21, 2021, documented in the Policy Statement: Pain Observation and Record UDA will be completed on every resident as part of the admission process. Pain will be re-observed and recorded any time a resident states that his/her pain level has changed/when pain medication or dosage is changed, or anytime the resident's condition significantly changes. Purpose: The management of pain is essential to enhance quality of life by routinely reviewing a resident's level of pain and providing and managing pain control in collaboration with the attending physician/Medical Director. General Guidelines: 1. A. Pain observation and Record UDA will be completed on every resident as part of the admission process, quarterly and upon significant change in resident status and become part of the medical record. 2. If a resident states, or shows signs that he/she is having pain and does not currently have a prescribed pain medication, or is not receiving relief from current type dosage frequency of pain medications; and this is considered unstable, the nurse will contact the attending physician to discuss pain observations and interventions and develop a plan of care to better control the pain.
Record review of the facility policy and procedure titled, Assisting the Nurse in Examining the Resident, provided by the DON reviewed August 2017 documented in the Policy Statement: .Purpose: The purposes of this procedure are to examine the condition of the resident's body and to observe the resident's performance admission Notes/admission Data Collection: admission Notes/admission Forms should include as a minimum documentation of the admission of a resident (as they may apply): .f. Vital signs and condition of resident upon admission (i.e. confused, weak, alert, etc.) g. Time physician was notified of the admission. h. Time physician's orders were received and verified l. Medications were ordered from the pharmacy
Record review revealed Resident #1 was admitted to the facility on [DATE] at 6:46 PM with diagnoses that included Encounter for other Orthopedic Aftercare and Malignant Stage 4 Neoplasm of Prostate with metastasis to multiple sites to include bone and Hypertension. Resident #1 had been previously admitted to the hospital on [DATE], he was status-post (s/p) second (2nd) major spinal surgery performed on 04/24/25. Resident #1 was noted, in facility records, as being Independent with Cognitive Skills for Daily Decision Making---Made decisions regarding tasks of daily life.
A telephone interview was conducted on 05/21/25 at 2:25 PM, with Resident #1's family member regarding the resident's care and treatment upon admission to the facility on [DATE] at 6:46 PM. The resident's family member stated Resident #1's pain medication was never given to him, and he said that the resident told him that he had pain all over his body, while family members were waiting there in the resident's room with him. The family member stated one (1) of his other family members spoke to the Supervisor at the time, but he said that the nurse gave no solution.
Review of Resident #1's progress notes dated 05/02/25, documented the day after admission to the facility, a family member called 911 to send the resident back to the hospital because she felt Resident #1's needs could not be met at the facility. The resident was transported to the hospital at 12:07 PM.
On 04/24/25 at 6:12 AM Resident #1's Hospital's Physician's History and Physical documented, Medications . Morphine Sulfate (MS) Contin 15mg extended release (ER) to give one (1) tablet (15mg) by mouth two (2) times daily. Indications: Non-acute pain, non-acute pain (Cancer), non-acute pain (Palliative Care) Oxycodone five (5) mg every eight (8) hours as needed for Pain up to 30 days. Indications: Non-acute pain.
Record review dated 05/01/25 at 1:43 PM of Resident #1's Hospital's Advanced Practice Registered Nurse's Progress Notes also documented, 1. Patient to continue with Morphine Sulfate (MS) Contin 15mg extended release (ER) scheduled every eight (8) hours for pain control. Patient to have Oxycodone five (5) mg every six (6) hours as needed for moderate/severe breakthrough pain .For the safety of the patient we ask that you not make any changes in their pain medications without speaking with us. If you feel that the medications need to be addressed, please feel free to contact us. We are always open to conversation
Further record review of both the 3008 Agency for Healthcare Administration (AHCA) Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form and of the facility's admission Nursing Data Collection form dated 05/01/25, documented that the Mental/Cognitive Status of Resident #1 at transfer was: Alert, oriented to person, place time and situation and follows instructions.
Review of the Minimum Data Set (MDS) assessment, Section GG 'Functional Abilities and Goals documented the resident was dependent for all of the following: Self-care, oral hygiene, toileting, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, mobility, roll left and right, chair-to-bed-to-chair transfer, toilet transfer, tub/shower transfer; with impairment on both sides.
Review of the Physician's Order Sheet (POS), May 2025 Medication Administration Record (MAR), Treatment Administration Record (TAR), and the progress notes dated 05/01/25 to 05/04/25 failed to document any on-going assessments for pain levels being done, for this resident.
There was no alternative pain medication, and as needed pain medication ordered for this resident, during his facility stay.
There was no documented evidence in the facility's record to show that the facility had contacted the physician to obtain orders for pain medication, to address the resident's Foley catheter care needs (not entered in facility computer system until the next day on 05/02/25), nor were there any orders to address the resident's surgical site care with staples.
Record review of the facility's Nursing Admission/Quarterly Observation form, section C2 pages five (5) and six (6), Pain Interview, revealed that this section had not even been started or completed by Staff A, Registered Nurse (RN), working on 05/01/25 on the 7 PM to 7 AM shift.
There was no physician's order written, nor entered to, Check for pain every shift, into the facility's computer system by Staff A, until 05/02/25, the next day.
During a side-by-side record review conducted with the Director of Nursing (DON), it was revealed that Resident #1 had not been administered any of the following physician ordered routine medications until the next day on 05/02/25, for the resident:
*Methocarbamol Oral Tablet 750 mg (Methocarbamol) to give 1 tablet by mouth three (3) times a day:
*Aspirin Oral Tablet Chewable 81 mg to give one (1) tablet by mouth one time a day;
*Sodium Chloride oral tablet one (1) gram to give one (1) tablet by mouth three (3) times a day for fifteen (15) days;
*Famotidine oral tablet twenty (20) mg to give one (1) tablet by mouth two (2) times a day; *Docusate Sodium oral capsule 100 mg to give one (1) capsule by mouth every twelve (12) hours as needed for Constipation;
*Xtandi oral tablet 80 mg to give two (2) tablets by mouth one (1) time a day;
*Morphine Sulfate ER Tablet Extended Release 15 mg *Controlled Drug* to give one (1) tablet by mouth every twelve (12) hours for pain.
*Naloxone HCl nasal liquid 4 mg/0.1 ml 4 mg in nostril as needed for in one (1) nostril may repeat every two (2) to three (3) minutes until medical assessment;
*Metoprolol Tartrate oral tablet fifty (50) mg to give one (1) tablet by mouth two (2) times a day; *Lidocaine-Prilocaine External Kit 2.5-2.5 % apply to affected area topically two (2) times a day for leg pain.
The listed medications were not placed into the facility's computer system until the next day on 05/02/25.
An interview was conducted on 05/21/25 at 3:36 PM, with Staff D, RN working on 05/01/25 on the 7 AM to 7 PM shift, regarding Resident #1's admission to the facility. Staff D stated that she only took the report from the hospital over the phone at change of shift, and she said that she reported this to the next shift. Staff D added that if a resident is admitted after 6 PM on the day shift, the evening/night shift would take over and handle following up with the new admission. Staff D stated she had not actually seen the resident at all that night. Staff D explained part of the admission process, that if a resident does not come with a narcotic prescription and states they are in pain, then the nurse would contact the Medical Director to get the order/script to be faxed to pharmacy. Staff D stated a resident comes into the facility with the history and summary report; the nurse would review the report and go to the Point-Click-Care (PCC) computer system, and under progress notes would enter a brief admission summary, discuss the diagnosis, vital signs and, if there are any ordered Antibiotics, etc. Staff D stated that a pain assessment is done along and in conjunction with the vital signs and is added to the admission summary report.
An interview was conducted on 05/21/25 at 3:54 PM with Staff A, regarding Resident #1's admission to the facility. Staff A acknowledged that she recorded a nursing progress note entry at 6:46 PM, . admit, awake, alert, oriented to person, place, time and situation (AAOX4) surgical site upper back with forty-one (41) staples, cover with dressing no s/s infection noted Foley catheter 18 French drainage clear yellow urine 500cc . Staff A was asked the potential for this resident's pain needs and contact the physician to obtain orders for his surgical site, pain management and Foley catheter care. Staff A stated that she forgot to do so. When asked , Staff A stated she did not reassess the resident for pain. When asked if a newly admitted resident with a recent surgical history comes to the facility, when she expects them to come to the facility having a script for some type of routine or as needed pain medication, Staff A said, yes. When asked if the nurse should re-assess and document the resident's pain, upon admission Staff A , responded, yes, but she acknowledged that she had not done so. When asked if she documented that Resident #1 was administered any of his ordered medications, during her shift , Staff A stated no, not to her knowledge.
During a telephone interview conducted on 05/21/25 at 5:16 PM with Resident #1's primary physician, he was asked if the doctor would be contacted or notified by the facility, of the resident's admission needs. The resident's doctor stated that the nurses ordinarily reach out to him, regarding medications and other orders.
The DON acknowledged on 05/21/25 at 5:04 that, if a resident is transferred to the facility from a hospital needing pain medication, she would expect them to have a script or the nurse is expected to contact the on call Medical Director's service, who in turn would notify the Pharmacy to obtain their medications. The DON further stated that the nurse is expected to do a pain assessment and evaluation on the resident, upon admission to the facility. The DON ended by saying Resident #1 should have received his ordered medication and that the nurse should have re-assessed, and documented the resident's pain level, during his facility stay.
Apr 2025
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Tube Feeding
(Tag F0693)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #167 was admitted to the facility on [DATE] with diagnoses of Anemia, Respiratory Failure, and Hyperlipidemia. A rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #167 was admitted to the facility on [DATE] with diagnoses of Anemia, Respiratory Failure, and Hyperlipidemia. A review of the Physician's order noted two overlapping orders for tube feeding: If vital AF 1.2 (tube feeding formulary type) is not available, may substitute with Peptamen 1.5 (tube feeding formulary type) at 240 milliliters (ml) every 4 hours dated 4/4/25. Another order was noted for 20 hours at 10:00 AM and off at 2:00 PM. Enteral Feeding: Vital Advanced Formula, 1000ml, 55ml an hour, which was dated 4/5/25.
A review of the Medication Administration Record showed that both above tube feeding orders were checked as administered in April 2025.
In an observation conducted on 4/7/25 at 10:35 AM, Resident #167 was noted in bed with the tube feeding Peptamen 1.5 at 50ml an hour, which was dated 4/7/25, but no start time. The tube feeding was noted at the 750ml mark out of the 1000ml capacity bag.
In an observation conducted on 4/7/25 at 3:30 PM, Resident #167 was noted in bed with the tube feeding Peptamen 1.5 at 50ml an hour, which was dated 4/7/25, but no start time. The tube feeding was noted at the 700ml mark out of the 1000ml capacity bag. This showed that only 50ml was administered in the last 1 hour and a half.
In an observation conducted on 4/7/25 at 5:20 PM, Resident #167 was noted in bed with the tube feeding continuous Peptamen 1.5 at 50ml an hour, dated 4/7/25, and no start time. The tube feeding was noted at the 600ml mark out of the 1000ml capacity bag, which showed that 100ml was infused in the last 2 hours.
In an observation conducted on 4/8/25 at 5:48 AM, Resident #167 was noted in bed with the tube feeding on hold. The tube feeding bag started at 5:00 AM on 4/8/25 and was at the 900ml mark out of a 1000ml capacity bottle.
In an interview conducted on 4/8/25 at 1:00 PM with Staff F, the Registered Nurse stated she only realized this morning when she started her shift that Resident #167 had two overlapping tube feeding orders. She asked the Nurse supervisor to check the tube feeding orders and update them accordingly. Staff F acknowledged that both orders were checked as given in the MAR under each specific order.
A review of the weights log revealed Resident #167's admission weight of 89.4 pounds, dated 4/5/25. A new weight was obtained on 04/08/25, as per this Surveyor's request, which showed Resident #167 was at 87.2 pounds, indicating a 2-pound weight loss.
In an interview conducted on 4/8/25 at 1:30 PM with Resident #167' son stated his father used to be around 120 pounds about a year ago and has been in and out of the hospitals for some time.
The nutrition assessment dated [DATE] showed the following: Resident #167's Ideal Body Weight was 136 pounds. He does not eat anything by mouth, and his only route of nutrition and hydration is enteral feeding. This assessment addressed the tube feeding order of Vital AF 1.2 every 4 hours but not the continuous order of tube feeding with Vital Advanced Formula, 1000ml, 55ml an hour. Resident #167 was noted at malnutrition and that the current tube feeding order was meeting needs.
A new tube feeding order for 20 hours of Enteral feeding-Peptamen (tube feeding formulary)1000ml,60ml, and hour, dated 4/8/25, was noted.
A review of the Care Plan showed Resident #167 has nutritional and hydration problems related to nothing by mouth status and medical history. It further revealed that enteral feedings and flushes should be provided as ordered.
3. Resident #169 was readmitted to the facility on [DATE] with diagnoses of Cerebral infarction, Gastrostomy, and Muscle Weakness. The Minimum Data Set (MDS) dated [DATE] showed Resident #169 had a Brief Interview of Mental Status (BIMS) score that is severely impaired. A review of the Physician ' s orders revealed an order for every shift of Peptamen 1.5 at 70ml an hour times 20 hours. The feed starts at 2:00 PM daily until a total volume of 1400ml has been infused. It may be substituted with Glucerna 1.5 (tube feeding formulary) if Peptamen 1.5 is unavailable, as dated 4/6/25.
A review of the weight log showed the following weights:
4/2/2025 169.8 pounds.
3/31/2025 171.0 pounds.
3/31/2025 172.0 pounds.
3/25/2025 174.8 pounds.
3/17/2025 176.4 pounds.
2/24/2025 187.3 pounds.
2/21/2025 188.0 pounds.
In an observation conducted on 4/7/25 at 12:12 PM, Resident #169 was noted in bed with the tube feeding Peptamen 1.5 running at 60ml an hour. The tube feeding was noted at the 800ml mark out of a 1000ml capacity bag, which was dated 4/7/25 but had no start time.
In an observation conducted on 4/7/25 at 3:33 PM, Resident #169 was noted in bed with the tube feeding Peptamen 1.5 running at 60ml an hour, which was dated 4/7/25 but had no start time. The tube feeding was noted at the 700 mark out of the 1000ml capacity bag. This showed that 100ml was administered in the last 3 hours, from 800ml to 700ml.
In an observation conducted on 4/7/25 at 5:20 PM, Resident #169 was noted in bed with the tube feeding Peptamen 1.5 at 60ml an hour, which was dated 4/7/25, but no start time. The tube feeding bag was noted at the 600ml mark out of a 1000ml capacity bottle. Only 200ml of formulary was administered in the last 5 hours, and not the necessary 350ml of formulary.
In an observation conducted on 4/08/25 at 6:20 AM, Resident #169 was noted in bed with the tube feeding Peptamen 1.5 running at 60ml an hour. The bag had a start date of 4/8/25 with a start time of 5:00 AM. It was also noted at the 900ml mark out of a 1000ml capacity bag. In this observation, Staff G, a Registered Nurse, stated Resident #169 tolerated his tube feeding well. She further said that she started the feeding tube a little less and increased it to where it needed to be when Resident #169 was more elevated with his head on the bed.
