RIVERWOOD CENTER
For profit - Limited Liability company
240 Beds
ASTON HEALTH
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
11/100
#554 of 690 in FL
Photo by Riverwood Center
Photo by Riverwood Center
Photo by Riverwood Center
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Riverwood Center in Jacksonville, Florida has received a Trust Grade of F, indicating significant concerns regarding the facility's quality of care. It ranks #554 out of 690 facilities in Florida, placing it in the bottom half, and #32 out of 34 in Duval County, meaning there are very few local options that perform better. The situation appears to be worsening, with reported issues increasing from 3 in 2024 to 8 in 2025. Staffing is rated at 3 out of 5 stars, which is average, and the turnover rate is 51%, close to the state average of 42%. However, the facility has faced concerning fines totaling $57,854, higher than 75% of Florida facilities, which raises red flags about compliance. Specific incidents have also been troubling; for instance, staff failed to honor a resident's Do Not Resuscitate order, prolonging her dying process, and another resident was not provided with necessary restorative nursing therapy, leading to significant weight loss. While the facility does have average RN coverage, the overall findings suggest families should carefully consider these serious issues when researching Riverwood Center.
- Trust Score
- F
- In Florida
- #554/690
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $57,854 in fines. Lower than most Florida facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Florida. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
11/100
Bottom 20%
Review needed
3 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Florida average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 51%
Near Florida avg (46%)
Higher turnover may affect care consistency
Federal Fines: $57,854
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: ASTON HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 29 deficiencies on record
2 life-threatening 1 actual harm
Jan 2025
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0676
(Tag F0676)
A resident was harmed · 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 provide restorative nursing therapy to ensure that ...
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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 provide restorative nursing therapy to ensure that a resident's abilities in activities of daily living did not diminish for two (Residents #193 and #56) of two residents reviewed for the dining restorative program, from a total of 11 residents participating in the dining restorative program, in a total survey sample of 56 residents. The 11 residents on the dining restorative program were at risk of further decline. Resident #193 suffered a significant weight loss.
The findings include:
1. During the dining observation on 01/06/25 at 11:50 AM, Resident #193 was observed seated at the dining table in the Caring Way unit. She was served a mechanical soft meal on a regular plate. She consumed 25% of her meal and then scooped the remaining food from her plate onto a paper napkin that was provided with the meal tray. Resident #137, who was seated beside her, was observed eating the food from the napkin and eventually he tried to eat the napkin.
During another observation on 01/07/25 at 12:00 PM, Resident #193 was observed seated at the dining table on the Caring Way unit. She consumed 25 % of her meal and was observed hand picking the rest of her food and putting it on an empty plate for a resident who was seated next to her. After emptying her plate, Resident #193 wheeled herself away from the table.
A review of the Certified Nursing Assistants' (CNA's) task for eating revealed that Resident #193 was documented as having consumed 100% of her meals on 01/06/25 and 01/07/25 for the lunch meals observed.
A review of the medical record revealed that Resident #193 was admitted to the facility on [DATE] with a re-entry on 10/16/24. Her diagnoses included, but were not limited to, traumatic subarachnoid hemorrhage without loss of consciousness, depression, anxiety, psychosis, urinary tract infection (UTI), and cellulitis.
A review of the resident's active physician's orders revealed the following:
10/07/24 - Buspirone 10 mg (milligrams) 2 tabs BID (twice daily) for anxiety.
10/15/24 - Hydroxyzine 10mg, four times a day for anxiety.
10/16/24 - Regular diet mechanical Soft texture, thin consistency.
10/16/24 - Consult with Dietician d/t re- admin with right hip Trochanteric Fixation Nail Advanced (TFNA).
10/16/24 - Restorative nursing program (RNP) to Provide set up assistance and verbal cuing to encourage intake. Goal - increase oral (PO) intake to prevent weight loss.
10/21/24 - Ativan 0.5 milligrams (mg) one tablet two times a day (BID) for anxiety.
10/26/24 - Zyprexa (Olanzapine) 5 mg in the morning for psychosis.
11/01/24 - Dietary adaptive equipment - Scoop plate.
01/02/25 - Ensure (nutritional supplement) three times a day for 30 days.
A review of a Restorative program referral note dated 10/11/24, indicated that Resident #193 was referred to the Restorative program by the speech therapist for eating and swallowing assistance with set up and verbal cues to prevent weight loss.
A review of the Weight Change note, dated 11/14/24, revealed that the resident was receiving a regular/mechanical soft/thin liquid diet. PO (oral) intake was documented as 100%. Resident #193 required set up/some assistance. The note further indicated that the author spoke with nursing who reported that the resident was very restless during the day and at mealtimes had difficulty getting food in her mouth sometimes due to constant movement. The resident's weight was noted to be 104.4 pounds (lbs.). Her body mass index (BMI) was 19.1; she had a height 62 inches, and she had a weight loss of 6.3% x 30 days and 9.1% x 90 days (significant weight loss). The goal was to have a stable weight. The recommendation included Ensure nutritional supplement daily (220 kcals, 10 grams protein) to support intake and weight stability.
The Interdisciplinary team (IDT) note dated 12/20/24, indicated that the IDT met to discuss the resident's weight. The team recommended to increase the Ensure to BID, continue the plan of care (POC) of weekly weights, and the dietician to continue to follow up.
A review of a Weight Change progress note dated 01/02/25, revealed that the resident was on a regular/mechanical soft/thin liquid diet. Oral intakes were 75% - 100% of meals. Weight loss included a 3.7 % loss for (x) 30 days, a 2.8% loss x 90 days, an 8.8% loss x 90 days, and an 11.5% loss x 180 days. The recommendation was to increase the Ensure nutritional supplement to TID (three times daily) to support weight stability (660 kcal /30 grams protein).
A review of the resident's care plan, revised on 10/17/24, revealed that Resident #193 needed limited to extensive assistance with eating. She needed help getting her meals set up (opening packages, cutting meat and buttering bread etc.) and would need some help eating. Resident #193 was at risk of for an alteration in nutrition related to her diagnoses of dementia, depression, malnutrition, requiring a mechanically altered diet, and weight loss. Interventions included encouraging /offering/assisting fluids to meals and throughout the day and encourage and assist the use of adaptive equipment. The care plan indicated that the resident had a need for the Restorative nursing program for eating/swallowing due to memory loss/cognitive decline.
A review of the Modification of Significant Change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24, revealed that the resident had a brief interview for mental status (BIMS) score of 05 out of 15 possible points, indicating severe cognitive impairment. The resident reported feeling depressed with little interest in doing things. No swallowing issues or dental issues were reported. The assessment noted that Resident #193 was on Restorative nursing.
A review of the Weekly Weights from 10/16/24 through 01/01/25 revealed that Resident #193 had an approximately 2.0 lbs. weight loss every two weeks. (Photographic evidence obtained)
A review of the facility's list of residents on the Restorative Nursing Program (RNP) revealed that Resident #193 was not on the list. (Copy obtained)
In a joint interview on 01/08/25 at 1:55 PM, Licensed Practical Nurse (LPN) T stated she was new to the program and she was still in the transition phase. Registered Nurse (RN) G/Assistant Director of Nursing (ADON) stated LPN T was in training for the role since she was previously in charge of a RNP. When asked how residents were added to the RNP, LPN T explained they were added through therapy referrals and nursing assessments/reports were used to determine if a resident was a candidate for the RNP. She explained that once a resident was added to the program, the RNP task was added to the [NAME] for the restorative staff to review and document when tasks were completed. When asked how residents were discontinued from the program, RN G stated residents were removed from the program when their goals had been met; when they refused to participate, or when the resident had reached their maximum potential (no further improvement). She added that she met with therapy weekly to discuss the residents' progress. LPN T confirmed that she was responsible for updating the RNP list and updating the residents' care plans. When asked about Resident #193, LPN T confirmed that Resident #193 was not on restorative dining. She said, She was discharged a month ago because she was able to feed herself. She confirmed that the resident had suffered weight loss. When asked to review the physician's orders and the care plan, she confirmed that Resident #193 had active orders for the RNP and stated it was her fault that she did not discontinue the orders. When asked to provide documentation of when Resident #193 was on the program, LPN T again confirmed that she could not find any documentation indicating that the resident had participated in the program.
During the interview on 01/09/25 at 10:22 AM, the Registered Dietician (RD) stated she conducted evaluations on admission and quarterly; however, residents who were considered high risk, such as those with tube feedings, pressure wounds, dialysis, and those with weight loss were seen more frequently, monthly at a minimum. When asked how she determined the dietary interventions, she stated she used clinical guidelines like calculated needs, weight, PO (oral) intake and preferences to supplement. When asked how she monitored residents' intake, she explained that she reviewed the Intake Tracker competed by nursing staff; she interviewed staff and residents, and at times sat with residents during meals. She confirmed that Resident #193 was on her list of high-risk residents due to weight loss. She stated she had been seeing the resident monthly for weight and she had recommended Ensure nutritional supplement TID as well as weekly weights. She stated her goal was for Resident #193 to maintain a stable weight. When asked what the barriers to the resident's goals were, she stated nursing had reported that Resident #193 was restless during meals. When she was asked about the resident's PO intake, the RD stated it was documented that the resident consumed 100% of most meals. When the surveyor explained the observations in the dining room, the RD stated if she knew that Resident #193 was not consuming 100% of the meals, she would have explored other interventions such as an appetite stimulant or finger foods, etc. She emphasized the importance of Resident #193 being supervised during meals in order to record accurate information about her oral intake.