The Nutrition assessment dated [DATE] revealed the following: Resident #169 is at risk for malnutrition with a weight loss of 6.1% over the past 30 days, likely due to tube feeding dislodgement and replacement. The current tube feeding order of Peptamen 1.5 at 60ml an hour for 20 hours is meeting estimated needs.
A follow-up nutritional note dated 4/6/25 showed Resident #169 had a Body Mass Index (BMI) of overweight status. The enteral regimen is adequate in nutrients to meet his current needs. The Clinical Dietitian recalculated the energy and protein needs and recommended increasing the tube feeding regimen to 70ml an hour from 60ml an hour. This was not followed in the above observations.
Based on observations, interviews, and record reviews, the facility failed to provide nutritional assessments and interventions in a timely manner which resulted in significant weight loss for 1 of 1 sampled resident (Resident #51); The facility also failed to follow tube feeding Physician's orders for 2 of 5 sampled residents (Resident #167 and Resident #169).
The findings included:
A review of the facility's policy titled Weighing and Weight at-risk Protocol and revised in March 2020 showed the following: Weights: Nursing to complete all weights with reweights on the following parameters: 0-175 pounds - variances of 4 pounds - loss or gain. Identification: When all weights (weekly and monthly) are completed, the Dietary Department will review weights for significant weight loss and at risk weight loss and determine variances with reweights as noted above. The Dietary Department will notify nursing staff of significant and at risk residents the next day during the morning meeting. Investigation: The Dietary Department and nursing staff begin investigating weight loss: Is the Resident assisted with eating? Is Staff assisting with eating appropriately? Giving enough time? Does the Resident like food? Have food preferences? Family involved in bringing food? Intervention: Notify Dietitian of newly identified significant weight loss. Review intakes at a minimum weekly. Documentation: Dietary will document within 72 hours of investigation. Dietary to document monthly until resolved. Review weekly with nursing and dietary until weight loss resolved. Keep minutes of the meetings. Resident reviewed, and interventions initiated on all residents with significant weight loss and at risk.
A review of the American Society for Parental and Enteral Nutrition titled Standards for Specialized Nutrition Support for Adult Residents of Long-Term Care Facilities dated February 2006 showed the following: Monitoring and Re-evaluating the Nutrition Care Plan, Parameters and Frequency: The frequency of monitoring should depend on the severity of illness, degree of malnutrition, and level of metabolic stress. Daily or more frequent monitoring should be required in residents who are critically ill, have unstable debilitating diseases or infections, are at risk for refeeding syndrome complications, are transitioning between Enteral feeding and oral diet, or have experienced complications. https://aspenjournals.onlinelibrary.[NAME].com/doi/10.1177/011542650602100196.
A record review showed that Resident #51 was admitted to the facility on [DATE] and readmitted back to the facility on 8/30/24 with diagnoses of seizures and type 2 diabetes mellitus without complications. The Minimum Data Set (MDS) quarterly dated 2/26/25 revealed that the Brief Interview of Mental Status (BIMS) score is 3, which indicates severe cognitive impairment.
A thorough review of the weight log for Resident #51 showed the following respectively:
4/8/2025: 123.4 pounds.
03/05/2025: 131.2 pounds.
02/05/2025: 129.2 pounds.
01/07/2025: 136.2 pounds.
12/11/2024: 139.8 pounds.
12/05/2024: 143.6 pounds.
11/05/2024: 146.6 pounds.
10/4/2024: 149.2 pounds.
09/30/2024: 152 pounds.
09/23/2024: 153.6 pounds.
09/16/2024: 157.4 pounds.
09/09/2024: 156.4 pounds.
09/04/2024: 155.6 pounds.
08/29/2024: 160.0 pounds.
08/15/2024: 165.0 pounds.
Further review showed a 7.8-pound weight loss from 03/05/2025 to 4/8/2025, which indicates a 5.9% weight loss in a month.
From 08/29 to 10/04 (36 days), severe weight loss of 6.7%.
From 08/29 to 11/05 (67 days), showed a severe weight loss of 8.37%
From 09/16 to 12/11 (3 months), showed a severe weight loss of 11.18%
Resident #51 had an overall significant trending weight loss of 25.2% from 08/15/2024 to 04/08/2025 (past 8 months).
The monthly weight taken on 4/8/25 was due to this Surveyor's intervention in attempting to obtain a monthly weight before Resident #51 left for the hospital.
A chronological review of the orders indicated the following:
In August 2024: Enteral Feed Order Glucerna 1.5 tube feeding at 60 ml per hour for 20 hours at 2:00 PM and off at 10:00 AM. This started on 08/30/2024 and was discontinued on 09/16/2024.
In September 2024: an order was placed for enteral feed two times a day Glucerna 1.5 tube feeding at 60 ml per hour for 12 hours on at 7:00 PM and off at 7:00 AM. This started on 09/16/2024 and discontinued on 09/18/2024.
An order was placed for enteral feed every night shift Glucerna1.5 tube feeding at 60 ml/hr. for 12 hours on at 6:00 PM and off at 6:00 AM. This started on 09/18/2024 and discontinued on 12/09/2024.
From 9/16/24 to 10/18/24, Resident #51 was only on tube feeding, which was not meeting her needs and was decreased from 20 hours to 12 hours a day on 09/16/2024.
In October 2024, an order was placed for an enteral feed every night shift, Glucerna 1.5 tube feeding 60 ml per hour for 12 hours at 6:00 PM and off at 6:00 AM. This started on 09/18/2024 and was discontinued on 12/09/2024.
An order was placed for a no-add-salt, low-concentrated sweet diet, mechanical soft texture, regular/thin consistency, and fortified foods for all meals, which started on 10/18/2024 and was discontinued on 12/9/2024.
In December 2024, an order was placed for a regular, no-added-salt diet with a puree texture and nectar-thick consistency and no fortified food from 12/10/2024 to 01/13/2025.
In January 2025, several orders were placed: from 01/13/25 to 01/15/25, a regular no-added-salt diet with a mechanical soft texture; from 01/15/25 to 01/15/25, a no-added-salt diet and low-concentrated sweet diet with a mechanical soft texture; from 01/16/25 to 02/06/25, a regular no-added-salt diet with a mechanical soft texture; and from 01/15/2025 to 03/19/2025, an order for Boost twice a day.
In February 2025: an order was placed for enteral feed two times a day Jevity 1.5 at 50 ml/hr. for 12 hours, to be run until 600 ml infused, on at 6:00 PM and off at 6:00 AM which started on 02/06/2025.
An order was placed for a regular diet mechanical soft texture on 02/06/2025.
An order was placed to add fortified foods with all meals on 02/06/2025.
A review of the orders indicated that Resident #51 spent 54 days (from 12/10/2024 to 02/05/2025) only being fed by mouth with no order of enteral feeding. Further review showed a second decrease in the tube from 60 ml/hr. to 50 ml/hr. from 02/06/2025.
A review of the Dietary progress note dated 08/30/2024 (the day after Resident #51 got readmitted to the facility from the hospital) revealed the following: The Registered Dietitian stated that Resident #51 estimated needs were 1825-2190 kilocalories, 73-88 grams of protein and 1825-2190 milliliters(ml) of fluids. Resident #51 was put on pleasure feeding of pureed/thin and tolerated the tube feeding well with no issues. The Dietary progress note further revealed an order clarification to Glucerna 1.5 (tube feeding formulary) at 60 ml x 20 hours (hrs.), flush with 50 ml for 20 hours, providing 1800 kilocalories (kcal), 99 grams (G) of Proteins and 1911 milliliters of total fluids, which will be meeting the lower end of the resident caloric needs and meeting over 100% of proteins.
A review of the Dietary progress note dated 01/15/2025 (135 days after the previous Dietary progress note) revealed the following: The Registered Dietitian stated that Resident #51 weighs 136.2 pounds and has a normal Body Mass Index (BMI) of 23.4 for height. The progress note further indicated that Resident #51 weight loss was likely due to the transition from tube feeding to per oral with variable intake. A recommendation of: Boost 1 can (240 ml) by mouth 2 times a day and fortified cereal at Breakfast with a diet of no added salt (NAS), mechanical soft, thin liquids were put in place.
A review of the Dietary progress note dated 02/06/2025 (the day after the 5.1% weight loss was identified) revealed the following: The Registered Dietitian stated that Resident #51 had significant weight loss calculated respectively for 1 month: 5.1%, 3 months: 11.8% and 6 months: 21.6% with a normal BMI for the height of 22.2 and a weight of 129.2 pounds. Further review showed a recommendation to discontinue: No added salt restriction, clarify diet to a regular, mechanical soft texture, thin liquids, and fortified food with meals. A re-estimation of the needs based on current weight indicated Kcal: 1770-2065, Protein: 59-77g, Fluids: 1770-2065 ml. A recommendation to re-start nocturnal feeds was placed with Jevity 1.5 (tube feeding formulary) at 50 ml per hour for 12 hours, run until 600 ml infused via percutaneous endoscopic gastrostomy tube (PEG) (on 6 PM, off 6 AM), water flush at 40 ml/hr and for 12 hours, run until 480 ml infused via PEG (on 6:00 PM, off 6:00 AM). It will provide 900 kcal, 38g protein, 936 ml free water, and 1080 ml total fluids. The new recommendation of tube feeding will be missing 870 kcal, 21g of protein, and 690 ml of fluids to meet the lower end of Resident #51's nutritional need, which would be provided from the diet intake by mouth (PO).
A review of the Dietary progress note dated 03/28/2025 revealed the following: The Registered Dietitian (RD) stated that Resident #51 weighed 131.2 pounds and had a BMI of 22.5 on 03/05/2025, which indicated weight loss resolved due to a 1-pound gain since 02/05/2025. A recommendation was made to continue a no added salt diet with a mechanical soft texture and thin liquid PO. The RD further stated that Resident #51's intake varies from 25% to 75%. A recommendation is to continue supplemental enteral feeds of Jevity 1.5 at 50 ml per hour for 12 hours starting at 6:00 PM daily until 600 ml has been infused (900 kcal and 42.5 grams of protein and 450 ml of free water). A review of the progress note further revealed a calculation of Resident #51 nutrient and hydration needs with PO diet and enteral regimen: Energy need:1500-1800 kcal, Protein needs:60-72 grams, and Fluid needs:1500-1800 ml. This indicates that the enteral feeding of 900 kcal, 42.5g of protein, and 450 ml of free water is not meeting the Resident's nutritional and hydration needs. The RD also stated that the enteral regimen is well tolerated, with no signs and symptoms of diarrhea, constipation, abdominal distention/cramping, fluid overload, or aspiration.
A review of the doctors' progress note dated 12/11/2024 indicated under the treatment section and sub-section of attention to gastrotomy tube a recommendation of Glucerna 1.5 tube feeding at 60 ml per hour for 20 hours at 2 PM and off at 10 AM. A review of the orders showed that this recommendation was never placed in the orders.
A review of the care plan initially dated 08/30/2024 and revised on 03/28/2025 stated that Resident #51 is at risk for nutritional and hydration problems. Risk related to nocturnal tube feeding as a supplement route of nutrition and hydration associated with Cerebro Vascular Accident. Medical diagnoses included Respiratory failure, Seizure, Essential Hypertension, Hypernatremia, Gastroesophageal Reflux Disease (GERD), and Diabetes Mellitus (DM). Mechanical soft diet provided PO at all meals.
A review of the past 30 days (from 03/09/2025 to 04/07/2025) of the amount eaten showed various percentages of food intake for Resident #51: 16 meals between 0 and 25%, 13 meals between 26 and 50%, 51 meals between 51 and 75% and 8 meals between 76 and 100%.
In an observation conducted on 04/07/2025 at 5:46 PM, Human Resources staff, Staff R, was seen setting up the tray and leaving the room right after. At 6:10 PM, the tray was still untouched; Resident #51 only ate the dinner roll and the cake. At 6:13 PM, Certified Nurse Assistant, Staff S, wrote 30% of the intake on Resident #51's meal ticket and took the tray out of the room.
In an observation conducted on 04/07/2025 at 6:25 PM, Registered Nurse (RN) Staff T was seen writing Resident #51's information, including the tube feeding start time (6:25 PM) on the tube feeding bottle. After setting up the feeding, the Staff realized the Peg tube was missing a part and called Registered Nurse Staff U for help. Staff T stated that she always sets up the tube feeding for Resident #51 at night because during the day the Resident eats by mouth.
In another observation conducted on 04/07/2025 at 6:40 PM, this Surveyor observed that the feeding started at 6:42 PM, but the monitor stopped and displayed an error message due to clogs. After multiple attempts, tube feeding finally started at 6:50 PM.
In an observation conducted on 04/08/2025 at 5:40 AM, Resident #51 was awake in bed with no tube feeding bottle running or noted in the room. Staff V, RN, stated Resident #51 vomited all over the bed and she stopped the tube feeding at 5:30 AM. The bottle was about half full when she stopped it. Staff V stated that Resident #51 usually tolerates her tube feeding well with no issues.
An order was placed on 04/08/2025 to send Resident #51 to the emergency room for coffee ground emesis identified on 04/08/2025.
In an interview conducted on 04/08/25 at 8:00 AM, the Director of Nursing (DON) stated that specific staff members take the weights on all residents, and the list is then given to Staff D, Medical Records, to put in the electronic system. Staff D calls the Registered Dietitian to discuss any weight losses before recording them in the electronic system. The DON said Resident #51's weight was taken on 4/1/25 but was not able to provide one and then said, Maybe it was written on a piece of paper.
In an interview conducted on 04/08/25 at 8:12 AM with Staff D, she stated she has two staff members who take the weights on all residents, and the list is then given to her to record in the electronic system. The monthly weights are taken on all residents from the 1st to the 5th of the month. If a resident has lost weight, the Registered Dietitian will ask for a reweigh to ensure the accuracy of the weights. For any weekly weights, the Registered Dietitian will provide her with a list of residents. When asked about the facility's policy for weights, Staff D stated residents' weights are taken on admission, once a week for 4 weeks, and monthly thereafter. For the monthly weights, the Registered Dietitian (RD) reviews all residents in the electronic system on a regular basis and will ask for a reweigh of any discrepancies. The RD comes to the facility once a week and has remote access as well to be able to assess the residents when not in the facility. When asked if the monthly weight was taken on Resident #51, Staff D said, It might have slipped us a little bit when we did all the monthly weights from the 1st to the 5th of this month.
According to Staff D, the RD can see any significant/severe weight losses when she reviews the weights of all residents. If she sees any weight loss, she will notify the RD as soon as possible.
In an interview conducted on 04/08/2025 at 11:00 AM, Resident #51's daughter (her caregiver) stated that she realized that her mother had lost a lot of weight and that she had been wanting to talk to someone. She said: I've been sad lately because that's not my mom'. Resident #51's daughter said her mother used to weigh between 200 and 230 pounds and that she is very concerned about the weight loss and how her mom looks now. Especially since she always attends all the care plan meetings and weight loss was never addressed or her preferences. She further explained that her mother doesn't like the food served in the facility, and that may be the reason why she only eats the sweets that are served. Resident #51's daughter stated that sometimes the Staff tells her that her mother eats 60% but doesn't believe it because her mother barely eats 30% when she is present, which is about 3 times a week.
In an interview conducted on 04/09/1015 at 12:30 PM, the Registered Dietitian (RD) stated that she started working for this facility on 03/12/2025 and works between 15 to 20 hours a week and comes only on Fridays. RD explained that she sees the residents on Fridays when she comes and logs in every day to see new admissions. If a new resident is admitted with something crucial like tube feeding, she calls the Director of Nursing and tries to do the assessment within 24 hours and after monthly. RD further explained that if a resident is on pleasure feeding, then the tube feeding must meet all the resident's needs. A resident on tube feeding is considered at high risk, and to take a resident off the tube feeding, one of the criteria is that the resident is consistently eating 75% or more. As for the weight, RD explained that she runs an exception report between last month and this month, which tells her what happened so she can make the necessary adjustments. RD did not adjust the tube feeding for Resident #51 because Resident had a 1-pound weight gain and was waiting for the monthly weight to consider changes. When asked by this Surveyor if she visited Resident #51 or spoke to her daughter regarding food likes and preferences, she said no.
The current facility Registered Dietitian did not reweigh Resident #51 or adjust the estimated needs of the Resident due to the 1-pound weight gain and did not consider the trending significant weight loss for the last 6 months.
In an interview conducted on 04/09/2025 at 2:28 PM, the Director of Nursing (DON) stated that she had four different dietitians in 6 months. There was no dietitian coverage from 12/07/2024 to 12/10/2024. The DON further explained that the expectation for a resident on tube feeding is to be seen weekly by the RD, and if residents are stable, then the visits should be monthly. She also expected the RD to recognize the weight loss on Resident #51 and acknowledged that no RD notes were placed for Resident #51 from August 2024 to January 2025 (4 months).
In an interview conducted on 04/09/2025 at 2:45 PM with a Registered Nurse, Staff E stated that she is familiar with Resident #51. She further stated that Resident #51 tolerates tube feeding well and has been eating between 50% and 60% on average.
In an interview conducted on 04/09/2025 at 3:00 PM with Medical Records, Staff D stated that she has been working at the facility for 6 years and is very familiar with Resident #51. Staff D explained that Resident #51 would drink a lot but only ate 25% more or less.
In an interview conducted on 04/10/2025 at 2:25 PM with a Certified Nurse Assistant (CNA), Staff P stated that she is familiar with Resident #51 and that her food intake depends on the type of food. For example, for Breakfast, she will eat 50% some days, but for lunch and dinner, she wouldn't eat more than 25%. Staff further stated that Resident #51 is not a big eater, and that Breakfast is the best one for her.
In an interview conducted on 04/10/2025 at 2:30 PM with the Registered Nurse, Staff Q stated that she is familiar with Resident #51. Staff Q explained that Resident #51 likes to drink (coffee, milk, and orange juice) more than eat. Her food texture changed on multiple occasions from pureed (because she did not want it) to regular texture. Once it was changed to a regular texture, Resident #51 started choking, so it had to be changed to mechanical chopped. Staff Q further stated that as the RN on the floor, the CNAs come to her and inform her of Resident #51's intakes. Breakfast is her best food, and she eats 50% of it.
In an interview conducted on 04/10/2025 at 2:10 PM, Resident #51's daughter (caregiver) stated that she is not happy with the weight loss; her dad cried when he saw his wife at the hospital because she had lost so much weight; That should have never happened in the first place, they should have been feeding my mom properly. The Resident's daughter further reported that the doctor at the hospital explained that her mother would never be able to eat by mouth again.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure call lights are within reach for 2 of 20 sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure call lights are within reach for 2 of 20 sampled residents (Residents #2 and #10).
The findings included:
1. Record review for Resident #10 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Osteoarthritis Left Knee, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side, Pain and Muscle Weakness (Generalized). The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response.
On 04/07/25 at 9:15 AM an observation was made of Resident #10 sitting up in bed with the call light draped behind the head of the bed and out of the reach of the resident.
On 04/07/25 at 11:15 AM an observation was made of Resident #10 being assisted by a staff member while in bed. The call light continued to be in the same place, draped over the head of the bed and inaccessible to the resident.
On 04/07/25 at 12:00 PM an observation was made of Resident #10 out of bed in the wheelchair. The call light continued to be in the same place, draped over the head of the bed and inaccessible to the resident.
During an interview conducted on 04/07/25 at 9:18 AM with Resident #10 who was asked if he can use his call bell, he said yes but he cannot reach it, it is probably behind him somewhere. When asked what he does if he needs to call for assistance, he said he has a big mouth and will have to yell.
An interview was conducted on 04/10/25 at 9:40 AM with Staff L, Registered Nurse (RN), who stated she has worked at the facility since October 2020. When asked about call lights, the RN stated the call bell is supposed to be within the reach of the resident at all times.
An interview was conducted on 04/10/25 at 9:50 AM with Staff B, RN, who stated she has worked at the facility since October 2020. When asked about call lights, she stated they need to be where the resident can reach it.
2. Record review for Resident #2 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Pulmonary Embolism with Acute Cor Pulmonale, Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing, Generalized Anxiety Disorder, Bipolar Disorder, Difficulty in Walking, Muscle Weakness, and History of Falling. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment.
On 04/08/25 from 8:30 AM to 8:40 AM an observation was made of Resident #2 constantly banging on her overbed table and yelling for help that she needed to go to the bathroom several times.
On 04/08/25 at 8:43 AM an observation was made of Staff M, Certified Nursing Assistant (CNA), going into the room to assist Resident #2. The resident's call light was clipped to the top corner of her pillow and the resident was unable to reach the call light.
During an interview conducted on 04/08/25 at 8:43 AM with Resident #2 the resident was asked about her call light and she just yelled at this surveyor to leave her alone.
During a side by side observation conducted on 04/08/25 at 8:44 AM with Staff M, CNA, she was asked if Resident #2 can use the call light. She looked for the call light and found it at the top of the bed hanging off of the bed. She then handed the call light to the resident and asked her if she could push it for assistance and the resident did push the call light and yelled at Staff M CNA, now are you going to help me.
CONCERN
(D)
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 observations and interviews, the facility failed to ensure the residents have a right to a safe, clean, comfortable and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the residents have a right to a safe, clean, comfortable and homelike environment for 6 of 27 resident rooms observed in the facility.
The findings included:
1). On 04/07/25 at 9:20 AM an observation made in room [ROOM NUMBER] A revealed the following:
*The wall behind the bed, was noted to be unsmooth and peeling paint.
*The standing fan across from the resident's bed was covered with dust and debris.
2). On 04/07/25 at 11:30 AM an observation made in room [ROOM NUMBER] revealed an uncovered fluorescent bulb in the entryway, inside of the room.
3). On 04/07/25 at 11:40 AM an observation made in room [ROOM NUMBER] revealed the following:
* An uncovered fluorescent bulb in the entryway, inside of the room.
* The A/C vents were covered with dust and debris.
* The lightbulb in the bathroom was out.
* Unpainted plaster on the bathroom wall, next to the soap dispenser
*A leaky faucet in the bathroom sink.
4). On 04/07/25 at 11:30 AM an observation made in room [ROOM NUMBER] revealed the following:
*An uncovered fluorescent bulb in the entryway, inside the room.
*A leaky faucet in the bathroom sink.
*A call light pull cord wrapped around the grab bar in the bathroom.
5). On 04/07/25 at 10:50 AM an observation made in room [ROOM NUMBER] revealed a missing light bulb in the entryway, inside the room.
6). On 04/07/25 at 11:15 AM an observation made in room [ROOM NUMBER] A revealed an uncovered fluorescent bulb in the entryway, inside the room.
A side-by-side tour of the facility was conducted on 04/10/25 at 10:20 AM with the Director of Maintenance who stated he has been at the facility for 1.5 weeks and the Administrator who started the week of survey. They acknowledged the above findings. The Administrator stated they will be working on the aforementioned items to get them corrected right away.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for pressure ulcer for 1 of 1 sampled resident reviewed for pressure ulcer (Resident #37) and failed to develop and implement a comprehensive person-centered care plan for psychotropic medication for 1 of 1 sampled resident reviewed for Mood/Behavior (Resident #59).
The findings included:
1. Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Type 2 Diabetes Mellitus, Muscle Weakness, and Unspecified Abnormalities of Gait and Mobility. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment.
Review of the Physician's Orders for Resident #37 revealed an order dated 04/04/25 for sacrum pressure ulcer stage 1 cleanse with normal saline (N/S), pat dry, apply calcium alginate daily and PRN (as needed) every day shift was discontinued on 04/04/25.
Review of the Care Plan for Resident #37 dated 12/27/23 with a focus on the resident has pressure ulcer to buttock related to Immobility. The goal was for the resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions included in part the following: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of skin breakdown Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size, stage.
In summary the review of the care plan for Resident #37 was not updated to indicate the sacral wound identified and did not indicate the pressure ulcer to the buttock had been resolved.
In summary the facility acquired sacral pressure ulcer was not updated on the care plan, additionally there were no interventions in place for Resident #37 to prevent the development of a pressure ulcer.
Review of the Wound Care Progress Note by the Wound Care Consultant company dated 04/08/25 documented in part the following: wound location: Sacrum, Length 4 centimeters (cm), Width: 3.2 cm, Depth: 0.2 cm. Status: Recurrent.
During an interview conducted on 04/09/25 at 12:30 PM with the Minimum Data Set (MDS) Coordinator who stated she is the only MDS coordinator and has worked at the facility for 3 years and in the MDS department for about 3 months. The MDS Coordinator stated that the Dietary department, Therapy department and the Social Worker all put in their own care plans, and she does all the nursing care plans. The MDS Coordinator stated she would update care plans as needed based on specific findings. When asked when a resident has a wound or skin care plan and develop a new pressure ulcer would the care plan be implemented or updated, she said yes. When asked what the time frame is to update the care plan when there is a new wound, she said if there is something new it should be updated within couple of days. When asked if there should be interventions in the care plan for prevention of skin issues or pressure sores especially if the resident has had a wound in the past, she said yes. The MDS Coordinator acknowledged she did not implement a care plan for the sacral pressure ulcer and that the care plan for the buttock wound should have been resolved a long time ago.
2. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Degenerative Disease of Nervous System, Pain, Restless Agitation, and Depression. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status could not be done due to the resident is rarely/never understood.
Review of the Physician's Orders for Resident #59 revealed in part the following orders:
An order dated 03/13/25 for Lorazepam Oral Tablet 0.5 MG give 1 tablet by mouth every 6 hours as needed for Agitation related to Restlessness and Agitation for 14 Days and was discontinued on 03/27/25.
An order dated 03/13/25 for Seroquel Oral Tablet 25 MG give 1 tablet by mouth one time a day for Depression (Psychosis) related to Depression, Unspecified and was discontinued on 03/24/25.
An order dated 03/24/25 for Seroquel Oral Tablet 25 MG give 25 mg by mouth every 12 hours for psychosis.
Review of the Care Plan for Resident #59 revealed there was no care plan for psychotropic medications including interventions to monitor for behaviors or side effects.
During an interview conducted on 04/10/25 at 9:30 AM with the Minimum Data Set (MDS) Coordinator who was asked if a resident who has psychotropic medications ordered would have a care plan, she said they should have a care plan for the psychotropic medication and include monitoring for behaviors and side effects. When asked about Resident #59, she acknowledged the resident had psychotropic medications ordered and no care plan in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, record review and interview, the facility failed to: 1) promptly notify the ordering ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, record review and interview, the facility failed to: 1) promptly notify the ordering physician and promptly administer oral Antibiotics to a resident, in a timely manner, for a resident with a Urinary Tract Infection (UTI) for 1 of 1 sampled resident (Resident #16); and, 2) failed to accurately document and assess the status and condition for a resident with a skin condition for 1 of 1 sampled resident (Resident #2).
The findings included:
1) Record review of the facility policy and procedure titled General Laboratory Information provided by the Director of Nursing (DON), reviewed 2024, documented in the Policy Statement: Communicating Urgent Results Notification will be provided to the Principal Investigator, Physician, or his/her authorized representative, as permitted or required by state and federal law, and these authorized personnel will have the responsibility of interpreting the result (s) in the context of the patient's clinical condition. The authorized personnel will be responsible for taking immediate action, if needed. If the authorized personnel are not qualified to make these decisions, he/she has the responsibility of communicating the information to a qualified person immediately All critical results are called in to the facility, three attempts are made to communicate with resident's nurse, DON or unit manager. If unable to communicate verbal results, Biogalax will send an Urgent Fax memo. The Urgent Fax form will state the Name, DOB of the patient and 'Attention to Nurse, DON or Unit Manager.' All critical results must be reported to nurse, DON, or unit manager at facility .
Record review revealed Resident #16 was re-admitted to the facility on [DATE] with diagnoses which included Dementia, Type 2 Diabetes Mellitus with Complications, Obstructive and Reflux Uropathy, and a History of Recurrent Urinary Tract Infections. He had a Brief Interview Mental Status (BIM) score of 15, indicative of intact cognition.
Review of Resident #16's record documented that the Physician's order had not been entered and uploaded into the facility's computer system by Staff I, a Licensed Practical Nurse, (LPN), until Wednesday 04/02/25 at 7:35 PM. Furthermore it was not translated and captured in the system, until later the next day on Thursday 04/03/25 and read as such: Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohydrate Macro) to give one (1) capsule by mouth two (2) times a day for Urinary Tract Infection (UTI) for ten (10) days, as ordered by the resident's current primary care physician PCP.
There had also been two (2) different previously entered computerized physician's orders which indicated for: 1) Urinalysis and Urine Culture dated Monday 03/24/25---one time only for Lethargy for one (1) day. And, 2) dated Wednesday 03/26/25---one time only for Lethargy for three (3) days.
Next, computerized record review of the nursing progress notes entered by Staff I, a Licensed Practical Nurse, (LPN) documented that, on Wednesday 03/26/25 at 07:03 AM, Per outgoing nurse report resident has labs .Urine and culture and sensitivity Unable to collect urine this shift even after enforcing extra fluid intake. Tried several times, but remained unsuccessful due to patient urinating in adult briefs by the time this writer had gone to him four (4) times. Oncoming nurse will be made aware. Collection cup left at bedside. Urine tubing, specimen envelope and urine requisition, will be given to relieving nurse. Staff I, also documented on Thursday 03/27/25 at 06:15 AM, Urine + Culture and Sensitivity drawn and picked up yesterday results remain pending. Oncoming nurse will be made aware
Further record review of the Laboratory Report for Resident #16 dated 03/25/25 revealed that Resident #16's urine specimen for Escherichia (E-coli) had been previously collected on Tuesday 03/25/25, received, resulted and reported on Thursday 03/27/25 at 5:43 PM.