2. During the dining observation on 01/06/25 at 11:50 AM, Resident #56 was observed having lunch in the Caring Way unit dining room. She was seated at a table by herself. She was eating mashed potatoes and she was leaving her carrots. She consumed 25% of her meal. When asked about the food, she stated she did not like carrots. She stated she only ate what she liked. When asked if she wanted a different item, she said, no. She thanked the surveyor for spending time with her and asked if the surveyor could return later.
A review of the medical record revealed that Resident #56 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, major depressive disorder, and anxiety disorder.
A review of the active physician's orders revealed the following:
11/26/24 - Mirtazapine 7.5 mg (milligrams) at bedtime for depression
12/17/24 - Depakote ER (extended release) 125 mg BID (twice daily) for mood disorder, and RNP - resident requires minimum assistance for set up. Have resident seated at a table with other residents who are verbal and can participate in social interaction and conversation exchanges.
A review of the resident's care plan, revised on 12/17/24, revealed that Resident #56 had a need for the Restorative Nursing program for eating/swallowing due to age-related comorbidities/medical condition. The goal was for the Restorative dining program to facilitate communication and social interaction outside of the memory care unit. Social interaction and conversational exchanges with peers and staff were needed in order to reduce social isolation.
A review of the RNP task performed from 12/17/24 - 01/08/24 revealed that the task was noted as completed six times.
During an interview on 01/09/25 at 1:34 PM, Certified Nursing Assistant/Restorative Aide S stated when residents were added to the RNP, LPN T notified her and the other restorative aides. She explained that LPN T also added the task to the [NAME] for the aides to document when tasks were completed. She stated the therapy department provided education/training when they referred residents to the RNP. She stated there were three Restorative aides who worked Monday - Friday, and each aide had their assigned residents. When asked if Resident #56 was in the program, she confirmed the resident was on the RNP and she was assigned to her. She was then asked if Resident #56 participated in the program. She replied, Honestly, I don't remember getting her. I take her the days I remember. She confirmed that Resident #56 did not refuse to participate and acknowledged that the resident enjoyed conversations.
A review of the facility's policy and procedure titled Restorative Nursing Services (revised 08/2022), revealed the following:
The policy standards included: To promote the residents' optimum function, restorative nursing programs may be developed by proactively identifying, planning, and monitoring of a resident's assessments and indicators. This creative nursing program refers to interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical mental and psychological functioning. Restorative programs may be initiated by nursing and/or therapy.
GUIDELINE:
1.
Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services like physical occupational or speech therapies.
2.
Residents may be started on restorative nursing program upon admission during the course of stay or when discharged to rehabilitative care.
3.
Restorative indicators are resident specific information that when alone or combined with other indicators establish the level of resident restorative potential.
4.
Restorative indicators may be identified by multiple disciplines utilizing various assessments physician orders progress notes environmental factors caregiver conversation and any other means of communication.
5.
Restorative nursing functions can be within one of the following categories:
a.
Range of motion.
b.
Splint or brace assistance
c.
Bed mobility
d.
Transfers
e.
Walking
f.
Dressing or grooming
g.
Eating and swallowing
h.
Amputation and prosthesis care
i.
Communication
j.
Toileting program
k.
Bladder retraining
6.
Restorative goals and objectives are individualized and resident centered and outlined in the resident's plan of care.
7.
Nursing assistance aids and other staff who are trained, will document provided techniques past relative care plan in the medical records.
8.
The registered nurse or licensed practical nurse conduct an evaluation on a routine basis to include progress towards goal and response to the program. Any changes will be documented in the medical record. The restorative care plan and care directive will be reviewed and revised as indicated.
9.
Restorative goals may include, but are not limited to, supporting and assisting residents in
a.
adjusting or adapting to changing abilities
b.
developing maintaining or strengthening his or her physical and psychological resources
c.
maintaining his or her dignity independence and self esteem
d.
participating in development and implementation of his or her plan of care.
.
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, resident and staff interviews, and record review, the facility failed to ensure that one (Resident #50) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to ensure that one (Resident #50) of 52 sampled residents currently residing in the facility, had access to his call light.
The findings include:
On 01/06/2025 at 12:05 PM, Resident #50 was observed seated in his wheelchair in his room at the foot of his bed facing the entrance to the room. He was wearing a short sleeved tee shirt, pants and non-skid socks. His right arm, wrist and fingers were contracted. He indicated he did not have any concerns. The call light was observed lying on top of the bed near the head of bed next to the pillow and out of reach of the resident. (Photographic evidence obtained) The resident was served lunch at 1:15 PM in his room, but his call light was not placed within his reach.
On 01/07/2025 at 11:28 AM, Resident #50 was observed in his room. He was seated in his wheelchair at the foot of his bed. The call light was observed lying on top of the bed near the head of the bed next to the pillow. (Photographic evidence obtained) He was wearing a short-sleeved tee shirt, pants and non-skid socks. One of his socks was falling off. He was asked if he was warm enough. He shook his head and stated no. He was asked if he wanted a sweater on and he nodded his head and stated yes. Certified Nursing Assistant (CNA) C was asked to assist the resident. She entered the room and asked the resident if he wanted a sweater. He told her yes. She did not move the call light within his reach.
On 01/07/2025 at 1:10 PM Resident #50 was observed eating his lunch independently. He was seated in his wheelchair at the foot of his bed. The call light was observed lying on top of the bed near the head of the bed/pillow.
On 01/08/2025 from 1:13 PM to 1:30 PM Resident #50 was observed eating lunch. He was seated in his wheelchair at the foot of his bed. The call light was observed lying on top of the bed near the head of the bed next to the pillow. (Photographic evidence obtained) He was asked if he wanted more food. He stated yes and nodded his head. CNA C was asked to assist him. She entered the room and asked the resident if he wanted more food. He stated yes. She did not move the call light within his reach. She took his lunch tray, told him she would bring another plate for him, and left the room.
A review of Resident #50's medical record face sheet revealed an admission date of 11/19/2019. His diagnoses included: hemiplegia and hemiparesis (weakness, limited ability on one side of the body) following cerebral infarction (stroke) affecting the right dominant side; anxiety disorder; dysphagia (difficulty swallowing); asthma; dysarthria (unclear speech) and anarthria (a severe speech disorder that results in the complete loss of the ability to speak), major depressive disorder; gastrointestinal esophageal reflux disease (GERD); hypertension; cognitive/communication deficit; abnormalities of gait and mobility; muscle wasting and atrophy; cataracts in both eyes.
A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #50 was assessed as having slurred or mumbled words; being understood and understanding others sometimes; impaired vision; a score of 09 out of 15 possible points on his Brief Intervew for Mental Status (BIMS), indicating moderate cognitive impairment, and no evidence of inattention, disorganized thinking, or altered level of consciousness. He was assessed as having lower extremity range of motion (ROM) impairment on both sides and ROM impairment on one side in his upper extremity. He used a walker and a wheelchair for mobility. For eating he required only set up and clean up. He was able to feed himself. He required substantial assistance for oral hygiene, bathing, upper body dressing and personal hygiene, sitting to lying, lying to sitting, sitting to standing and transfers. He was dependent on staff for toileting, lower body dressing and putting on/taking off footwear. He required substantial assistance to wheel himself in his wheelchair, and he A ras currently receiving occupational therapy.
A review of his care plan, dated 08/22/2023 and revised on 10/13/2024, revealed a focus area for activities of daily living (ADLs)/self-care related to chronic medical conditions, muscle weakness, hemiplegia and hemiparesis and a need for assistance with personal care. Interventions did not include encouraging the use of his call light. A review of the care plan dated 04/17/2024 and revised on 10/13/2024, revealed a focus area for being at risk for falls related to impaired balance and mobility, poor safety awareness due to cognitive decline, muscle weakness, abnormal gait and mobility, and use of psychotropic medication. Interventions included encouraging and reminding the resident to use his call bell and to wait for staff assistance with transfers, ambulation, toileting, etc. as indicated.
A review of the occupational therapy recertification, progress report, and updated therapy plan for a certification period of 12/02/2024 through 02/28/2025, revealed that Resident #50 would increase his left upper extremity strength by 1-2 grades in order to enable him to assist more with functional transfers and maintain range of motion of the right elbow to prevent an increase in contractures.