Additional computerized record review was conducted of the two (2)---a) Physician Progress note dated 03/24/25 at 01:00 AM by Resident #16's PCP documented .Nursing has concerns regarding change in mental status, but patient appears to be at baseline mental status CBC, CMP, ammonia, A1C ordered for lethargy and b) Physician Progress note dated 03/26/25 at 01:00 AM by Resident #16's PCP documented . including change in mental status, Change in Mental Status (03/24/25) Workup initiated: CBC, CMP, ammonia, CXR, UA/UCx. Continue frequent mental status monitoring. As well as, progress notes documented by the Resident's Physician Assistant's (P.A.)'s, progress note visit entered on Tuesday 04/01/25, revealed that the abnormal urine culture results had been first identified and discovered by the P.A., who in turn documented the following entry in the facility record, Pt with new UTI + E-coli. Will start Macrobid 100 mg BID x ten (10) days
There was no documentation noted in the nurses' progress notes dated from Wednesday 03/26/25 at 07:03 AM through 04/03/25 at 06:59 AM, to indicate if, when or what time the ordering physician had been notified of these abnormal urine culture results, by the facility.
However, further review of Resident #16's April 2025 Medication Administration Record (MAR), documented for the Macrobid 100 mg was not started until Thursday 04/03/25 at 09:00 AM, which is approximately one week after the lab results were reported to the facility.
On 04/03/25 at 06:59 AM, Staff I, also documented, Antibiotic Diagnosis: UTI with Macrobid to be started this morning as ordered x 10 days (until Wednesday 04/12). Medication received this morning from pharmacy .
A brief telephone interview was conducted on 04/09/25 at 2:06 PM with the a supervisor at the Diagnostic laboratory to clarify the date and time the facility received the results was 03/27/25 at 5:43 PM. He state he would speak with someone and get back to this surveyor, however, there was no response received back during the survey.
A telephone interview was attempted on 04/09/25 at 2:22 PM with Resident #16's Physician's Assistant/PCP, in order to ascertain whether or not the physician's office had been notified of Resident #16's abnormal urinalysis and urine culture result of Escherichia (E-coli), by the facility. This Surveyor left a voice message. However, there was no response received back during the survey.
A telephone interview was conducted on 04/10/25 at 9:33 AM with Staff I, in order to ascertain whether or not Resident #16's abnormal urine culture results had been promptly reported to the ordering physician. Staff I also acknowledged that the abnormal urine culture lab work had previously been collected on 03/25/25, and reported back to the facility on [DATE] at 5:43 PM, per the lab report. When asked, did you document in the resident's record that you promptly notified the resident's ordering physician of the abnormal E.coli urine culture result, she responded, by saying that, another nurse may have. And Staff I was also asked if she knew why there had been a seven (7) day delay between receiving Resident #16's abnormal urine culture lab work and in Resident #16 finally receiving his oral antibiotics. Staff I responded by saying that, she was not working that whole time and she did not know. However, Staff I, acknowledged that the next nurse should have followed up to find out if the lab results had been obtained so that the resident could have received proper treatment, as indicated.
During an interview conducted on 04/09/25 at 3:22 PM with the DON, she was also asked to describe the process that occurs when an abnormal lab result report comes in, and who would be responsible for notifying the Physician of this and where would it be documented. The DON responded by saying that, the laboratory would call the facility directly, whenever there was an abnormal or critical lab result. And, she said that the lab would ask to speak to a nurse, take his or her name, and would then fax over the abnormal lab result to the main fax machine located on the [NAME] wing across from the nurses' station, at the facility. Then, the DON said that the assigned nurse would be responsible for reaching out and contacting the ordering physician ASAP, with the abnormal lab results. Next, the DON indicated that the responsible nurse would initial the result, note that the Physician was notified, and would place the abnormal lab result in the box, located at the nurses' station, to be uploaded into the system the next morning, by their medical records department. The DON ended by acknowledging that there was no book or tracking log, at this time, in place to record and store the resident's abnormal lab results, in the facility.
Staff member J, a Registered Nurse (RN), who had been working on Thursday 03/27/25 at 5:43 PM, when the lab result was reported in from the lab, was no longer working with the facility and unavailable for an interview.
There was no care plan on file specifically for Urinary Tract Infection, care, for this resident.
In fact, the physician notification and subsequent order for Resident #16's oral antibiotic had not been performed nor obtained prior, by the facility. The physician's order for treatment was not initiated, with an intervention until five (5) days later, after it was first discovered by the Physician's Assistant.
In Summary, the oral antibiotic had not been started and administered to Resident #16 until seven (7) days after the abnormal lab results had been reported to the facility by the laboratory.
The DON further recognized and acknowledged on 04/09/25 at: 3:30 PM that facility nursing staff, should have followed through with promptly notifying the ordering physician and she also indicated that there should not have been a delay of seven (7) days between the facility having received an abnormal urine culture result and for Resident #16 finally having received his ordered oral antibiotics for treatment.
2) Record review of the facility policy and procedure titled Dressing, Non-Sterile provided by the Director of Nursing (DON), reviewed April 2019, documented in the Policy Statement: This procedure may involve potential/direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Purpose: The purposes of this procedure is to provide guidelines for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria. Steps in the Procedure: .15. Observe the wound and surrounding skin .Reporting and Documentation: The following information be documented in the resident's electronic record medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care give
Record review revealed Resident #2 was re-admitted to the facility on [DATE] with diagnoses which included Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing, Bipolar Disorder, Unspecified and Generalized Edema. She had a Brief Interview Mental Status (BIM) score of 5, indicating severe cognitive impairment.
During an observational tour conducted on 04/07/25 at 11:03 AM, Resident #2 was observed, her left pant leg partially pulled up, with a partially attached dressing, located on her left upper front shin area with two (2) exposed and uncovered sutures noted underneath. And, upon closer observation of Resident #2's left leg, just above her left knee, she was observed to have four (4) additional exposed and uncovered sutures noted. Photographic Evidence Obtained. Resident #2 was asked, in general if she had any pain, at this time and she replied, yes, sometimes she has an intermittent pressure type pain from the top of her left knee to her upper left shin, pain level 8/10, for which she gets medication for. It was noted that the edges of both incisions with sutures, were well approximated, with no redness or drainage noted, at this time.
Record review of the current physician's orders dated 04/07/25 documented, Left lower extremity: Clean surgical site with normal saline (N/S), pat dry, apply Xeroform, cover with protective dressing daily.
Record review of Resident #2's re-admission note dated 03/24/25 documented, Left leg Tibia Fibula fracture, bruises behind left calf from the fracture Skin is warm and dry to touch.
However, further record review of all subsequent nursing progress dated from 03/24/25 until 04/08/25, makes no mention of the existence, presence, current status nor current condition of Resident #2's exposed and open to air sutures or surrounding skin, on her left lower shin, nor on the upper portion above her left knee.
An additional record review of a progress note dated 04/04/25 by Staff K, an RN, in which it was documented, Resident left Tibia Fibula Fracture dressing changed: cleanse with N/S, pat dry, apply Xeroform, cover with protective dressing. Wound dry and clean no sign of infection noted, no swelling, redness, drainage noted, no complaints of pain. Treatment in place will continue to monitor. Again, there was no mention of the existence, presence, current status nor current condition of Resident #2's sutures or surrounding skin on her left lower shin, nor on the upper portion above her left knee.
During a subsequent observation conducted on 04/09/25 at 11:04 AM, Resident #2 was now observed with three (3) dressings, all initialed and dated 04/09/25, with one (1) located on the area above her left knee, a second one located to the resident's left upper and a third one located on the resident's lower outer front shin area covering the previously seen sutures, of the two (2) upper skin dressing areas. Photographic Evidence Obtained.
During a brief interview conducted on 04/09/25 at 11:04 AM with Resident #2's assigned nurse Staff L, RN, she stated that all three (3) dressings had been changed earlier that morning by Staff E, an RN, and by the Assistant Director of Nursing (ADON).
An interview was conducted on 04/09/25 at 2:45 PM with the ADON, in which she acknowledged that she did assist Staff E, during the dressing change to Resident #2's left lower leg earlier that morning at 7 AM, and she acknowledged that Resident #2 did have sutures in place in her left lower leg at various locations. The ADON also acknowledged, as recorded in the resident's Treatment Administration Record (TAR) dated April 7th and April 8th, that Staff K had also initialed that she had done the dressing changes to the left lower extremity for Resident #2. However, she also stated and noted that neither Staff K, nor Staff E, had documented anything regarding the existence, presence, current status nor current condition of Resident #2's sutures or surrounding skin on her left lower shin, nor on the upper portion above her left knee, in Resident #2's record for the date of April 9th 2025.
There was no care plan specifically addressing Resident #2's surgical dressing and sutures.
Moreover, there was no record of the nursing progress note for the dressing change performed on 04/09/25 at 7 AM, for this resident's left lower leg.
Record review was also conducted of the TAR for the dates of Monday April 7th, Tuesday April 8th by Staff K, and for the date of Wednesday April 9th by Staff E, RN, Staff nurse, who performed the left lower dressing change, all indicated with initials that the dressing had been done and the physician's order was: Left lower extremity: Clean surgical site with N/S, pat dry, apply Xeroform, cover with protective dressing daily one time a day - Start Date Monday 04/07/25 at 0800 AM.
Nonetheless, there had still been no mention of the existence, presence, current status, nor current condition detailing Resident #2's sutures or surrounding skin on her left lower shin and on the upper portion above her left knee, anywhere in the resident's record for either of these three (3) above dates.
The DON recognized and acknowledged on 04/09/25 at: 3:14 PM, that the resident's complete skin status, including her sutures, should be assessed and should have been documented in detail in the resident's record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that a resident receives care, consistent with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 1 sampled resident reviewed for pressure ulcers (Resident #37).
The findings included:
Record review for Resident #37 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Type 2 Diabetes Mellitus, Muscle Weakness, and Unspecified Abnormalities of Gait and Mobility. The Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 10, indicating moderate cognitive impairment.
Review of the Physician's Orders for Resident #37 revealed in part the following orders:
*An order dated 02/06/24 Weekly skin assessment every Tuesday 7:00 AM to 7:00 PM Shift.
*An order dated 04/04/25 for sacrum pressure ulcer stage 1 cleanse with normal saline (N/S), pat dry, apply calcium alginate daily and PRN (as needed) every day shift was discontinued on 04/04/25.
*An order dated 04/05/25 sacrum: Cleanse with N/S, pat dry, apply calcium alginate daily and PRN (as needed) every day shift for wound.
*An order dated 04/04/25 for air mattress.
*An order dated 04/06/25 to encourage resident to turn and reposition frequently.
Review of the TAR (Treatment Administration Record) for the month of April 2025 had no documentation of wound care to the sacrum was provided on 04/04/25.
Review of the Progress Notes for Resident #37 from 03/01/25 to 04/04/25 revealed no documentation of turning or repositioning the resident nor was there documentation of the resident refusing to be turned and repositioned.
Review of the Care Plan for Resident #37 revealed no care plan for the sacral pressure ulcer or prevention of pressure ulcers.
Review of the Wound Care Progress Note by the Wound Care Consultant company dated 04/08/25 documented in part the following: wound location: Sacrum, Length 4 centimeters (cm), Width: 3.2 cm, Depth: 0.2 cm. Status: Recurrent.
An interview was conducted on 04/09/25 at 11:05 AM with the Assistant Director of Nursing (ADON) who stated she has worked at the facility or 1 year. When asked how do you identify if a resident is high risk for development of pressure ulcer, the ADON stated by doing a Pressure ulcer screening and Braden scale assessment and history of resident. They are done on admission, depending on the score of the screening or assessments it will populate to reassess the resident. If the resident is high risk when it would populate for a reassessment again but does not know the exact time frame for the reassessment to be completed next. When asked about Resident #37, the ADON stated the resident had a pressure ulcer screening done on 10/12/24 that documented a score of 7 indicating less than 8 not high risk for developing a pressure ulcer. On 12/31/24 the resident had a Braden Scale Predicting Pressure Sore Risk documenting a score of 17 indicating at risk for developing a pressure ulcer.
The ADON verified the resident had an order dated 02/06/24 for skin checks every Tuesday 7:00 AM to 7:00 PM shift. The licensed nurse weekly skin observation were completed on 12/11/24, 01/08/25, 01/22/25, 02/19/25, 03/26/25, 04/05/25, and 04/08/25. The ADON acknowledged the weekly skin checks were not performed weekly as ordered.
The ADON then stated on 04/04/25 documented in an Exception report was sacral ulcer stage I, however she believes this was documented as stage I in error and should have been a stage II. The documentation on 04/05/25 of sacral ulcer as stage 2. When asked if the wound care to the sacrum was documented as performed on 04/04/25 as ordered, the ADON acknowledged there was no documentation of the wound care being performed.
An interview was conducted on 04/09/25 at 10:30 AM with Staff A, Certified Nursing Assistant (CNA), who stated she has worked at the facility for 7 years. When asked does she turn and reposition residents and if so how often, she said they turn and reposition residents every 2 hours. When asked where she documents the turning and repositioning, she said they do not have a place for her to document this in the electronic medical record.
An interview was conducted on 04/09/25 at 10:45 AM with Staff B, Registered Nurse (RN), who stated she has worked at the facility since 2020. When asked what interventions the facility uses to prevent pressure ulcers or skin breakdown, she said they do weekly skin check and turn and reposition the resident's every 2 hours. When asked where this is documented, she said the weekly skin assessments are documented in the Weekly Skin Check Assessment. When asked about the documentation for turning and repositioning, she said only if there is an order they are documented on the TAR (Treatment Administration Record) or they can document on a progress note.
During an interview conducted on 04/09/25 at 1:30 PM with the Director of Nursing (DON) who was asked about Resident #37 and sacral wound, she stated some nurses had documented a sacral wound but not any measurements or staging, she said this may have been documented incorrectly, because all of the orders for treatment were for buttock wounds at the time when this documentation was in effect in late December 2024 to early January 2025. The 3008 form from the transferring hospital dated 12/19/23 documented skin condition of sacrum and buttocks as having road rash. The DON acknowledged there was no evidence in the resident's medical record that she had a pressure ulcer on her sacral wound while at the facility. The DON provided a statement on letterhead signed by her and dated 04/09/25 Resident #37 does not have any history of pressure ulcer on her sacrum.
During a telephone interview conducted on 04/10/25 at 1:45 PM with the Advanced Registered Nurse Practitioner (ARNP) from the wound care company who was asked about the documentation of the sacral wound care for Resident #37 dated 04/08/25, she said she put recurrent because that is what the DON had told her that the resident had a sacral wound in the past. She stated this was the first time she had seen the resident, and she did not review the chart, she just documented based on what the DON had told her.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Anxie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Anxiety Disorder, Dementia, and Muscle Weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #45 had a Brief Interview of Mental Status (BIMS) score of 11, which indicates moderate cognitive impairment.
A review of the Physician's orders showed an order for Apixaban (an anticoagulant medication): give one tablet, 2.5 milligrams, every 12 hours, for Chronic Atrial Fibrillation. No order was noted to monitor side effects or adverse effects of the above medication.
A review of the Care Plan dated 8/20/24 showed the following: Resident #45 is on anticoagulant therapy related to Atrial Fibrillation. Resident #45 will be free from discomfort or adverse reactions to anticoagulant use through the review date. It further showed to monitor/document/report adverse reactions of anticoagulant therapy: blood-tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, loss of appetite, sudden changes in mental status, significant or sudden changes.