During an interview with the Director of Rehabilitation on 01/09/2025 at 11:25 AM, she stated Resident #50 was currently on case load for physical therapy (PT) and occupational therapy (OT) only. He had been receiving OT for at least a year and a half. She was not sure if the OT therapist was working on use of his call light or not.
During an interview with Occupational Therapist (OT) B on 01/09/2025 at 11:34 AM, she stated Resident #50 was her resident for occupational therapy. She was working on his right hand and arm contractures. She was not working with him specifically for call light use. She stated he could use his call light and understood when to use it. She agreed to take Resident #50 back to his room to demonstrate his ability to use the call light. She wheeled him back to his room and backed him in next to his bed with his left hand nearest to the bed. His call light was on the bed next to the pillow. She took the call light and clipped it to the resident's shirt near his left hand. She explained to him that she wanted him to demonstrate the use of the call light. He immediately took the call light cushion and squeezed it. The call light was engaged. When asked if he understood that he should use the call light when he needed assistance, he nodded his head yes. OT B took the call light cord and stretched it out toward the end of the bed. It did not reach the end of the bed. She confirmed that the resident would not be able to reach it if he was sitting in his wheelchair at the end of the bed.
During an interview with CNA C on 01/09/2025 at 12:01 PM, she stated Resident #50 coild use his call light and knew when to use it. She stated, Oh yeah, he knows. She confirmed that the call light would not reach past the end of the bed if they had the resident sitting at the foot of his bed in his wheelchair. She confirmed that he would not be able to reach it when clipped to the bed cover near the head of the bed, nor would he be able to wheel himself around to reach it.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to honor the personal pri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to honor the personal privacy of one resident (#81) reviewed for personal privacy from a total survey sample of 56 residents.
The findings include:
On 01/06/25 at 1:30 PM, Resident #81 was observed in her semi-private room. She had no privacy curtain.
On 01/06/25 at 2:30 PM, the resident's room was observed. There was no privacy curtain in place for this resident.
On 01/07/25 at 10:17 AM, the resident was observed standing inside her doorway looking out into the corridor. There was no privacy curtain in place for this resident's area of the room near the window.
A record review revealed that Resident #81 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, neurological disorder due to known physiological condition with behavioral disturbance, mood disorder due to known physiological condition, and major depressive disorder.
A review of athe resident's care plan revealed the following Focus Areas:
Resident has ADL (activity of daily living) self-care deficit related to ADL needs and participation vary, chronic medical conditions, Dementia. (initiated 7/22/24, revised 11/05/24),
Resident has impaired cognitive function/impaired thought processes related to Alzheimer's. (initiated 7/29/24, revised 11/05/24)
On 01/08/25 at 4:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) P, the nurse caring for Resident #81. She was asked who was responsible for hanging the privacy curtains in resident rooms. She stated, Housekeeping. They are also the ones who change the curtains as needed. She was asked who was responsible for making sure there was a privacy curtain for each resident. She stated, They have someone twice a week that goes around and checks all the rooms for different things like privacy curtains and the housekeepers also check it every day when they go in the rooms. The nurse was asked to accompany the surveyor to the resident's room to observe the privacy curtain. The nurse was asked if the resident had a privacy curtain. She stated, No ma'am, she doesn't but I can get her one.
On 01/08/25 at 4:46 PM, an interview was conducted with the Administrator. She was asked what the facility had in place for monitoring the resident's rooms to ensure their environment provided privacy. She explained that the facility had a Guardian Angel Program, and the department heads and managers were assigned so many rooms to monitor 2-3 times weekly.
Guardian Angel Rounds worksheets were provided by the Administrator on 1/9/2025 at 11:00 AM which revealed that on 1/1/2025, a room round for room [ROOM NUMBER] B was conducted and No curtain, was identified.
On 01/09/25 at 11:14 AM, an interview was conducted with Housekeeper X who spoke Spanish as a first language. Certified Nursing Asisistant (CNA) Y assisted with translation. Housekeeper X was asked who was responsible for hanging the privacy curtains in the resident rooms. She stated, the floor tech. She was asked how the floor tech determined which rooms needed privacy curtains. She replied, I'm not aware of a schedule, just as needed, anyone can put in TELS (computer work order program). It goes directly to maintenance and then to the floor tech.
On 01/09/25 at 8:55 AM, the Administrator was asked to provide the facility's Privacy and/or Privacy Curtains Policy. At 9:01 AM, the Director of Nursing reported that the facility did not have a policy specific to privacy or privacy curtains. She provided the facility's Resident Rights Policy (issued 9/21, revised 1/24 - 2 pages):
Standard: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of residents.
Procedure:
1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
t. privacy and confidentiality
.
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 observations, interviews, record review, and policy and procedure review, the facility failed to implement the comprehe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to implement the comprehensive care plan to meet the resident's medical needs for one (Resident #43) of one resident reviewed for transmission based precautions from a total of 56 residents in the survey sample. Specifically, isolation precautions were not followed as indicated in the care plan.
The findings include:
On 01/06/25 during a 12:33 PM interview, Resident #43 stated she had scabies but wanted to be out of isolation, as she was not being treated. No precautions sign or PPE (personal protective equipment) were on her door. (Photographic evidence obtained)
On 01/07/25 at 9:00 AM, no precautions sign or PPE were observed on the resident's door.
On 01/08/25 at 9:30 AM, no precautions sign or PPE were observed on the resident's door.
A review of the resident's medical record revealed the following physician's orders:
01/08/25 - Permethrin External cream 5%, apply all over head to toe topically every night shift for scabies for one day.
01/05/25 - Contact precautions: Encourage and assist resident to maintain contact precautions for scabies from 01/05/25 to 01/08/25.
12/28/24 - Clobetasol Propionate External Lotion 0.05%, apply to rash on body topically two times a day for rash and itch for 14 days, avoid face and genitals.
12/27/24 - Contact precautions: Encourage and assist resident to maintain contact precautions (scabies) from 12/27/24 to 01/03/25.
12/11/24 - Diphenhydramine HCL (hydrochloride) Oral tablet 25 mg (milligrams), Give 1 tablet by mouth every 8 hours as needed for itching.
(Photographic evidence obtained)
The resident's physician ordered on 01/08/25 at 8:52 AM that the isolation to be discontinued. A progress note dated 12/28/24 by the physician stated the resident was taken to Urgent Care on Christmas day by her daughter during LOA (leave of absence) and was treated for itching and rashes on her body with Permethrin. She returned to the facility on [DATE] with rash diminished. Per the physician's note, Patient is on contact isolation for scabies.
A review of the resident's care plan dated 10/17/22, next review date 01/12/2025, revealed the following:
Resident requires isolation related to scabies, isolation will be maintained while infection is actively transmittable, wear appropriate PPE when giving care to resident. (Photographic evidence obtained)
A review of the resident's [NAME] revealed it included a task for isolation precautions for high contact activities. (Photographic evidence obtained)
A review of the medication administration record (MAR) revealed, Contact Precautions for scabies every shift until 01/09/25 with signatures noted indicating contact precautions were in place during that time. (Photographic evidence obtained)
During a 01/09/25 interview with Certified Nursing Assistant (CNA) D at 9:50 AM, she stated she was a restorative CNA and worked in most areas of the facility. She further stated when she saw a yellow bag on a resident's door, she would ask the nurse what was going on with that resident. The facility also had in-service training about EBP (enhanced barrier precautions and TBP (transmission-based precautions). She stated it was put on the [NAME] as well. She was aware of the difference in types of precautions and what PPE to don for each type. She stated she was not aware of any cases of scabies recently.
During a 01/09/2025 interview with Licensed Practical Nurse (LPN) E at 10:45 AM, she stated she had been employed in this facility for three months. EBP and TBP were taught during orientation using a power point presentation. The unit manager took off orders, and would make sure a sign was on the resident's door as well as PPE. She was not aware of the contact precautions for Resident #43. She stated they ended on 01/05/25 per the electronic medical record. She did not look at all of the resident's orders, just the orders on the MAR. She stated the resident's daughter brought her back to the facility after being on a leave of absence and told the nurse she was treated with Permethrin at an urgent care clinic while on LOA.
During a 01/09/25 interview with Unit Manager (UM) F at 11:00 AM, she stated Resident #43 should have been on isolation precautions until 01/08/25. She further stated the resident had her treatment and technically could be off precautions in 24 hours. When she was asked when the treatment was given, she searched through the electronic record for the date of treatment. There was a progress note dated 12/28/24 indicating that the resident's daughter had her mother treated at home on [DATE]. She confirmed there was a current order for contact isolation until 01/08/25. She stated the infection control nurse would usually put the signage and PPE on resident doors once the order was completed.
During a 01/09/25 interview with Infection Preventionist G at 11:20 AM, she stated she worked with the unit managers and nurses to ensure the residents' precautions were correct. She would ensure initially that the proper signage and PPE were on the residents' doors. If she was not in the facility, the Assistant Director of Nursing (ADON) would complete this task, and on the 3-11 shift, the house supervisor was responsible. She confirmed that there was an order for contact isolation for Resident #43 and the discontinuation date was 01/09/25. She stated this order should have been followed since it was an active order.