Further record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #45 did not show that the facility was monitoring the side effects and adverse reactions of the anticoagulant medication.
In an interview conducted on 4/9/25 at 10:47 AM with the Director of Nursing (DON), she stated that there should be a batch order to monitor the side effects of anticoagulant medication, and nursing should document this in the MAR and the TAR.
In an interview conducted on 04/09/25 at 10:51 AM, Staff H, a Registered Nurse, stated Resident #45 was on an anticoagulant and was being monitored for side effects such as bleeding and bruising. She then said it is documented in the MAR and the TAR and proceeded to show this Surveyor in the electronic system. She then responded to the surveyor and said,It is not here.
Based on interviews and record reviews, the facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications for 2 of 5 sampled residents reviewed for Unnecessary Medication (Resident #1); for 1 of 1 resident sampled residents reviewed for Mood/Behavior (Resident # 59); and failed to ensure adequate monitoring of side effects of residents prescribed anticoagulants (blood thinner) for 1 of 1 sampled residents reveiwed for Unnecessary Medications (Resident #45).
The findings included:
1. Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Degenerative Disease of Nervous System Unspecified, Pain, Restless Agitation, and Depression. The Minimum Data Set assessment dated [DATE] documented in Section C, a Brief Interview of Mental Status could not be done due to the resident is rarely/never understood.
Review of the Physician's Orders for Resident #59 revealed in part, the following orders:
*An order dated 03/13/25 for Lorazepam Oral Tablet 0.5 MG give 1 tablet by mouth every 6 hours as needed for Agitation related to Restlessness and Agitation for 14 Days and was discontinued on 03/27/25.
*An order dated 03/13/25 for Seroquel Oral Tablet 25 MG give 1 tablet by mouth one time a day for Depression (Psychosis) related to Depression, Unspecified and was discontinued on 03/24/25.
*An order dated 03/24/25 for Seroquel Oral Tablet 25 MG give 25 mg by mouth every 12 hours for psychosis.
*An order dated 03/24/25 for Side Effect Observation Order #2: 15-Appetite change/weight change ; 16-Insomnia ; 17-Confusion ; 18-Akathisia-restlessness/pacing/inability to sit still/anxiousness/sleep disturbances ; 19-Tardive dyskinesia--lip smacking/chewing/abnormal tongue movement/spasmodic movement of arms/legs-rocking/swaying ; 20-Blood abnormalities ; 21-Sore throat ; 22-Seizures ; 23-Photosensitivity ; 24-Suicidal ideations ; 25-Gastrointestinal disturbances ; 26-Hepatic or renal abnormalities ; and 27-Ataxia every shift for Behaviors.
*An order dated 03/24/25 for Side Effect Observation Order #1: 1-Dystonia, torticollis (stiffness of neck) ; 2-Anticholinergic symptoms: dry mouth/blurred vision, constipation/urinary retention ; 3-Hypotension ; 4-Sedation/drowsiness ; 5-Increased falls/dizziness ; 6-Cardiac abnormalities (tachycardia, bradycardia, irregular, H.R., NMS) ; 7-Anxiety/agitation ; 8-Blurred Vision ; 9-Sweating/rashes ; 10-Headache ; 11-Urinary retention/hesitancy ; 12-Weakness ; 13-Hangover effect ; and 14-Pseudo parkinsonism every shift for Behaviors.
*An order dated 03/24/25 for Behavior Code 1 : Depressed / withdrawn - Document # of times behavior occurred each shift every shift for Behaviors
An order dated 03/24/25 for Behavior Code 1 : Depressed / withdrawn - Document # of times behavior occurred each shift every shift for Behaviors.
*An order dated 03/24/25 for Behavior Code 2 : Agitated - Intervention Codes: 1. One on one 2. Activity 3. Adjust room temperature 4. Backrub 5. Change position 6. Give fluids 7. Give food 8. Redirect 9. Refer to progress notes 10. Remove resident from environment 11. Return to room [ROOM NUMBER]. Toilet every shift for Behaviors.
*An order dated 03/24/25 for Behavior Code 3 : Agitated - Document Outcome Code: I-Improved ; S-Same ; W - Worsened every shift for Behaviors.
In summary Resident #59 was ordered 2 separate antipsychotic medications (Lorazepam and Seroquel) on 03/13/25 and there was no order to monitor side effects or behaviors for these medications until 03/24/25.
Review of the Medication Administration Record (MAR) and Treatment Medication Administration (TAR) for Resident #59 documented the resident had received the Seroquel as ordered, and was not administered the Lorazepam. There was no documentation of behavior or side effect monitoring until 03/24/25.
Review of the Care Plan for Resident #59 revealed there was no care plan for psychotropic medications including interventions to monitor for behaviors or side effects.
An interview was conducted on 04/10/25 at 9:40 AM with Staff L Registered Nurse (RN) who stated she has worked at the facility since October 2020. When asked about when a resident is receiving psychotropic medications do they monitor for behaviors and side effects, she said yes. When asked where this is documented she said on the MAR and if there is a behavior or side effect observed then you make a progress note.
An interview was conducted on 04/10/25 at 9:50 AM with Staff B Registered Nurse (RN) who stated she has worked at the facility since October 2020. When asked about when a resident is receiving psychotropic medications do they monitor for behaviors and side effects, she said yes. When asked where this is documented she said on the MAR and if there is a behavior or side effect observed then you make a progress note.
2. Record review revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute Chronic Diastolic (congestive) Heart Failure and Cardiac Arrest due to an underlying heart condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score was 3, which indicates severe cognitive impairment.
A review of the physician orders indicated that Resident #1 had an order for Citalopram Hydrobromide Oral Tablet of 10 milligrams (mg.) once a day for Depression dated: 02/27/2025.
A review of a care plan dated 04/07/2023 indicated that Resident #1 is prone to side effects and changes in behavior, mood and cognition related to the use of antidepressant medications. Observation and monitoring for potential changes in behaviors, mood and side effects such as rigid muscles, insomnia, appetite loss, dry eyes, dry mouth, fecal impaction, and gait changes are necessary.
A review of the physician orders, Medication Administration Record (MAR) and the Treatment Administration Record (TAR) indicated that the facility failed to implement interventions to monitor changes in behavior, mood and potential side effects related to the use of antidepressant medications for Resident #1.
In an interview conducted on 04/10/2025 at 11:00 AM, Director of Nursing (DON) stated that they don't monitor mood and behaviors or side effects for antidepressant medications because it's not part of the protocol that they follow.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to wear or don appropriat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to wear or don appropriate personal protective equipment (PPE), preventing infection control, during high-contact resident care activity for 1 of 1 sampled resident observed for Indwelling Urinary Catheter, Resident #171.
The findings included:
Record review of the facility policy and procedure titled Enhanced Barrier Precautions provided by the Director of Nursing (DON) reviewed November 2019 documented in the Policy Statement: Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-resistant Organisms (MDRO) to staff hands and clothing
Record review of the facility policy and procedure titled Catheter Care, Urinary provided the DON reviewed July 2015 documented in the Policy Statement: This procedure may involve potential/direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Protective Barriers that may be needed: .Gown .Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract
Record review revealed Resident #171 was admitted to the facility on [DATE] with diagnoses which included Neurogenic Bladder. She had a Brief Interview Mental Status (BIM) score of 00, indicating severe cognitive impairment.
A physician's order dated 04/03/25 documented for Enhanced Barrier Precautions: Wound/foley catheter/biliary drain.
During an observation conducted on 04/09/25 at 9:52 AM, of Peri-care-Foley catheter care for Resident #171, it was noted that Peri-care-Foley catheter care was being performed by Staff N, a Certified Nursing Assistant (CNA). Staff N was observed setting up, preparing and beginning to perform hands-on Peri-care and Foley catheter care on this resident, while only wearing gloves, with no protective PPE gown on. During the start of this observation, Staff N was observed leaning over, and in-close proximity to the resident, whose peri-area with his Foley catheter, was visibly exposed. Staff N was subsequently interrupted, by Staff Member O, a CNA, who reached inside of Resident #171's room door in order to hand Staff N, a protective gown to wear. Upon inquiry by the surveyor, Staff N, was unable to provide a clear explanation, when asked, as to why she had begun pulling back the resident's covers, touching his person, re-positioning his Foley catheter and proceeding to begin with the resident's peri-Foley care, without first donning a clean protective gown over her clothing, prior to performing this procedure, for Resident #171.
On 04/09/25 at 10:17 AM an interview was conducted with Staff O, in which she was asked about why she was observed handing a protective gown through the resident's room door to Staff N, after peri-Foley care had already begun for this resident. Staff O acknowledged that she had done so because she noticed that Staff N, was not wearing one and she said that she should have been, since the resident had a Foley catheter, in place.
During an interview on 04/09/25 at 2:17 PM, the DON (Director of Nursing), also functioning as the Infection Control Nurse) stated that on 04/02/25 and 04/09/25, she had recently educated the nursing staff nurse on the importance of Infection Control procedures, including appropriate PPE as well as handwashing and providing Perineal care to the residents. The DON acknowledged that the CNA should have donned appropriate PPE gown, prior to performing Peri-care-Foley care for Resident #171.
Photographic Evidence Obtained
Jan 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy and procedure, observation, interview and record review, the facility failed to ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy and procedure, observation, interview and record review, the facility failed to ensure that it followed physician's orders for medications and supplements for 2 of 6 sampled residents observed during a Medication Administration Observation (Resident #16 and Resident #166).
The findings included:
Review of the facility policy and procedure titled, Medication Administration, provided by the Director of Nursing (DON) dated 04/14/23, documented in the Policy Statement: Medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: .10. Review Medication Administration Record (MAR) to identify medications to be administered .14. Administer medication as ordered in accordance with manufacture specifications 20. Correct discrepancies and report to nurse manager .
1) Resident #16 was admitted to the facility on [DATE] with diagnoses which included Surgical Aftercare following Surgery on the Circulatory System, Cardiac Pacemaker, Hypothyroidism, Hypertension, Hyperkalemia, Gastroesophageal Reflux Disease and Hyperkalemia. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact).
Record review revealed on 11/30/23, the physician's order documented, Multiple Vitamin Tablet, Give one (1) tablet by mouth one time a day for skin; no minerals included. (Photographic Evidence Obtained).
Further record review of Resident #16's MAR dated 01/01/24 thru 01/17/24 revealed that the licensed nurses had been signing off, as giving the Multiple Vitamin tablets one (1) time a day.
However, during a Medication Administration Observation conducted on 01/17/24 at 9:15 AM with Staff A, a Registered Nurse (RN), for Resident # 16, Staff A was observed preparing a daily Multivitamin tablet with Minerals, along with other ordered medications, for Resident # 16.
2) Resident #166 was admitted to the facility on [DATE] with diagnoses which included Encephalopathy, Right Bundle Branch Block, Hypertension, Diabetes Mellitus and Benign Prostatic Hyperplasia. He had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired).
Record review revealed on 01/02/24 a physician's order documented, Aspirin Tablet Chewable, Give one (1) tablet by mouth one time a day.
On 01/05/24 the physician's order documented, Multiple Vitamin Tablet, Give one (1) tablet by mouth one time a day for skin; no minerals included.
Further record review of Resident #166's MAR dated 01/03/24 and 01/06/24 through 01/17/24 both revealed that the licensed nurses had been signing off, as giving an Aspirin chewable 81mg one (1) tablet and a Multiple Vitamin tablet one (1) time a day, respectively.
However, subsequently, on 01/17/24 at 9:24 AM, a Medication Administration Observation was conducted with Staff A, RN who was preparing a daily Multiple Vitamin tablet with Minerals and a chewable Aspirin tablet along with other ordered medications, for Resident #166 all in one (1) cup. Resident #166 proceeded to swallow whole, all of the medications provided in the cup; with no instructions or directions provided to Resident #166 by Staff A, with regards to exactly how the chewable Aspirin tablet was to be ingested, as ordered, by the Physician.
On 01/17/24 at 9:39 AM, an interview was conducted with Staff A, regarding the physician's order for regular Vitamins v.s. Vitamins with minerals being administered to Residents #16 & #166, she verbalized the difference between the two, and she acknowledged that this should have been clarified with Resident #166's physician, prior to administration. And, Staff A also acknowledged that she had not provided any instructions or directions to Resident #166, with regards to exactly how the chewable Aspirin tablet was to be ingested.
During a telephone interview conducted on 01/17/24 09:54 AM with the Guardian Consulting Services Pharmacy Doctor regarding the variation between a regular Multivitamin order v.s. Multivitamins with Minerals orders, as well as chewable Aspirin orders, he stated overall that in all cases, the physician's order should be followed, and orders are to be taken as written.
It was initially reported to the Surveyor, on 01/17/24 at 10 AM by DON and the Regional Nurse, that the facility administered the bottle of multivitamins with minerals, as a stock medication on hand, so that everyone who gets multivitamins, gets multivitamins with minerals.
Upon further interview, the Regional Nurse indicated that she was wrongfully informed regarding the above and she added that the facility did carry both regular multivitamins and multivitamins with minerals. Therefore, it was concluded Staff A, did have access to a regular multivitamin, but none was provided to either Resident #16, nor to Resident #166, during the Medication Administration Observation.
A subsequent interview was conducted on 01/17/24 at 10:20 AM, with the DON, in which she indicated that another medication cart did contain an ordered bottle of Multivitamins without minerals. She also acknowledged that there was a difference between the two (2) regular Multivitamins vs. Multivitamins with Minerals. The DON further acknowledged that this should have been clarified with both Resident #16 and with Resident #166's physician as to exactly which was acceptable, prior to administration with the physician's order being followed; this was not done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide nutritional supplements as ordered, for 1 of 9...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide nutritional supplements as ordered, for 1 of 9 sampled residents reviewed for nutrition, Resident #57.
The findings included:
Record review revealed Resident #57 was admitted to the facility on [DATE]. According to the resident's most recent 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status score of 10, indicating that the resident was 'moderately' cognitively impaired. The resident's diagnoses at the time of the assessment included: Hip fracture, Seizure disorder, Bipolar disorder, Chronic lung disease, History of falling, Osteoporosis without pathological fracture, Hypothyroidism, Vitamin D deficiency, Constipation and Pain. The assessment documented that the resident had no swallowing disorders, no dental concerns and the resident was able to eat independently with setup and clean up assistance.
Record review revealed Resident #57's dietary orders included:
12/28/23 - Regular diet, Regular texture, Regular/Thin consistency - fortified foods with all meals for Diet.
12/11/23. - House shake - with meals for nutrition support.
01/08/24 - Snack BID (twice daily) (2PM & HS (bedtime) Snack) - two times a day for nutrition support.
Resident #57's care plan for nutrition, initiated on 11/13/23, documented, The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t (related to) medical dx (diagnosis) infections, dementia, osteoporosis, fx (fracture), hypothyroidism, seizures.
The goal of the care plan was documented as, The resident will maintain adequate nutritional/hydration needs maintain CBW (current body weight) +/- 3-5%. With a target date of 02/28/24.