During a 01/09/25 interview with the Director of Nursing (DON) at 11:52 AM regarding the isolation precaution order for Resident #43 ordered on 01/05/25 at 11:00 PM, she stated she completed this order and did not know why the signage or PPE was not put on the door. She stated the resident had treatment while on LOA with her daughter and the original contact precautions were discontinued on 01/03/25.
A review of the facility's policy and procedure titled Standards and Guidelines: Physician Orders (revised 1/2024), revealed the following:
Procedure:
9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.
A review of the facility's policy and procedure titled Standards and Guidelines: Medication Administration (revised 1/2024), revealed the following:
Procedure:
19. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.)
.
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 observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #47) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 56 residents.
The findings include:
On 01/06/25 at 11:22 AM, Resident #47 was observed resting in bed with elongated, jagged fingernails on both hands. She was asked if the staff trimmed her fingernails and she replied, One nurse cut my nails once since I've been here. She was asked if she preferred her fingernails long. She stated, I prefer them short. She was asked how her fingernails had been maintained since she was admitted . She replied, Usually when I'm doing something they just break off down to the quick and hurt. The resident was observed with tremors of both hands. (Photographic evidence obtained)
A review of Resident #47's medical record revealed she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, COPD (chronic obstructive pulmonary disease), ASHD (arteriosclerotic heart disease), type 2 diabetes mellitus (DM), HLD (hyperlipidemia), polyneuropathy, Vitamin B12 deficiency, mood disorder, allergic rhinitis, depressive disorder, insomnia, and HTN (hypertension).
A review of the quarterly MDS (Minimum Data Set) assessment, dated 12/20/24, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15/15, indicating that she was cognitively intact. No psychosis or behaviors were indicated. The resident was independent with eating tasks, but required substantial/maximal staff assistance with transfers and toileting, partial/moderate assistance with bed mobility, and substantial/maximal assistance with personal hygiene.
A review of the resident's care plan revealed the following focus areas:
- Resident is at risk for skin impairment related to DM, fragile skin and incontinence. Intervention: Encourage resident with nail care as tolerated. (10/10/2023)
- Resident has an ADL/self-care deficit related to chronic medical conditions. Intervention: Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene. (10/10/2023)
- Resident is at risk for chronic pain and/or is at risk for pain related to chronic physical disability.
On 01/09/25 at 2:36 PM, an interview was conducted with Certified Nursing Assistant (CNA) V. She was asked who was responsible for trimming, cleaning and filing the fingernails of diabetic residents. She stated, I really can't answer that. I've only started working down here today, and diabetics are not always done like residents who are not diabetic. I would have to ask someone. She was asked when fingernail care was provided and if there was a schedule or specific time that fingernail care was done. She stated, Normally on a daily basis as needed. She was asked if she was taking care of Resident #47 today. She stated, yes. She was asked if she provided fingernail care today. She stated, no. She was asked if she received ADL (activities of daily living) training/education, and did it include fingernail care. She stated, Yes, it talked about fingernail care but not specifically fingernail care for diabetics.
On 01/09/25 at 2:51 PM, an interview was conducted with Licensed Practical Nurse (LPN) U. She was asked if she was familiar with Resident #47. She stated, yes. She was asked if the resident required staff assistance with personal hygiene and grooming. She replied, Yes, but she can do more for herself than she does. We try to encourage her to get up out of bed more. She used to get up every day and go out to smoke, but she stopped. She was asked who was responsible for trimming, cleaning and filing the residents' fingernails including diabetic residents. She stated, The CNA. She was asked if there was a specific schedule for when fingernail care was provided. She stated, When it's needed.
A review of the facility's policy and procedure titled ADL Care and Services (issued 04/2020, revised 01/2024), revealed:
Standard:
Residents will be provided with care and treatment, as appropriate to maintain or improve their ability to carry out activities of daily living. (ADLs)
Guideline:
Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Procedure:
4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
a. hygiene (bathing, dressing, grooming, nail care and oral care)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observations, record reviews, and staff interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and...
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Based on observations, record reviews, and staff interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one (Resident #18) out of four residents observed during medication administration, from a total survey sample of 56 residents. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents.
The findings include:
During medication administration observation on 1/7/25 at 9:40 AM, Licensed Practical Nurse (LPN) M was preparing medication for Resident #18. After reviewing the medication administration record (MAR), she stated she did not have the Fluoxetine that was ordered for Resident #18. She checked the MAR and identified that the medication had been ordered from the pharmacy on 12/29/24. She stated it should arrive later today. She then stated she would place an order for it again now, just in case, which she did.
A review of Resident #18's physician's orders revealed and order dated 3/25/23 for Fluoxetine HCL (hydrochloride) oral capsule, give 20 milligrams (mg) by mouth in the morning for major depressive disorder, recurrent, unspecified. (Photographic evidence obtained)
A review of Resident #18's January 2025 MAR revealed the Fluoxetine had not been not given on 1/7/25 or 1/8/25. (Photographic evidence obtained)
During an interview with LPN M on 1/8/25 at 1:00 PM, she confirmed that the Fluoxetine had not yet been delivered by the pharmacy and Resident #18 had missed a second dose.
An interview with the Director of Nursing (DON) on 1/8/25 at 1:35 PM revealed that the expectation was for the nurse to re-order medications within 3-4 days before they ran out. Delivery of ordered medications was expected every day, but the nurse should call the pharmacy to check when the medication will be delivered, notify the physician if the medication will be missed, and get an order to hold the medication if needed. The nurse should also check to see if the medication is available in the facility.
A review of the facility's policy and procedure titled Standards and Guidelines: Physician Orders (revised 1/2024), revealed the following:
Procedure:
9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.
A review of the facility's policy and procedure titled Standards and Guidelines: Medication Administration (revised 1/2024), revealed the following:
Procedure:
9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party if indicated.
19. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.)
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, record reviews, staff interviews, and policy and procedure reviews, the facility failed to ensure a medication error rate of less than 5% based on three errors out of 26 opportu...
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Based on observations, record reviews, staff interviews, and policy and procedure reviews, the facility failed to ensure a medication error rate of less than 5% based on three errors out of 26 opportunities for error. The three errors (failure to administer medications and crushing enteric coated medication) resulted in an error rate of 11.54%. Two (Residents #18 and #51) of four residents observed during medication administration from a total survey sample of 56 residents were affected. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents.
The findings include:
1. During medication administration observation on 1/7/25 at 9:40 AM, Licensed Practical Nurse (LPN) M was preparing the medication for Resident #18. After reviewing the medication administration record (MAR), she stated she did not have the Fluoxetine that was ordered for Resident #18. She checked the MAR and identified that the medication had been ordered from the pharmacy on 12/29/24. She stated it should arrive later today. She then stated she would place an order for it again now, just in case, which she did. She then proceeded to pull Potassium Chloride extended release (ER) and the rest of the scheduled medications for Resident #18 out of the medication cart. She put them into a clear plastic sleeve and crushed all of the medications together. She then put the crushed medication mix into a cup of applesauce and administered it to Resident #18. When the Potassium Chloride ER with Do Not Crush on the packaging was pointed out to her, LPN M stated she would have to call the doctor and get it changed to maybe a liquid form for Resident #18, as she needed her medications crushed. (Photographic evidence obtained)
A review of Resident #18's physician's order, dated 9/4/22, revealed an order for Potassium Chloride ER extended release 10 MEQ (milliequivalents), give 1 tablet by mouth one time a day for hypokalemia, swallow whole, do not chew or crush. Another order dated 3/25/23, was for Fluoxetine HCL (Hydrochloride) oral capsule, give 20 milligrams (mg) by mouth in the morning for major depressive disorder, recurrent, unspecified. Further review of the active physician's orders revealed no order to crush medications. (Photographic evidence obtained)
A review of Resident #18's January 2025 MAR revealed that the Fluoxetine was not given on 1/7/25. (Photographic evidence obtained)
2. During another medication administration observation on 1/7/25 at 1:00 PM, LPN N was preparing medication for Resident #51. After checking the resident's blood sugar and the resident's MAR, LPN N began to prepare Humalog (a fast-acting insulin) from a multi-dose vial. He took out the vial and a new syringe. He then punctured the rubber top of the vial with the needle and pulled back two units of insulin into the syringe. According to UptoDate.com (an evidence-based clinical resource accessed on 1/9/25 at 1:00 PM), he should have cleansed the rubber top of the vial with an alcohol swab, drawn back air into the syringe of an equal amount of the Humalog that was to be administered (2 units) and injected air into the vial before pulling out the 2 units of Humalog from the vial.
In an interview on 1/7/25 at 1:00 PM, LPN N confirmed that he did not wipe the insulin vial and stated that he was not aware that should be done.
During an interview with LPN M on 1/9/25 at 12:10 PM, she stated she knew there was no order for Resident #18's medications to be crushed, but she knew they needed to be crushed from the nursing report of all the residents assigned to Seaway Cart 1 (LPN M's cart) and having a C next to Resident #18's name. (Photographic evidence of the report obtained)
A review of the facility's policy and procedure titled Standards and Guidelines: Physician Orders (revised 1/2024), revealed teh following:
Procedure:
9. Physician orders should be followed as prescribed, and if not followed, this should be recorded in the resident's medical record during that shift. The physician should be notified and the responsible party if indicated.
A review of the facility's policy and procedure titled Standards and Guidelines: Medication Administration revised 1/2024, revealed the following:
Procedure:
9. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
16. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the rational in the resident's medical record and notify the physician and responsible party if indicated.
19. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to assist residents in ob...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy and procedure review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Resident #84) of two residents reviewed for dental care, from a total survey sample of 56 residents.
The findings include:
On 01/06/25 at 11:59 AM, Resident #84 was observed to be pleasantly confused. Even standing several feet away from her, she had noticeably foul-smelling breath.
On 01/07/25 at 10:30 AM, Resident #84 was observed sitting up in a recliner in her room. Even standing several feet away from her, she had noticeably foul-smelling breath.
On 01/07/25 at 3:30 PM, Resident #84 was observed and continued to have noticeably foul smelling breath.
On 01/08/25 at 11:23 AM, a record review conducted for Resident #84 revealed an admission date of 12/19/2020 and diagnoses including dysphagia (difficulty swallowing), cognitive/communication deficit, and GERD (gastroesophageal reflux disease).
A review of the resident's quarterly MDS (minimum data set) assessment, dated 09/30/24, revealed a BIMS (brief interview for mental status) score of 99, indicating that the interview was unable to be completed due to refusal, nonsensical answers to too many questions, or was unable to answer enough questions to accurately assess cognitive status. No psychosis or behaviors were indicated, and the resident required substantial/maximal assistance with eating, bed mobility, toileting, transfers, personal hygiene, and oral hygiene. The MDS indicated pain symptoms and vocalization of pain. No swallowing problems were indicated. A mechanically altered diet was documented but no dental issues or special treatments, procedures, or programs were noted.
A review of the resident's active physician's orders revealed she was receiving a regular diet, pureed texture, and thin-consistency fluids.
A review of the resident's active care plan revealed the following focus areas:
- Customer has behavioral tendencies of spitting in a cup. (initiated 12/22/20, revised 12/22/20)
- Resident has a potential for side effects/adverse reactions related to use of medication related to insomnia. (initiated 1/13/21, revised 7/12/24)
- Resident has an ADL (activities of daily living) self-care deficit related to chronic medical conditions. Goal: Resident will maintain and/or improve ADL functioning through next review. Interventions: ADL Care, the resident may need dependent assistance to limited extensive assistance x1 or x2 for ADL care. (initiated 10/10/23 revised 9/30/24)
- Resident the has potential or an actual oral health concern, has cognitive impairments and needs assistance to complete oral care tasks. Goal: Resident will have no complications related to oral health concerns. Interventions: Assist with or provide mouth care as needed to ensure task completion. Review ADL care plan interventions for degree of assistance needed. Coordinate arrangements for dental consultation and transportation as needed or ordered. (initiated 7/12/24, revised 9/30/24)
- Resident has impaired cognitive function/impaired thought processes related to a diagnosis of cognitive communication deficit (initiated 9/30/24, revised 9/30/24).
A review of the resident's medical record from 01/01/24 through 01/08/25 revealed that there were no dental consultations or dental hygienist visit notes in the record.
A review of CNA (certified nursing assistant) ADL (activities of daily living) tasks from 12/26/24 through 01/08/24 revealed that the resident received oral hygiene at least twice daily with no refusals documented.
A review of a Quarterly/Annual/Significant Change Nursing Evaluation, dated 12/05/24, revealed that an oral assessment was completed. Section IX Oral/Dental Evaluation revealed
A. Evaluation: #2 Teeth, b. No natural teeth, #9 Breath, c. Other (Specify below), #11 Comments regarding Oral/Dental Status: NA. B. Determination: #1 Notify MD for possible Dental Consult, b. No, 2. Additional Comments, NA. (A copy of the assessment was obtained.)
On 01/08/25 at 12:33 PM, an interview was conducted with the Director of Nursing (DON). She was asked if the facility contracted with any vendors for dental services. She stated, I think we use [dental provider name]. She was asked how often they visited. She replied, I believe the dentist comes monthly and the hygienist comes twice a month, but you can verify that with social services. She was asked where the resident's dental consultation notes would be located in the record. She stated, They should be in the EMR (electronic medical record) under documents, but if not, they may be in medical records waiting to be scanned in. She was asked to provide any dental records the facility had available for Resident #84.
On 01/08/25 at 1:51 PM, the interview resumed with the DON. She reported that the facility was unable to locate any dental consultation reports or any dental progress notes for Resident #84. She was asked what the facility's process was for new admissions regarding dental evaluations. She reported that the oral assessment was completed by the nurse within the admission assessment that was completed by the admitting staff. She was asked if all residents admitted to the facility were required to be evaluated or screened by dental services. She stated, Dental services does not usually evaluate or screen all new admissions, only by request of the resident or resident representative, or by the nursing staff when issues are identified. She was asked if there would be any reason why a resident would not have been screened by dental services, with the exception of refusals. She stated, If they've never requested services or there was never a need identified. She was asked if she was familiar with Resident #84. She stated, yes. She was asked if she was aware of the resident's oral condition. She stated, I'd have to get back with you on that; I'm not sure. She was asked what process the facility had in place to improve the resident's oral health. She stated, I will get back with you on that. The dental services policy was requested. She was asked how often the residents received oral care. She stated, Definitely daily, or more. She was asked to explain the process if a resident refused oral care. She explained that the CNA (certified nursing assistant) should attempt to provide oral care 2-3 times, and if the resident continued to refuse, the CNS should notify the nurse, who also attempted to get the resident to cooperate. If the nurse failed, the family was notified. She was asked if a resident had any health issues, where that information would be located. She stated, The CNA can look on the [NAME] for anything related to ADL care; the nurse looks on the care plan. The DON was asked to review the resident's care plan pertaining to the resident's oral condition. The DON was unable to describe what the resident's particular oral condition was, how it was identified, and how that lead to a care plan being initiated on 07/12/24 and revised on 09/30/24.
On 01/09/25 at 4:01 PM, an interview was conducted with CNA W. She was asked what her process was when a resident refused care. She stated, I go report it to the nurse. She was asked where the residents' hygiene supplies were kept/located. She stated, In a bag in their drawer with their name on it. She was asked how often she provided the residents with oral care. She stated, Once a shift since I work on the evening shift. She was asked to explain what she might observe for a resident when she performs mouth care. She stated, Bleeding of the gums, how the gums look if their swollen. She was asked if she observed something unusual, who she would report it to. She stated, To my nurse, whoever is working that evening. She was asked if she was taking care of Resident #84 today. She stated Yes, I take care of her every evening. She is on my regular assignment. She was asked if the resident was cooperative when she provided mouth care. She shook her head and stated, No, she is not cooperative with care. She was asked if she'd provided oral care for her today. She stated, Not yet, I usually wait until after dinner. CNA W was asked if she had noticed anything unusual when providing mouth care for Resident #84. She stated, Yes, her breath has a terrible odor, and I've mentioned it to the nurse. She used to work on our shift but now I'm not sure what shift she works. She was asked if anyone had spoken with her about the resident's breath and further care/consultation to be provided. She replied, Not to my knowledge, they just tell me to brush her teeth, and I tell them that I do brush her teeth, but I believe there's something else wrong that goes beyond brushing her teeth.
A review of the facility's policy and procedure titled Dental Consults (issued, 10/2020, revised 01/2024), revealed:
Standard: The facility will facilitate dental services through the services of a Consultant Dentist as indicated.
Guideline:
1. Our facility does not have dental providers on staff, and therefore contracts with external providers to provide dental services to residents as indicated.
2. The facility will contract with an external Dental provider to provide Dental Services to residents as indicated and to provide the following:
1. providing consultations to physicians and providing other services relative to dental matters.
2. Providing a dental assessment of residents as ordered by attending physician.
3. Performing or supervising an annual re-evaluation for each resident as needed.
5. Providing necessary information concerning residents to appropriate staff, care planning conferences, and/or committees.
.
Feb 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that residents unabl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure that residents unable to carry out activities of daily living (ADLs), received necessary care and services to maintain proper grooming and personal hygiene, by failing to provide nail care for two (Residents #8 and #11) of four residents reviewed for ADLs, from a total sample of 16 residents.