Interventions included:
o Provide and serve diet as ordered.
o Provide and serve supplements as ordered
o Provide, serve diet as ordered. Monitor intake and record q (every) meal.
During an observation of breakfast served to the residents in their rooms, on 01/17/24 at 7:49 AM Resident #57 was observed in bed with breakfast on her overbed table eating independently. The resident was served hot cereal, biscuit, sausage, hash browns and fluids. During the observation, the resident stated that she usually did not eat the hot cereal, as she didn't care for it. It was noted that the resident was not served a 'House Shake' as ordered.
During an observation of breakfast being served to the residents in their rooms, on 01/18/24 at 7:53 AM, Resident #57 was observed with breakfast on her overbed table. It was noted that the resident did not receive the 'House Shake' with breakfast. Resident #57 stated that she was not aware that she was supposed to receive supplements.
During an interview, on 01/18/24 at 7:54 AM, with the Food Service Director (FSD), when asked about providing the supplements to the residents, the FSD stated that the House Shakes were kept in the cooler in the kitchen and placed on the tray to be included with meals. When asked how the kitchen staff would be aware of the order for the House Shake, the FSD stated that the order would be reflected on the tray ticket that accompanied the meals.
During an interview, on 01/18/24 at 10:53 with the Registered Dietitian (RD), the RD confirmed that the order for House Shakes for Resident #57 was for each meal.
Review of Resident #57's tray tickets, that accompanied the meals, revealed that the order for House Shakes was not reflected on the tray tickets.
A review of Resident #57's ADL (Activities of Daily Living) task worksheet revealed that staff were documenting that Resident #57 consumed 100% of the supplement, although it was discovered that the resident was not receiving them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident #17), selec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident #17), selected for nutrition review, received physician ordered thickened liquids (Honey), prepared in a design to meet the individual's needs.
The findings included:
During the review of the clinical record of Resident #17, the following were noted regarding the resident:
Date of admission: re-admission on [DATE]
Diagnoses: Dysphagia, Parkinsonism, Hypokalemia, Protein-Calorie Malnutrition
Current physician's orders:
09/8/23: Dysphagia Pureed Diet, Honey Thick Liquids - Dysphagia
08/9/23: Magic Cup BID (twice daily) - Nutritional Supplement
01/16/24: Promod Oral Liquid 30 ml BID - Wound Care
Weight History:
01/4/24 = 131 # (pounds)
12/4/23 = 139 #
10/4/23 = 146#
07/5/23 = 149 #
06/5/23 = 154#
Height = 66 (inches)
Body Mass Index (BMI) = 21.2
MDS (Minimum Data Set) assessment: 12/23/23
Section C: BIMS (Brief Interview for Mental Status Score) = 5 (Cognitive Impairment)
Section GG: Eating = Extensive Assist
Section K: Coughing/Swallowing Difficulty
Mechanically Altered Diet: Food & Liquids
Care Plan Review: 12/27/23
for Nutritional Problem failed to have the following approaches:
* Pureed diet
* Honey Thick Liquids
* Oral Nutritional Supplements
* Total Feed by Staff with Meals
During the screening of facility residents on 01/16/24 at 10:30 AM, it was noted that Resident #17 had a Styrofoam cup of water, located at the bedside. Further observation noted the Styrofoam cup had the resident room and bed number documented on the cup. Observation noted that the water in the Styrofoam cup was thin and not thickened to Honey Consistency.
During observation of facility residents on 01/17/24 at 11:30 AM, it was noted that Resident #17 it was again noted a Styrofoam cup of water located at the bedside. Further observation noted the Styrofoam cup had the resident's room and bed number documented on the cup. Observation noted that the water in the container was thin and not thickened to Honey Consistency. During the observation, the surveyor requested the facility's Corporate Nurse to view the Styrofoam cup at bedside and confirmed that physician ordered honey thickened liquids were not at the bedside.
On 01/17/24 at 12:15 PM, an observation of the medication cart was conducted by the surveyor. The observation noted that only Nectar Thick liquids were located on the cart, for use with medication pass. Interview with the Corporate Nurse Consultant at the time of the interview noted that Honey Thick Water is not available for residents, prescribed for physician ordered Honey Thick Liquids.
Interview with the Food Service Director on 01/17/24 at 1 PM noted that Honey Thickened Liquids (water, milk, and assorted juices) are not purchased and are not available for residents who are prescribed with physician ordered Honey Thick Liquids.
A review of the resident's Diet Census for 01/16/24 noted that there were currently 2 residents which includes Resident #17, with physician ordered Honey Thick Liquids. The Honey Thick Liquids were being ordered for the diagnosis of Dysphagia.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined that the approved menu was not being followed that potentially affected 55 facility residents who eat orally, which included 11 of...
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Based on observation, interview, and record review, it was determined that the approved menu was not being followed that potentially affected 55 facility residents who eat orally, which included 11 of 11 sampled residents reviewed for nutrition (Resident #7, #10, #17, #19, #33, #37, #39, #44, #45, #55, and #63).
The findings included:
1) During the review of the approved facility menu for the lunch meal of 01/16/24, the following were noted:
* Broccoli Florets (Alternative Lunch Vegetable and to be served to Dysphagia Advanced, Dysphagia Mechanical, and Dysphagia Pureed)
* Pureed Vegetable Quiche (Dysphagia Pureed Diet)
* Cheese Sauce (2 ounces to be served over Vegetable Quiche (Regular Diet, Dysphagia Pureed)
* Snickerdoodle Cookie - 2 ounces- (Regular Diet)
Observation of the lunch tray assembly line in the main kitchen on 01/16/24 at 11 AM accompanied with the FSD (Food Service Director) and Corporate FSD noted the following:
-Broccoli Florets - not prepared and no alternative was prepared. During interview with the FSD it was revealed that the Broccoli was not delivered in time for the lunch meal service. The FSD was not aware that an alternative vegetable substitute should be documented on the menu and prepared and served.
-Pureed Quiche - not prepared in time for the serving of the lunch meal. Interview with FSD at the time of observation, revealed that there was not enough time to prepare the pureed Quiche.
-Pureed Snickerdoodle Cookie - not prepared in time for tray line service. Interview with the FSD at the time of observation was not enough time to prepare the pureed snicker doodle cookie.
-2 oz Snickerdoodle Cookie - only 3/4-ounce cookie served.
-2 oz Cheese Sauce for Mechanical Soft/Pureed - not prepared or served- During an interview at the time of the observation, it was revealed that the FSD was unaware of what menu item the cheese sauce was to be prepared for. During an interview with the Corporate Registered Dietitian on 01/18/24 at 1:30 PM, it was reported that the cheese sauce was to be served over the Vegetable Quiche.
2) During the review of the approved facility menu for the breakfast meal of 01/17/24, it was noted that a 3-ounce portion of Sausage Gravy was to be served to residents for the following diets: Regular Diet, Dysphagia Advanced Diet, Dysphagia Mechanical Diet, and Dysphagia Pureed Diet.
Observation of the breakfast meal in the main kitchen on 01/17/24 at 7 AM, accompanied with the FSD and Corporate FSD, noted the following:
* A 2-ounce portion (ladle) was being served for the above-mentioned diets. Interview with the FSD at the time of the observation revealed that the breakfast cook failed to review the approved breakfast menu, to ensure that portion sizes are followed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food, in accordance with professional standards for food service...
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Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food, in accordance with professional standards for food service safety, for potentially 55 of the facility's 61 residents.
The findings included:
1) During the initial kitchen/food service observation tour conducted on 01/16/24 at 8:50 AM, and accompanied with the Food Service Director (FSD), the following were noted:
a) Staff A was noted to be washing resident dishware in the facility dish machine. Staff A stated to the surveyor that the dish machine is at a low temperature and sanitizes by Chlorine chemical. The surveyor requested the FSD to test the final rinse chemical level. Following 3 separate Chlorine Strip tests, it was noted that there was presence of chemical in the final rinse water. The surveyor requested that the washing of resident dishware cease until the machine was properly sanitizing and to re-sanitize the washed dishes in the 3-compartment sink.
A review of the chemical testing log noted that the level was checked for regulatory compliance of 50 Parts Per Million (PPM), of Chlorine, and noted that the machine passed the Chlorine strip test the morning of 01/16/24.
On 01/16/24 at 10:00 AM, the FSD approached the surveyor and submitted a Chlorine test strip for the dish machine, that was dark black/purple in color. The FSD stated to the surveyor that the reason the dish machine failed the chemical test was that the 5-gallon chemical container was empty, and a new container was connected to the dish machine. The surveyor informed the FSD that the chemical test for the dish machine that was submitted indicated too much Chlorine. The surveyor informed the FSD that chemicals were left on the dish surface and were potentially toxic to the residents. The surveyor requested to view a new live testing of the dish machine. Two new chemical test strips again confirmed that there was a toxic level of Chlorine in the final rinse. The surveyor requested that the chemical company be contacted to service the dish machine as soon as possible.
On 01/16/24 at 11:15 AM, the representative technician from the chemical company was in the facility to assess the dish machine. The representative stated to the surveyor that the 5-gallon Chlorine chemical container was empty earlier without the staff knowledge. It was further stated that the facility has low water pressure require numerous dish racks need to send through the machine until the regulatory chemical level of 50 PPM is met.
A review of the repair slip left by the chemical company technician dated 01/16/24 noted documentation that the dish machine sanitizer was adjusted to 50 PPM and that the water levels in the machine were lower than previously set and had to be adjusted.
b) Observation of the Artic Air Reach-in refrigerator #1 noted the following:
* One gallon of Italian Dressing was noted to have a stamped manufactures expiration date of 08/30/23. The FSD stated that the dressing is still being utilized for resident meals. The surveyor requested that the dressing be discarded immediately.
* Small pan of pineapple pieces was noted to be labeled with a preparation date of 01/07/24 and a use by date of 01/14/24. The FSD stated that the pineapple pieces were beyond the facility's policy of a 'use by date' of 7 days. The surveyor requested that the pineapple pieces be discarded.
* The door gasket of the unit was noted to have a large tear of approximately 7 inches. The surveyor stated to the FSD, the gasket is required to be replaced to ensure that temperatures are held at the regulatory requirement of 41 degrees F (Fahrenheit) or below.
c) Observation of the dry/canned food storage room noted the following:
* One #10 can of Marinara Sauce and one #10 can of Sliced Apples located on storage shelves were both noted to have a large dent. The surveyor requested that the cans be removed from the shelf and discarded.
* The floor of the storage room was noted to be heavily soiled, stained and had areas of dried food matter.
2) Observation of the main kitchen and lunch tray assembly line on 01/16/24 at 11:30 AM noted that hot foods were not being held at the regulatory temperature of a minimum of 135 degrees F. A test of the hot food temperatures utilizing the facility's digital food thermometer noted the following:
Vegetable Quiche - left out at room temp (8 servings) = 120 degrees F
Pork Loin -1/3 loin - left out on cutting board at room temp = 121 degrees F
Pork Chunks on assembly line (10 large pieces) = 102 degrees F
3) Observation of the breakfast meal in the Main Kitchen on 01/17/24 at 7:15 AM accompanied with the FSD and Corporate FSD noted the following:
*Dish Machine = low chemical level (less than 50 PPM (Chlorine). Interview with the FSD at time of observation revealed the Chemical company technician was notified of the issues for a second time. During an interview with the Chemical technician representative while in the facility on 01/17/24 at 10 AM, revealed that the dish machine water levels had to be readjusted again to ensure 50 PPM (Chlorine).
4) Observation of the tray line in the main kitchen was conducted on 01/18/23 at 11:45 AM. Temperature of foods were taken by staff utilizing the facility's calibrated digital food thermometer. The temperature testing noted that cold foods were not being kept at 41 degrees F or below. Specifically, the pan of pureed marinated green beans was recorded at 54 degrees F. The surveyor informed the Food Service Director that the vegetable was not being held at the required regulatory temperature and should not be served until the vegetable was 41 degrees F or below. A review of the production sheet for the lunch meal noted that 10 residents had physician ordered pureed diets that ordered the pureed marinated green beans.
Sept 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy and procedure, the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy and procedure, the facility failed to provide nail care for 1 of 5 sampled residents (Resident #11) reviewed for Activities of Daily Living (ADLs).
The findings included:
Review of the facility policy and procedure titled Nail Grooming with a last review date of 07/24/18, provided by the facility's Director of Nursing (DON) documented, regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary .
Review of Resident #11's clinical record documented an initial admission to the facility on [DATE] under hospice care. The resident's diagnoses included Dementia, Anemia, Hypertension, Pain, Depressive episodes and Unsteadiness on feet.
Review of Resident #11's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 of 15, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the facility staff with her ADL's.
Review of Resident #11's care plan titled Self-care Deficit as evidenced by: weakness and cognitive impairment initiated on 09/01/21 and revised on 07/11/22 documented provide ADL care to ensure daily needs are met .
On 08/30/22 at 10:01 AM, during an initial observational tour, Resident #11 was observed lying in bed with her eyes open. Observation revealed the residents both hands fingernails were long, sharp, jagged, unkempt. Further observation revealed the resident's right hand fingernails with dark debris underneath. An attempt was made to interview the resident but the resident kept looking at the surveyor and did not answer any questions asked.
On 08/31/22 at 1:46 PM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA), at Resident #11's bedside. Staff G stated that she fed Resident #11 today, because the resident was having trouble with her hand and added that both of her hands were stiff. Staff G, stated the resident could not hold a piece of burger during lunch time. Staff G stated the resident used to eat by herself. Staff G, was asked who will provide the residents with fingernail care and she stated that any CNA can do it. Staff G added she asks the nurse before nail care to see if the resident was diabetic. Consequently, a side by side review of Resident #11's fingernails was conducted with Staff G, and Staff H, CNA. Staff G stated the resident's nails were long and confirmed one fingernail was jagged and dark color material was noted under the nail bed.
Subsequently, Staff C, a Registered Nurse (RN), Resident #11's nurse, was called to the resident's bedside. A side by side observation of resident's fingernails was conducted with Staff C, Staff G and Staff H. Staff C stated the resident's fingernails needed to be filed or provided nail care. Staff C stated that it is the CNAs responsibility to provide the resident's fingernail care. Staff H stated Resident #11's fingernails needed a cut. During the observation, a brief interview was conducted with Resident #11, and she was asked if she would like her fingernails done and she stated Yes. Staff G and Staff H both stated the facility has a CNA that comes in later who provides the residents with hair and nail care.
On 09/01/22 at 9:54 AM, observation revealed Resident #11 in bed, attempting to eat her breakfast. Further observation revealed the resident continued to have both hands with her fingernails unkempt, jagged and long. The facility staff had not provided the resident with fingernail care, even after it was brought to their attention by the surveyor.
On 09/01/22 at 11:54 AM, an interview was conducted with Staff I, CNA who stated the CNA also provides the residents with fingernail care, if they need it.