The findings include:
1. During an interview with Resident #8 on 2/12/24 at 10:10 AM, his left hand was observed to be contracted around a washcloth. He explained that without the washcloth, his fingernails would dig into his palm. The resident's fingernails on both hands were soiled with dark brown substance resembling feces around the cuticles and under each nail. When asked if he was receiving any assistance with handwashing or nail care, he replied, No, I am not.
A record review for Resident #8 revealed he was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of medically complex conditions, bipolar disorder, diabetes mellitus, depression, post-traumatic stress disorder and contracture.
A review of the 5-day Medicare minimum data set (MDS) assessment, dated 12/15/23, revealed Resident #8 had a brief interview for mental status (BIMS) score of 15 out of 15 points, indicating cognitively intact. The assessment did not indicate any rejection of care. The resident required some help to complete activities of daily living (ADLs) and had upper and lower extremity impairments on one side. The resident was dependent on staff and required substantial to maximum assistance with bathing.
A second observation of Resident #8 was made on 2/13/24 at 9:30 AM. He was feeding himself breakfast. The fingernails on both hands were again observed with dark brown matter under the nails and around the cuticles. Resident #8 again denied receiving assistance with handwashing or nail care, explaining he just runs his right hand under the water from the sink in his room to wash it. After confirming he was his own representative, Resident #8 granted permission to photograph his nails. (Photographic evidence obtained)
A review of Resident #8's care plan dated 8/9/23, indicated the resident needed assistance with ADLs related to weakness, decreased mobility status-post recent hospitalization/illness. The goal was to maintain and or his improve current level of function through next review date. Interventions included, but were not limited to, encourage and assist with ADLs including bathing and hygiene. (Photographic evidence obtained)
2. During an interview with Resident #11 in his room on 2/13/24 at 9:38 AM, he was asked about nail care. He showed both hands and fingernails. Both of his hands were severely contracted, and his fingers were bent in several directions. The nails on both hands were elongated and several of them had dark gray matter underneath them. Resident #11 stated he scratches himself a lot and that might be what the dark debris was from. He stated he was his own representative and granted permission for a photo. (Photographic evidence obtained) The resident held his hands out and said his fingernails had grown out; they used to be nubs. He could not report how often his nail care was offered and provided.
A record review for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of cerebrovascular accident (CVA, or stroke), quadriplegia, multiple sclerosis and hand contracture.
A review of the quarterly MDS assessment, dated 1/14/24, revealed Resident #11 had a BIMS score of 15, indicating cognitively intact. The resident was dependent on staff for showering/bathing and required partial to limited assistance with personal hygiene.
During a second visit to Resident #11's room on 2/13/24 at 1:30 PM, he was asked if he had ever refused to let staff provide fingernail care. He stated, Not to my knowledge.
Resident #11 was care planned on 1/14/24 for an ADL self-care performance deficit related to chronic medical conditions, and CVA. Interventions included provision of appropriate assistance with hygiene. He was also care planned for his behavioral needs, which included his preference to have nails trimmed every week. (Photographic evidence obtained)
A review of the Certified Nursing Assistant (CNA) daily tasks found in the last 30 days, showers or a bath was provided on 4 days: 1/19/24, 1/21/24, 2/11/24 and 2/12/2024. Nail care was not included on the CNA task list.
An interview was conducted with Employee E, CNA, on 2/13/24 at 9:43 AM. She stated CNAs provide nail care to residents. If a resident needs care they should be provided that care. Resident #8 requires prompts in the morning to complete hygiene. He sometimes refuses, but when he needs it, he demands that care. When asked if she knew he engaged in rectal digging, due to the color of the debris under and around his nails, she stated she believed he might. Resident #8 might also be trying to wipe himself after bowel movements. When shown the photographs of Resident #8 and Resident #11's fingernails, she acknowledged the undesirable conditions.
During an interview with Employee F, CNA, on 2/13/24 at 11:00 AM, she was asked who provides nail care to residents. She replied all aides provide nail care as needed by the residents.
During an interview with the Director of Nursing (DON) on 2/13/24 at 2:30 PM, she was shown the pictures of Resident #8 and #11's fingernails. She confirmed they were unclean and in need of attention. The DON said they were always on the staff about that, and she has already started correcting the concern by having staff make rounds and provide nail care today.
A review of the Standards and Guidance ADL care and Services issued 4/2020 and revised 1/2024 stated:
Standard: Residents will be provided with care, treatment and services as appropriate to improve their ability to carry out ADLs.
Guideline: Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Procedure:
1. Residents will be provided with care, treatment and services to ensure their ADL needs are met.
4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with .
a. Hygiene (bathing, dressing, grooming, nail care and oral care)
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure wound care was provided as ordered for two (Residents #2 and #3) of two residents reviewed for wound care, from a total sample of 16 residents.
The finding include:
1. On 2/12/24 at 10:40 AM, Resident #2 was observed lying in bed on his left side. His eyes were closed and did not answer to his name being called, resp 16/minute. His right foot was observed to be wrapped in gauze and dated 2/10/24. The bottom of his right foot which was observed wrapped in gauze, which was colored, and dirt was on both the exposed foot (heel) and the gauze.
A record review for Resident #2 revealed an admission date of 12/5/23, with diagnoses of congestive heart failure, insomnia, unspecified psychosis, dementia, major depressive disorder, mixed anxiety disorder.
A review of 5-day minimum data set (MDS) assessment, dated 12/12/2023, revealed Resident #2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The assessment also documented he exhibited verbal behaviors towards others, had no indication of rejection of cares, and exhibited no functional impairment in range of motion. The resident required physical assistance with showers/baths, personal/ toilet hygiene, and was at risk for pressure wounds.
On 2/12/24 at 1:00 PM, a phone call to Resident #2's spouse was made (listed as Emergency Contact #1, POA). She was asked for permission to photograph the resident. She verbally granted permission. She was asked if she had anything she'd like to share about the care and services he receives at the facility. She stated, Generally, they provide pretty good care, I do get concerned about his foot, they tell me it's starting to heal. It's been over 2 months; the wound did happen here. I don't know how it happened, one day I did see it was skinned up. They said it probably happened when he fell. He's been on antibiotics twice. The wound nurse told me recently, last week, that it's getting better.
On 2/13/24 at 8:15AM, Resident #2 was observed lying in bed with his eyes closed, resp 16/minute. His right foot was observed with a gauze wrap dressing dated 2/10/24. The right foot was observed with dirt on the open /exposed areas of the bottom of his foot. His left foot sock was observed to have bright red stains on the toe area of the sock. (Photographic evidence obtained)
A medical record review for Resident #2 revealed pertinent physician's orders which read: Podiatry consult for wound on bottom of right great toe, cut nails on 12/18/2023, 12/20/23: wound culture to right foot, 12/20/23: wound culture to right foot, 12/20/23, 1/23/24: cleanse right foot wound with wound cleanser pat dry, apply xeroform/gentamycin abdominal rolled gauze QD/PRN, 2/4/24: encourage and assist resident with turning and repositioning when in bed every shift, 2/14/24: weekly skin check, 12/12/23 NAS diet, reg texture thin consistency.
On 02/13/2024 at 9:30 AM, an interview was conducted with Employee B Registered Nurse (RN). She was asked to read Resident #2's treatment order. She responded, Cleanse right foot with wound cleanser, pat dry, apply gentamycin/xeroform ABD rolled gauze every day, on the 7-3 shift and as needed if it comes off. (Photographic evidence obtained) When Employee B RN was asked who performs the wound care. She stated, I do it every day, Monday through Friday and another RN does it on the weekends. When Employee B RN was asked if she performed the wound care on Resident #2 yesterday, she stated, Yes. When asked how often the wounds are evaluated and documented, and where it is documented. Employee B RN said she evaluates the wounds every day when she does the treatments and if she observes any changes, she calls the RN Wound Care Consultant for further recommendations. Employee B RN was informed that Resident #2's dressing had been observed on 2/12/2024 and 2/13/2024, and both days the resident's right foot dressing was dated 2/10/2024. Employee B RN then stated, I didn't do it yesterday, I told the nurse up there to do it, and I didn't hear back from her.
On 2/13/2024 at 12:37 PM, Resident #2 was asked for permission to observed his wound care treatment, which he agreed. Employee B RN/Wound Care Nurse, Wound Care Consultant and a male CNA were present. The dressing that was previous on the resident's right foot on 02/13/2024 (dated 02/10/2024) was observed to have been replaced with a bordered gauze dated 2/13/2024. Employee B RN removed a soiled bordered dressing from the top of the resident's right foot. The wound bed was 100% covered with yellow slough. The Wound Nurse Consultant measured the wound. While wearing the same gloves that she wore to remove the soiled dressing from the top of Resident #2's right foot, Employee B RN painted the left foot 2nd digit with a betadine solution. While wearing the same gloves that she had just used to treat the left foot 2nd digit, Employee B RN then proceeded to treat the top of right foot wound (she did not change gloves, she did not sanitize or wash her hands in-between these procedures). Employee B RN cleansed the wound on top of right foot with wound cleanser, applied Silvasorb gel, covered with xeroform, then covered with ABD pad, wrapped with Kerlix dressing, removed gloves, discarded in pink bag, taped and dated the dressing, and then washed her hands. After the treatment Employee B RN was asked if she had sanitized her hands during the treatments. She stated, No, I didn't wash or sanitize my hands after I removed the soiled dressing, and no I did not wash my hands or sanitize in-between treatments. I was just trying to get finished, but it's ok.
2. A record review for Resident #3 revealed an admission date of 12/20/2023 and discharged date of 01/31/2024, with diagnoses of left foot osteomyelitis, partial traumatic trans phalangeal amputation of the left thumb, end stage renal disease, peripheral vascular disease, hypertension, type 2 diabetes mellitus, and major depression.
A review of Resident #3's pertinent physician's orders were reviewed that included: wound vac to left heel, cleanse with normal saline the apply wound vac, change every 3 days, on 7-3 shift Mon-Wed-Fri (12/24/2023), wound vac to left heel, cleanse with NS then apply wound vac change every 3 days, on 7-3 shift Tues-Thurs-Sat (12/24/2023). Cleanse left foot top area with NS then wound gel cover with dry dressing (12/23/2023). Consult wound care: DX left foot incision on wound vac (12/22/2023), Consult wound care for wound to left foot with wound vac (12/21/2023), Check wound vac placement and function every shift, if malfunctioning notify provider (12/20/2023), Isolation-Contact precaution every shift for osteomyelitis left foot.
A 12/21/23 progress note for Resident #3 noted: the resident was asking about wound vac, he has a dressing to left lower extremity (LLE) that was clean dry and intact (CDI), Wound care is consulted for wound management. A 1/21/2024 progress note revealed resident requested wound care from DON and was told his nurse was working and wound be in shortly.
A review of the medication administration record/treatment administration record for Resident #3 revealed there was no documentation of wound care/treatments or wound vac application from 12/20/2023 (admission date) to 12/25/2023. (Photographic evidence obtained)
On 2/13/24 at 9:30 AM, an interview was conducted with Employee B RN, Wound Care Nurse regarding Resident #3. She stated that Resident #3 was admitted to the facility without the wound vac in place, but he came with an order for the wound vac. She did not know if he was admitted from the hospital or not because she was not present. She stated, The facility called me and asked if there was a wound vac in the facility. Employee B RN confirmed that Resident #3 had an order for the wound vac the day he was admitted to the facility, but he didn't bring it with him from the hospital, the facility was to supply the wound vac. She had already ordered one before Resident #3 was admitted , because she had to send a used one back to the new company they now use. The new company replaces it, which takes about 3 days for the wound vac to come. Employee B RN stated she does the initial skin assessment on admissions and the Wound Consultant visits the resident when she comes weekly. She stated, I was on vacation so another RN would have done the initial assessment, and the initial assessment would be documented under progress notes, or under the general note or health status note. Employee B RN was asked to explain why the resident was admitted on [DATE] but the wound vac was not applied until 12/25/2023, according to the MAR/TAR. (Photographic evidence obtained) Employee B RN stated, I'm not sure about that because I was not here. When asked what kind of treatment the resident received from 12/20/2023 to 12/25/2023. Employee B RN reviewed Resident #3 electronic health record (HER) and stated, I'm not sure, because I wasn't here, but I don't see any treatments documented for 12/20/2023 through 12/25/2023. When asked if treatments would be documented anywhere else in the record. Employee B RN stated, I don't see any other documentation in the chart. When asked what the facility process for receiving progress notes, when residents visit providers outside of the facility. Employee B RN stated, Normally we would have notes from any provider outside of the facility, but the resident kept all his notes and paperwork and would not give us anything accept the orders, there were no new orders that were received, the doctor's office gave verbal orders to change the wound vac every 3 days which was the same order we already had.
A review of the facility's Wound Care and Treatment Policy/Procedure (issued 03/2020 and revised on 1/2024) read:
Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.
Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed.
Procedure:
Preparation: 1. Verify that there is a physician's order for this procedure.
Steps in the Procedure
2. Perform hand hygiene thoroughly
4. Put on exam gloves. Loosen tape and remove dressing.
5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene thoroughly.
6. Put on gloves
Documentation: The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, and change in condition, and problem or complaint made by the resident related to the procedure, If the resident refused the treatment and the reason(s) why, the signature and title of the person recording the data. (Photographic evidence obtained)
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
2. On 2/13/2024 at 12:37 PM, Resident #2 was asked for permission to observed his wound care treatment, which he agreed. Employee B RN/Wound Care Nurse, Wound Care Consultant and a male CNA were prese...
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2. On 2/13/2024 at 12:37 PM, Resident #2 was asked for permission to observed his wound care treatment, which he agreed. Employee B RN/Wound Care Nurse, Wound Care Consultant and a male CNA were present. The dressing that was previous on the resident's right foot on 02/13/2024 (dated 02/10/2024) was observed to have been replaced with a bordered gauze dated 2/13/2024. Employee B RN removed a soiled bordered dressing from the top of the resident's right foot. The wound bed was 100% covered with yellow slough. The Wound Nurse Consultant measured the wound. While wearing the same gloves that she wore to remove the soiled dressing from the top of Resident #2's right foot, Employee B RN painted the left foot 2nd digit with a betadine solution. While wearing the same gloves that she had just used to treat the left foot 2nd digit, Employee B RN then proceeded to treat the top of right foot wound (she did not change gloves, she did not sanitize or wash her hands in-between these procedures). Employee B RN cleansed the wound on top of right foot with wound cleanser, applied Silvasorb gel, covered with xeroform, then covered with ABD pad, wrapped with Kerlix dressing, removed gloves, discarded in pink bag, taped and dated the dressing, and then washed her hands. After the treatment Employee B RN was asked if she had sanitized her hands during the treatments. She stated, No, I didn't wash or sanitize my hands after I removed the soiled dressing, and no I did not wash my hands or sanitize in-between treatments. I was just trying to get finished, but it's ok.
A record review for Resident #2 revealed an admission date of 12/5/23, with diagnoses of congestive heart failure, insomnia, unspecified psychosis, dementia, major depressive disorder, mixed anxiety disorder.
A review of 5-day minimum data set (MDS) assessment, dated 12/12/2023, revealed Resident #2 had a brief interview for mental status (BIMS) score of 7 out of 15, indicating severe cognitive impairment. The assessment also documented he exhibited verbal behaviors towards others, had no indication of rejection of cares, and exhibited no functional impairment in range of motion. The resident required physical assistance with showers/baths, personal/ toilet hygiene, and was at risk for pressure wounds.
A medical record review for Resident #2 revealed pertinent physician's orders which read: Podiatry consult for wound on bottom of right great toe, cut nails on 12/18/2023, 12/20/23: wound culture to right foot, 12/20/23: wound culture to right foot, 12/20/23, 1/23/24: cleanse right foot wound with wound cleanser pat dry, apply xeroform/gentamycin abdominal rolled gauze QD/PRN, 2/4/24: encourage and assist resident with turning and repositioning when in bed every shift, 2/14/24: weekly skin check, 12/12/23 NAS diet, reg texture thin consistency.
A review of the facility's policy titled Infection Control- Infection Prevention and Control Program (revised 6/2023) revealed:
Standard: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
Guidelines: The infection and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is based on accepted national infection prevention and control standards in accordance with local, state, and federal regulations and guidelines.
Prevention of Infection:
1. Important facets of infection prevention include:
c. Educating staff and ensuring that they adhere to proper techniques and procedures; (Photographic evidence obtained)
A review of the facility's Wound Care and Treatment Policy/Procedure (issued 03/2020 and revised on 1/2024) read:
Standard: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.
Guideline: Only staff trained to complete physician orders will complete wound care and treatments as prescribed.
Procedure:
Preparation: 1. Verify that there is a physician's order for this procedure.
Steps in the Procedure
2. Perform hand hygiene thoroughly
4. Put on exam gloves. Loosen tape and remove dressing.
5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene thoroughly.
6. Put on gloves
Documentation: The following information should be recorded in the resident's medical record: The type of wound care given, the date and time the wound care was given, the name and title of the individual performing the wound care, and change in condition, and problem or complaint made by the resident related to the procedure, If the resident refused the treatment and the reason(s) why, the signature and title of the person recording the data. (Photographic evidence obtained)
Based on observations, record review, interviews, and facility policy review, the facility failed to practice proper infection control measures by 1) failing to wear required personal protective equipment (PPE) for one (Resident #12) of one resident reviewed for transmission base precautions, and 2) failing to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound care dressing change for one (Resident #2) of one resident observed during wound care, from a total sample of 16 residents.