On 09/01/22 at 11:56 AM, an interview was conducted with Staff J, CNA, assigned to Resident #11. Staff J stated she provided ADL care to the resident this morning and got her out of bed. Staff J was asked who does the residents fingernail care and she stated that sometimes she herself would do it and added that the facility had a CNA that does fingernail care for the residents. Staff J was asked if she trimmed Resident #11's fingernail today and she stated she saw the resident's fingernails were long, but did not trim them. Staff J was asked if she was planning to do Resident #11's fingernails today and replied that she will do it as soon as she finished with the surveyor's interview.
On 09/01/22 at 3:45 PM, during an interview, the facility's DON was apprised of Resident 11's unkempt fingernails. The DON was informed that a side by side observation of the resident's fingernails was conducted on 08/31/22 with the staff and the resident fingernails continued to be untrimmed as of 09/01/22 at 11:56 AM. The DON stated that a facility wide of all residents fingernails was conducted on 08/31/22 and some residents were found to need fingernail care. The DON stated that the CNA documentation did not specify when fingernail care was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who requires respiratory care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who requires respiratory care is provided such care as ordered by the physician and failed to document O2 (oxygen) saturations for every shift, as ordered by the physician for 1 of 1 sampled residents (Resident #254).
The findings include:
Review of the policy, titled Respiratory Oxygen Administration - Nasal Cannula Clinical Practice Guideline last reviewed on 07/25/22, included the purpose: oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Humidification of oxygen is used for a flow rate of four liters per minute or greater, or if requested by a patient.
Record review for Resident #254 revealed that the resident was admitted to the facility on [DATE] and discharged to hospital on [DATE] at 11:00 PM. The residents diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Unspecified Acute Lower Respiratory Infection, Depression, Allergy Unspecified, Shortness of Breath, Anxiety Disorder, and Acute upper Respiratory Infection.
Review of Section C of the Minimum Data Set (MDS) assessment documented that Resident #254 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. Review of Section G of the MDS documented that Resident #254 had bed mobility self-performance of extensive assistance with support of one person assist, transfers and toilet use both have a self-performance of limited assist with support of one person assist. Review of Section O of the MDS documented that Resident #254 was receiving oxygen therapy.
Review of the Physician's Orders showed that Resident #254 had an order dated 08/26/22 for oxygen, which read: continuous O2 via nasal canula at 3 liters every shift, an order dated 08/18/22 for oxygen therapy: check humidification bottle every shift, change when empty every shift; days, nights, and an order dated 08/18/22 for oxygen therapy: O2 saturations (Sats) every shift day, nights.
Review of the Care Plan dated 08/17/22 for Resident #254 with a focus on resident is at risk for shortness of breath, impaired breathing pattern secondary to diagnosis of respiratory failure, COPD with exacerbation, Congestive Heart Failure (CHF). Goal was resident will not have shortness of breath as evidenced by respirations within normal range. Interventions included monitor for episodes of shortness of breath and implement interventions as ordered, notify Medical Doctor (MD) if ineffective and follow up as indicated, oxygen per Medical Doctor (MD) order, prompt participation in activities that do not depend on physical stamina or exertion. provide reassurance and support to prevent anxiety during episode of shortness of breath.
Record review for Resident #254 revealed the night shift (7:00 PM -7:00 PM), from 08/16/22 to 08/31/22 documentation revealed the OS saturation was not documented as ordered.
Record review from 08/16/22 to 08/31/22 for Resident #254 revealed there were only 2 progress notes for the night shift (7:00 PM -7:00 PM). Progress note dated 08/29/22 at 7:38 PM included the resident was seen by the medical doctor (MD) this evening. Antibiotic (ABT) ordered for Bronchitis. Resident's emergency contact was notified of change in status and new order. Progress note dated 08/31/22 at 11:06 PM revealed the resident left facility via stretcher x2. Left in stab le condition.
Record review of progress note for Resident #254 dated 08/31/2022 revealed resident requesting facility to send her to the hospital. Resident is awake and alert, noted anxious, vital sign blood pressure (BP) 159/99, pulse (P) 100 respirations (R)18, temperature (T) 97.3, oxygen saturation (SO2) 93% with continuous O2 at 3L. Safety measure in place and comfort. Doctor aware, resident friend was called but no respond.
Record review of Resident #254's vitals report from 08/18/22 to 08/30/22 revealed O2 saturations were only documented on the day shift.
Record review of Resident #254's treatment administration record (TAR) from 08/18/22 to 08/30/22 revealed O2 saturations were only documented on the day shift.
During an observation conducted on 08/30/22 at 10:15 AM, Resident #254 was wearing oxygen 2.5 liters via nasal canula with the oxygen tubing dated 08/28/22. It was noted that no oxygen humidification water bottle was observed.
Photographic evidence obtained.
During an observation on 08/31/22 at 9:50 AM Resident #254 was wearing oxygen at 3 liters via nasal canula. Resident #254 continued to not have the oxygen humidified, as evidenced by no humidification water bottle (photographic evidence obtained). The resident also had small amount of bloody mucous in a tissue that she stated had come from her nose earlier in the morning.
During an interview conducted on 08/30/22 10:18 AM with Resident #254, she stated that she told the nurses she needed bottled water for her oxygen, but the nurses told they have none.
During an interview conducted on 08/31/22 at 12:50 PM with Staff C Registered Nurse (RN) when asked if Resident #254 has an order for humidified oxygen, she stated yes, the resident has an order to check humidification of oxygen. When asked if she checks the humidification water bottle per the order to see if it needs to be replaced, she said yes but did not think she did it today.
The nurse and surveyor went to the bedside where the oxygen concentrator was and there was no humidification water bottle. When the nurse was asked if she could point out where the humidification water bottle was, she said there is none. When asked if she knew where the supply of humidification water bottles was kept, she stated in the treatment cart. Another unidentified nurse standing by told Staff C, the humidification water bottles are not kept in the treatment cart; they are kept in the central supply storage room.
During an interview conducted on 08/31/22 at 10:48 AM with Central Supply/Scheduler, when asked if the facility has a supply of oxygen humidification water bottles, she stated they always have 5-6 bottles of sterile water for oxygen humidification. She verified this by showing the surveyor the 6 bottles in the storage room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of facility policy titled Medication Storage, Storage of Medication dated 10/07, included outdated contaminated discon...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of facility policy titled Medication Storage, Storage of Medication dated 10/07, included outdated contaminated discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock.
During the medication storage task on 08/31/22 at 10:14 AM, an observation was made with Staff B Licensed Practical Nurse (LPN). In the [NAME] medication room refrigerator, it was observed that there were 3 expired medications. The first medication was Omeprazole 2mg/ml suspension labeled with date opened as 07/28/22 and to discard after 14 days (photographic evidence obtained). The second and third medications were PPD (for tuberculin skin test) 0.1cc prefilled liquid with expiration date of 08/27/22 and 08/28/22 (photographic evidence obtained). The freezer located inside the refrigerator had ice buildup on inside and outside with freezer with the freezer door not being able to be closed all the way (photographic evidence obtained).
During an interview, conducted on 08/31/22 at 10:15 AM with Staff B, she stated she will ensure the expired medication are properly discarded and will inform her supervisor to make sure the freezer is defrosted.
During the medication storage task on 08/31/22 at 10:31 AM with Staff K, Registered Nurse (RN), in the East medication room, it was observed that the freezer located inside the refrigerator had ice buildup on the inside and outside with freezer, with the freezer door not being able to be closed securely (photographic evidence obtained).
During an interview, conducted on 08/31/22 at 10:35 AM with Staff K, she stated she will inform her supervisor to make sure the freezer is defrosted.
Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured medications in 1 of 3 Medication carts and 1 of 2 Treatment carts, during an initial observational tour; 2) ensure that it discarded expired medications in 1 of 2 Medication Storage Rooms; and 3) ensure that it properly supervised medications, during Medication Pass Observation for 2 of 7 sampled residents observed (Resident #25 and #155).
The findings included:
1) Review of the facility policy and procedure titled Medication Storage/Storage of Medication, reviewed 10/07 provided by the Director of Nursing (DON), documented in the Policy Statement: Medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies are locked or attended by persons with authorized access .
1) During an observational screening tour conducted on Monday 08/30/22 at 9:50 AM, it was observed that the [NAME] side medication cart A was left in front of Resident #7's room (who was just immediately located inside of his partially opened bedroom door) unlocked, un-secured and unattended and visible to other residents, staff members and visitors, at the far end of the hallway approximately thirty-seven (37) feet four (4) resident room doors away from the [NAME] nurses' station for 5-7 minutes; the nurse Staff A, a Licensed Practical Nurse (LPN), was down the hallway exiting the [NAME] nurses' station returning to the unlocked Med cart containing Nineteen (19) resident medications.
Resident #7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Depression, Hypertension, Gastroesophageal Reflux Disease and Chronic Atrial Fibrillation. He had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired). Photographic evidence was obtained of the un-locked/un-attended/un-secured [NAME] side medication cart A.
On 08/31/22 at 10:38 AM, an interview was conducted with Staff B, an (LPN), regarding the un-locked/un-attended medication cart and she acknowledged that medication cart was left un-locked and un-attended and it should not have been.
On 08/30/22 at 3 PM, it was observed by two (2) Agency for Healthcare Administration (AHCA) surveyors that the East side wing treatment cart was left approximately five (5) feet away from the East nurses' station entrance unlocked, un-secured and unattended and visible to other residents, staff members and visitors. The day nurse, Staff C, a Registered Nurse (RN), was down the hallway approaching the East nurses' station returning to the unlocked treatment cart containing eight (8) different resident medications and multiple other over-the-counter (OTC), non-specific medications. Photographic evidence was obtained of the un-locked/un-attended/un-secured East side wing treatment cart.
On 08/31/22 at 10:42 AM, an interview was conducted with Staff C regarding the un-locked/un-attended medication cart and she acknowledged that the treatment cart was un-locked, and it should not have been.
The DON further acknowledged and recognized that the un-locked/un-attended medication and treatment carts should remain locked and secured, at all times, this was not done.
3) On 08/31/22 at 8:25 AM, medication administration observation for Resident #25 performed by Staff C, a Registered Nurse (RN) was conducted. Staff C poured the following medications: Vitamin C 500 milligrams (mg), Gabapentin capsule 300 mg (an anticonvulsant), Lactulose (a liquid laxative) 30 millimeters (ml), Famotidine (used to reduce the amount of acid in the stomach) 20 mg and Pro-Stat 15 ml (liquid protein). Observation revealed Staff C, RN, donned gloves, opened the Gabapentin capsule and poured into a medication cup, mixed it with the Vitamin C and Famotidine and crushed them together. At 8:33 AM, Staff C, RN entered Resident #25's room with a foam tray containing the crushed medication and the two liquid medications, placed the tray with the medications on top of the resident's table located in front of the resident and readily accessible to the resident. During the medication administration observation, Staff C, RN was observed exiting the resident's room, leaving all poured medications for Resident #25 on top of the table unattended. Staff C was observed outside the resident's room by the medication cart parked in the hallway and retrieving a blood pressure machine. At 8:38 AM, observation revealed Staff C assisting Resident #25 with taking the medications. The Staff C stated the resident preferred to take the medications with a straw. Observation revealed Staff C again exited the resident's room leaving the medications unattended on top of the table. Staff C walked to the medication cart, retrieved a straw, returned to the resident's bedside and proceeded to administer the liquid medications with a straw.
4. On 08/31/22 at 2:02 PM, medication administration observation for Resident #155 performed by Staff C was conducted. Observation revealed Staff C entered the resident's room with a foam tray that contained one bag of Ampicillin (an antibiotic) premixed in a saline bag, a ten (10) millimeters (ml) saline flush syringe and alcohol pads. Continued observation revealed Staff C placed the foam tray with the antibiotic and the saline syringe on top of the resident's dresser across the bed, walked approximately 10 feet away from the medications to the bathroom and returned to the bedside after one (1) minute. The foam tray with the medications was unattended, visible from the hallway and accessible to the staff and visitors. Further observation revealed Resident #155's roommate had a visitor in the room while the medications were left unattended on top of the dresser. Staff C returned to the resident's bedside completed the administration of the intravenous antibiotic, flushed the intravenous device with five (5) ml of saline using the syringe. Furthermore, observation revealed Staff C placed the saline syringe into her Fanny Pack and stated she will use it later.
On 08/31/22 at 2:58 PM, during an interview, Staff C stated she threw away the previous syringe she placed in her Fanny Pack.
On 09/01/22 at 12:02 PM, an interview was conducted with Staff C, who confirmed that she left the resident's medication unattended on the table/dresser. Staff C added that she did it because the surveyor was in the room. Staff C stated that resident's medications are not to be left unattended.
On 09/01/22 at 3:45 PM, during an interview, the DON was apprised of findings. The DON stated the nurses are to keep an eye on the residents medication once they have poured them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a form designed to meet the individual needs of 3 of 3 sampled residents with ...
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Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a form designed to meet the individual needs of 3 of 3 sampled residents with physician ordered pureed/dysphagia diet (Resident's #3, #25, and #49) .
The findings included:
1) During the review of the approved menu for the lunch meal of 08/30/22, it was noted that sauteed green beans were to be served for physician ordered pureed diets.
During the observation of the lunch meal on 08/30/22, in the main kitchen it was noted that there was a small pan of what appeared to be a green vegetable located in the steam table. The breakfast/lunch cook identified the pureed vegetables as green beans, and that there were 2 residents that were to be served the pureed green beans. Further observation noted that there were visible large pieces of green beans in the mixture. The surveyor pointed out the pieces of green beans in the mixture and confirmed the surveyors observation. Further discussion noted that the breakfast/lunch cook was unaware that the pureed mixture is required to be smooth due to residents with diagnoses of dysphagia and the potential for silent aspiration if eaten. The cook also also stated she has been employed for approximately 3 months and has had no training on the preparation of pureed foods. At the request of the surveyor, a taste test of the pureed green bean mixture was conducted and the results confirmed large pieces of green beans within the pureed mixture. The surveyor informed the cook that the pureed green beans was not pureed in a form to meet the needs of residents of residents requiring pureed foods.
2) During the observation of the lunch meal on 08/31/22 at 11 AM, in the main kitchen, it was again noted that there was a small pan of what appeared to be a green vegetable. The cook identified the item as pureed peas. It was again noted by the surveyor that there were visible pieces of peas in the pureed mixture. At the request of the surveyor a taste test of the pureed mixture was performed and noted large pieces of peas in the mixture. The cook was informed that the pureed mixture did not meet the consistency of pureed to meet the needs of the 3 residents.
A review of the diet census noted that there were currently 3 residents with physician ordered pureed diets that included:
Resident #25:
09/01/22 - Change diet from mechanical soft to pureed with nectar thickened liquids
01/25/22 - Physician's diagnoses of Dysphagia
07/05/22 - Physician's diagnoses of Eating Disorder
Resident #3:
08/12/22 - Physician ordered Dysphagia Pureed Diet with Fortified Foods for All Meals
Resident #49:
08/31/22 (re-admission) - Physician ordered Dysphagia Pureed Diet
12/18/20 - Physician diagnoses of Dysphagia
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an observational tour conducted of the East hallway bathroom, located directly off the East side nursing station, on 0...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an observational tour conducted of the East hallway bathroom, located directly off the East side nursing station, on 08/30/22 at 2:23 PM, it was noted that there were two (2) live roaches/insects observed/video-recorded for a total of forty-seven (47) seconds, one (1) of which was a large dying roach/insect was noted lying on its belly, legs folded in, with its antennae still actively moving was observed on the floor of the East unit bathroom near the side wall on the floor. And, a second (2nd) live roach/insect actively running/mobile inside in the East bathroom. This East bathroom is near resident rooms and approximately thirty-eight (38) feet away from the resident facility kitchen doorway entrance.
Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in resident rooms and laundry area.
The findings included:
1) During the initial resident screening tour conducted on 08/30/22 and environment observation tour conducted on 09/01/22 at 1 PM, and accompanied with the Director of Maintenance and Director of Housekeeping, the following were noted:
Main Dining Room - Five wall mounted air-conditioning vents were noted to be full of condensation and were dripping down onto dining room tables (5) and the floor. It was also noted that resident food tray carts and staff was under the dripping condensation.
Laundry Room - The covers of 2 soiled linen transportation carts were noted to have large cracks and pieces of the covers were missing. The wash room floor had large areas of black stains and 4 areas that appeared to have black mold type matter.
Staff Bathroom and room [ROOM NUMBER] were both noted to have a large live roach. Photos were taken and the evidence was shown to the Administrator.
room [ROOM NUMBER] - Room floor noted to be covered with black stains, bathroom door frame noted with peeling paint; the window bed floor landing mat was heavily soiled and torn; and over-bed table was rust laden.
room [ROOM NUMBER] - Five disposable shaving razors were located on a dresser, that was visible from the hallway. The surveyor requested that the razors be secured immediately. Room walls noted to have large areas of peeling paint; and electrical cords were not secured to the walls.
room [ROOM NUMBER] - Room walls noted with large areas of peeling paint; and cable TV cord not secured to the wall.
room [ROOM NUMBER] - Bathroom baseboard in disrepair; toilet requires re-caulking to the bathroom floor, and room base boards falling off from walls.
room [ROOM NUMBER] - Room walls in disrepair and required re-painting; missing window shade slat; room floors had numerous black stains; and the window bed wheelchair noted to have cracked and torn arms.
room [ROOM NUMBER] - Room floor covered with black stains; wheelchair (A-bed) arms were ripped and torn; room walls had areas of peeling paint; and dresser drawers were broken.
room [ROOM NUMBER] - Room floor covered with black areas and stains.
room [ROOM NUMBER] - Room floor covered with black areas and stains; and room walls had areas of peeling paint and required re-painting.
room [ROOM NUMBER] - Room floor was heavily black stained; and the floor area near the bathroom entrance was lifting.
room [ROOM NUMBER] - Room floor was heavily black stained; and the toilet required re-caulking to the bathroom floor.
room [ROOM NUMBER] - Exterior to room dresser was scratched and damaged.
room [ROOM NUMBER] - Room floor was heavily black stained.
room [ROOM NUMBER] - Room floor was heavily black stained; and the toilet required re-caulking to the bathroom floor.
room [ROOM NUMBER] - Bathroom noted to have foul and pervasive urine odor.
Hallway (between room [ROOM NUMBER] to #350) the wall handrails located on both sides of the hallway were noted to be heavily worn and stained.
Following the tour, the issues were again confirmed with the Directors. The Maintenance Director stated that there is a Maintenance/Housekeeping log book located at the each nurses station (2). Staff are are required to document any issues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to follow the approved menu for potentially 53 of the 56 facility residents that included 38 of the 39 sampled facility resident...
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Based on observation, interview, and record review, the facility failed to follow the approved menu for potentially 53 of the 56 facility residents that included 38 of the 39 sampled facility residents.
The findings include:
During the review of the approved menu for the lunch meal of 08/30/22 , the following were noted to be served for the meal to regular diet, mechanical soft diets, renal diets, and pureed diets:
½ cup - Sauteed [NAME] Beans
½ cup - Chopped [NAME] Beans
½ cup - Sugar Snap Peas
½ cup - Parmesan Noodles
½ cup - Chocolate Pudding Parfait
½ cup - Mashed Potatoes
½ cup - Pureed Marinated Chicken Thigh
During the observation of the lunch meal in the main kitchen and interview with the lunch cook on 08/30/22 at 11 AM, the following were noted:
(a) Observation noted that a tong was being utilized for a serving of green beans. The menu documented a 4 ounce (#8 scoop) be utilized as a standard portion. Observations noted that the portion size being served varied for residents.
(b) Observation noted that a 2-ounce portion of ground green beans was being served. The menu documented that a 4 ounce (#8 scoop) be utilized as standard portion.
(c) Observation noted Sugar Snap Peas were not prepared or served. The cook stated that the peas were not available and an alternate vegetable was not prepared.
(d) Observation noted that spaghetti with parmesan cheese was being served in place of Parmesan Noodles. The cook stated that the spaghetti was not available. It was also noted that a ½ cup portioning serving utensil was not being utilized as per the approved menu. The spaghetti was noted to be served with tongs and the portion was guessed.
(e) Observation noted that chocolate pudding was being served with a number #12 scoop (2 ounces) instead of the approved menu documented portion of 4 ounces (#8 scoop) . It was also noted that plain chocolate pudding was served instead of the chocolate parfait. The cook stated that she was unaware that the menu documented Chocolate Pudding Parfait and also stated she did not have knowledge of how to prepare the parfait.
(f) Observation noted that a 2 ounce portion (#12 scoop) of mashed potatoes was being served. The menu documented a 4-ounce (#8 scoop) portion.
(g) Observation noted that a 2 ounce (#12 scoop) of pureed chicken was being served to pureed diets. The menu documented a 4 ounce (#8 scoop) portion.
During the lunch observation on 08/30/22, the surveyor reviewed the approved menu with the cook (Staff G) and confirmed that the menu and portion sizes documented, were not being followed.
A review of the menu issues noted that on 08/30/22, it was noted that 53 of the 58 facility residents ate by mouth. Of the 53 residents who ate by mouth , 38 of the 39 residents were noted to be on the Stage 2 Sample.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined that 29 residents, including 9 sampled residents (Resident's #4, #10, #11, #21, #25, #33, #49, #104, and #254) failed to receive p...
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Based on observation, interview, and record review, it was determined that 29 residents, including 9 sampled residents (Resident's #4, #10, #11, #21, #25, #33, #49, #104, and #254) failed to receive physician ordered Fortified Meals (High Protein/High Calorie diet).
The findings included:
During the review of the approved menu for the lunch meal of 08/30/22, it was noted that residents with physician orders were to receive a portion of Fortified Potatoes and review of the approved breakfast meal noted residents with fortified foods were to receive fortified Cooked Cereal (Oatmeal).
During the observation of the lunch meal in the main kitchen on 08/30/22 at 11 AM, it was noted that there was a half pan of mashed potatoes to be served. Interview with the cook at the time of the observation revealed that the potatoes were regular and when asked about fortified the cook stated that she was not aware that fortified mashed potatoes were required to be made, and that residents requiring fortified mashed potatoes would receive regular. During the lunch meal, it was noted that the was no Food Service Manager in charge or available to review the meal findings.
During the observation of the breakfast meal in the main kitchen of 08/31/22 at 8 AM, it was noted that there as only 1 pan of Oatmeal. The breakfast cook stated again she was unaware that Fortified Cooked oatmeal was to be prepared and that residents on Fortified foods would receive regular cooked cereal. The cook also stated that she was unaware of how to prepare fortified foods.
A review of the diet census for 08/31/22 noted that there were 29 residents with current physician orders for Fortified Foods with meals. Further review noted that the list of 29 residents with current physician orders for Fortified Meals that included Resident #4, #10, #11, #21, #25, #33, #49, #104, and #254.
During an interview with the facility's Registered Consultant Dietitian on 08/31/22, it was confirmed that the fortified foods were not being prepared and served as per physician orders. At the request of the surveyor the Fortified meal program was submitted by the Consultant. The review noted the following:
Breakfast : Fortified Hot Cereal - review of the facility's standardized recipe noted the addition of the ingredients of whole milk, non-fat powdered milk, sugar, and margarine to increase protein/ calorie content.
Lunch: Fortified Mashed Potatoes - review of the facility's standardized recipe noted the addition of the ingredients of half & half creamer and margarine to increase protein/calorie content.
Dinner - Fortified Pudding - commercially prepared high protein/calorie pudding.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service s...
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Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include: ensure dishware are are chemically sanitized as per regulation, holding of foods are regulatory temperatures, maintenance of refrigeration unit to maintain temperatures as per regulation, maintenance of the exhaust hood to prevent food contamination, and failure to defrost foods as per regulation. This has the potential to affect 53 residents, who reside at the facility and eat orally.
The findings include:
Review of the facility policy and procedure titled, Ware Washing, revised 9/2017, provided by the Director of Nursing (DON), documented in the Policy Statement: All dishware, service ware and utensils will be cleaned and sanitized after each use. Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. 3. Temperatures and/or sanitizer concentrator logs will be complete, as appropriate.
1) During the initial kitchen/food service observation tour conducted on 08/30/22 at 9 AM, the following were noted:
(a) There was no supervisor or dietary manager on duty for the day. Kitchen staff included only 1 cook and 1 diet aide for the preparation and serving of the breakfast and lunch meals. The Food Services Director (FSD) was reportedly not available.
(b) The dish machine was noted to be washing during the tour. At the surveyors request, a chemical (Chlorine) test was conducted on the machines final rinse. The test results noted that the final rinse test failed, as there was no chemical level in the final rinse water. It was also noted that the final rinse temperature of the dishmachine was noted not to meet the requirement of a minimum of 120 degrees F. The rinse water was recorded at 110 degrees F. Five more tests were conducted of the chemical final rinse of which all 5 failed. The surveyor informed the cook that the dishmachine could not be used until the chemical rinse met the requirement.
(c) Trauleson Reach-I freezer #1 was noted to have door gaskets that were laden with a black mold type matter and soiled interior. The exterior of the unit was noted to be covered in dripping condensation.
(d) The exterior surface of the food preparation table was noted to be black in color.
(e) Observation of Artic-Air reach-in refrigerator #2 noted to have door gaskets (2) that were laden with a black mold type matter.
(F) Reach-in refrigerator #3 was noted to have the gaskets pulled off of the door. There was a heavy amount of dripping condensation due to the gaskets.
(g) The interior of the convection oven was noted to have a heavy build up of black carbon and grease and was nit being cleaned on a regular basis.
(h) The exterior of the exhaust hood was noted to have a build-up of grease/oil type matter along the out edge. The unknown condensation was noted to be dripping onto foods, food preparation equipment, food contact surfaces and staff result in potential of food borne illness and food contamination.
(i) Raw chicken (approx. 10 pounds) was noted to be thawing at room temperature in the sink. The internal temperature of the chicken was taken and was noted to be 60 degrees F. The surveyor informed the cook that running cold water must be used for thawing and that the raw chicken should be discarded.
(j) Observation of the milk refrigerator noted that the door gasket was black mold laden. It was also noted that there was no thermometer located within the unit. Cartons of milk (48) felt room temperature to the touch. At the surveyors request he temperature of the milk was taken utilizing the facility's calibrated thermometer and was record at 52 degrees F. Staff stated that the milk was out at room temperature for the tray line for approximately 1 hour without refrigeration. The surveyor informed the cook the milk must be always held at the minimum of 41 degrees F or below. The surveyor requested that the milk cartons be discard. It was also noted that individual portions of Yogurt (32) was recorded at 48 degrees F.
(k) Observation of cooking equipment (pots & pans) noted that approximately 20 pans were soiled, stained, and covered in black carbon.
(l) During the observation tour, it was noted that during the testing of food temperatures with the facility's food thermometer that there were no alcohol swabs available for the sanitizing of the thermometer. The cook was noted to utilize the thermometer without sanitizing prior to use.
2) During a second tour of the main kitchen on 08/30/22 at 11 AM, the following were noted:
(m) Continued chemical testing noted that 3 test failed and the machine was not chemically sanitizing resident dishware (Chlorine 50 ppm). It was noted that all resident dishware was being washed and sanitized in the 3-compartment sink.
Based on the analysis/assessment of the dish machine, it was concluded that the dish machine was not sanitizing (and there was no level of chemicals noted) in the kitchen. It was further revealed that there was no log kept of how often sanitizing solution was being periodically tested to help assure that it maintained the correct concentration and none of the employees in the kitchen, were aware of how to do proper testing.
The facility continued to serve meals to the residents on unsanitized/contaminated dishware on 08/29/22 and 08/30/22 until surveyor intervention, and disposable dishware was then used.
On 08/30/22 at 1:30 PM, during consecutive interviews conducted with, the facility's District Manager, facility's Account Manager, the (DON) and with the Assistant Director of Nursing (ADON), it was acknowledged and recognized by all parties that the facility's kitchen dish machine was not properly sanitizing the residents dishware, the solution (PPM) parts per million was not sanitizing correctly, nor registering for the low temperature dish machine, as per regulation of (50) PPM Chlorine.
(n) During the observation of the lunch meal in the main kitchen on 09/01/22 at 11 AM, temperatures of foods were taken by the facility cook, utilizing the facility's calibrated thermometer. The test revealed that cold foods were not being held at the required regulatory temperatures of 41 degrees F or below, as evidenced by the following:
Egg Salad Sandwich (3) = 45 degrees F
Caesar Salad (35) = 56 degrees F
Shredded Lettuce Salad with Caesar Dressing = 53 degrees F
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 22 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $62,700 in fines. Extremely high, among the most fined facilities in Florida. Major compliance failures.
- • Grade F (35/100). Below average facility with significant concerns.
- • 74% turnover. Very high, 26 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Golfcrest Nursing Center's CMS Rating?
CMS assigns GOLFCREST NURSING CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Golfcrest Nursing Center Staffed?
CMS rates GOLFCREST NURSING CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 74%, which is 28 percentage points above the Florida average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Golfcrest Nursing Center?
State health inspectors documented 22 deficiencies at GOLFCREST NURSING CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 21 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Golfcrest Nursing Center?
GOLFCREST NURSING CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by BENJAMIN LANDA, a chain that manages multiple nursing homes. With 67 certified beds and approximately 69 residents (about 103% occupancy), it is a smaller facility located in HOLLYWOOD, Florida.
How Does Golfcrest Nursing Center Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, GOLFCREST NURSING CENTER's overall rating (3 stars) is below the state average of 3.2, staff turnover (74%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Golfcrest Nursing Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Golfcrest Nursing Center Safe?
Based on CMS inspection data, GOLFCREST NURSING CENTER 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 3-star overall rating and ranks #100 of 100 nursing homes in Florida. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Golfcrest Nursing Center Stick Around?
Staff turnover at GOLFCREST NURSING CENTER is high. At 74%, the facility is 28 percentage points above the Florida average of 46%. Registered Nurse turnover is particularly concerning at 73%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Golfcrest Nursing Center Ever Fined?
GOLFCREST NURSING CENTER has been fined $62,700 across 1 penalty action. This is above the Florida average of $33,706. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Golfcrest Nursing Center on Any Federal Watch List?
GOLFCREST NURSING CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.