The findings include:
1. On 2/12/24 at 11:44 AM, Employee D, Certified Nursing Assistant (CNA) was observed entering Resident #12's room without donning personal protective equipment (PPE). The door for Resident #12's room was observed to contain a PPE hanger with pockets that were observed to contain a box of gloves, a package of disposable blue gowns, N95 face masks, and face shields and a sign stating, Contact Precautions. The sign was observed to say: Put on gloves before room entry. Discard gloves before room exit. Put gown on before room entry. Discard gown before room exit. When Employee D came out of the room, she was asked if she was required to don PPE prior to entering this room. She stated, Yes, but I was just handing him his lunch tray at the door.
On 2/12/24 at 11:47 AM, Employee D was observed entering the same room with PPE on. When she exited the room, she removed her PPE outside the room. She was then observed walking down the hall with the PPE (disposable blue gown and gloves) in her hands.
A record review for Resident #12 revealed an admission date of on 12/8/23, with diagnoses of cellulitis right lower limb, cellulitis left lower limb, major depressive disorder, anxiety disorder, and unspecified psychosis not due to a substance or known physiological disorder.
A review of Resident #12's physician's order dated 2/3/24 read: Permethrin external cream 5%: apply to back, buttocks topically one time a day for rash for 5 days. Place once a day and wipe off after 10 hours. Physician's order dated 2/10/24 read: Permethrin external cream 5%: apply to trunk, buttocks, and back topically one time a day for scabies until 2/14/24: apply on for 10 hours wash off x 5 days.
On 2/13/24 at 8:00 AM, Employee C, Patient Care Assistant (PCA) was observed inside Resident #12's room without any PPE on. The door for this room was observed to contain a PPE hanger with pockets that were observed to contain a box of gloves, a package of disposable blue gowns, N95 face masks, and face shields and a sign stating, Contact Precautions. When Employee C exited the room, she was asked if she knew what precautions Resident #12 was on. She stated, He has scabies, the man in the D bed. When asked if she had been trained to don PPE when entering a room with a precaution sign on the door. She stated, I've only been here for a week. Someone did tell me, I think. I was just making the beds. Resident #12 was observed inside the room.
During an interview with the Infection Preventionist on 2/13/24 at 11:00 AM, she was asked about the contact precautions for Resident #12. She stated, Resident #12 had a rash, and I couldn't get a dermatologist in to see him, so his regular doctor here did go in and see the resident and he didn't feel it was anything contagious, but the family had concerns, so the doctor did order a treatment of Permethrin. When asked if the resident was placed on Contact Precautions because of the rash, she stated, Yes. When was asked what Contact Precautions means for anyone entering the room, the Infection Preventionist stated, Wear PPE when entering the room, gloves, a mask, and a gown. When she was asked if she was aware that two different staff members were observed Resident #12's room without wearing PPE. She stated, Yes I was told yesterday that one was in there. I asked her why, she said she was bringing him his lunch tray. When the Infection Preventionist was asked if she was aware of a second employee going into Resident #12s room without donning PPE this morning. She stated, Yes, I spoke to her after I was told she went into the room without PPE. She said that was her first time up on the unit. I told her that wasn't an excuse, that when you see something on the door, that's not a normal case, and if you see a sign you need to ask. She's a Patient Care Assistant (PCA) and she said she didn't know.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility's policy, the facility failed to provide appropriat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility's policy, the facility failed to provide appropriate and timely assistance for one (Resident #5) of five residents reviewed for activities of daily living (ADLs), who required extensive assistance with toileting.
The findings include:
A review of Resident #5's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, personal history of TIA (Transient ischemic attack) and cerebral infarction, mood disorder due to known physiological condition, muscle weakness and anxiety disorder.
A review of the admissions minimum data set (MDS) assessment, dated 7/12/23, revealed a brief interview for metal status (BIMS) score of 3 out of a possible 15, indicating severely impaired cognition. Resident #5 required total dependence with transfers, locomotion on/off unit and personal hygiene, extensive assistance with bed mobility, eating and toilet use. He was frequently incontinent of bladder and always incontinent of bowel.
During a tour of the facility on 8/7/23 at 11:23 am, Resident #5 was observed sitting in a Broda positioning wheelchair in an open area in the center of the unit used for resident activities and dining. The residents pants were visibly soaked, and a puddle of liquid (light gold in color) was observed underneath his wheelchair. (Photographic evidence obtained)
On 8/7/23 at 12:18 pm, Employee G, a certified nursing assistant (CNA) was observed standing over Resident #5 in the dining area, cutting his food on a plate. She suddenly stopped cutting the food and walked away from him. As she left, Resident #5 began feeding himself. Shortly thereafter, Employee G went back to where Resident #5 was seated. As she approached him, she stopped to avoid the puddle of liquid (light gold in color) which remained on the floor. She redirected her path to Resident #5 and approached him from the other side of the table. During this time seven other staff members were observed in the room, including the Assistant Director of Nursing who was providing feeding assistance to another resident.
On 8/7/23 at 12:20 pm, Employee H, a personal care attendant (PCA) was told about the puddle of liquid on the floor. He immediately notified Employee G who was seated at the table with Resident #5 providing feeding assistance. He also signaled her that the residents paints were wet. She responded, I know, I'll get it.
On 8/7/23 at 12:49 pm, Resident #5 was observed seated in the same area as he had upon the initial observation. His pants remained soaked, and the colored liquid remained beneath his chair. At this time a CNA was observed walking by Resident #5. See observed the liquid (light gold in color) but did not address the resident's condition or the liquid on the floor.
On 8/7/23 at 12:51 pm, while exiting the area where Resident #5 was sitting, six staff members were observed in the area. The resident remained seated in the Broda positioning wheelchair with his pants visibly soaked with liquid. The puddle of liquid (light gold in color) remained on the floor under his chair. (Photographic evidence obtained)
During an interview on 8/7/23 at 2:56 pm with Employee CNA G, she stated she had been employed at the facility for a year and a half and had received training on Abuse and Neglect, Resident Rights, and Activities of Daily Living (ADL) care. When asked how she identified neglect or not meeting the residents ADL needs, she said, Not taking care of the resident. When asked how she ensures resident needs are met, she said, Go back and clean them up and make sure they're at the standard you want them to be, clean their nails, brush their teeth and their hair and check and change them. She was familiar with Resident #5 and confirmed she knew he was wet. She explained that she could not do the check and change while she was in the process of feeding him. When asked why she did not change the resident after she finished feeding him, she replied, I was still feeding another resident at that time. We can't stop with the feeding because it's cross contamination. When asked if anyone else was available to change the resident, she replied, Someone could have changed him, but everyone was feeding the residents at the time. When asked if she felt Resident #5 was neglected/ADLs not met, she replied, It was kind of like neglect but what was we supposed to do. I thought we couldn't do that if we were feeding residents because of the cross contamination.
During an interview on 8/7/23 at 3:13pm with Employee PCA H, he stated he had been employed at the facility for two months. He stated he received training on Abuse and Neglect, Resident Rights, and Activities of Daily Living (ADL) care. When asked about his observation and response to the incident involving Resident #5, he stated that once he was alerted to the puddle of liquid, he got a wet floor sign, relayed the message to his charge nurse, and tried to find facility maintenance. He confirmed Resident #5's CNA was Employee G and acknowledged he observed the resident's pants were wet. He explained that he was advised staff are supposed to leave the floor with the resident and change them at that time and someone else would take over the feeding. He stated as a PCA he is not allowed to provide feeding assistance nor is he able to remove the resident from the floor to provide toileting assistance.
During an interview on 8/7/23 at 3:37 pm with the Director of Nursing, she stated the expectation is to take the person out and to change them. She said, Under the old company they would say it was cross contamination if you would stop feeding the person to go change them. I've in-serviced them and have education going on for the 3-11 pm people. It was the old company's policy, but we haven't been under them for more than a year. I told them they need to get used to doing it this way. She confirmed Employee G had been employed with the facility for a year and a half.
A review of the facility's Policy and Procedure for Activities of Daily Living (ADLs), revised on March 2018, revealed: Residents who are unable to carry out their activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Policy Interpretation and Implementation
2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
c. elimination (toileting)
(Photographic evidence obtained)
.
Feb 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 01/31/2023 (Tuesday) at 11:45 AM, Resident #70 stated he hadn't been shaved in over a week, maybe more, and had a heavy gr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 01/31/2023 (Tuesday) at 11:45 AM, Resident #70 stated he hadn't been shaved in over a week, maybe more, and had a heavy growth of facial hair forming into a beard and mustache. The resident stated most of the time he didn't receive a shower or a full bath, he was just wiped off while in bed. He stated before his illness, he showered everyday and he would like to receive a shower more frequently.
On 02/01/2023 (Wednesday) at 10:02 AM, Resident #70 was observed lying in bed on his back, resting with his eyes closed. There were no changes to his facial hair. He had not been shaved.
On 02/01/2023 at 12:00 PM, Resident #70 was observed sitting up in bed, alert and oriented. He stated he asked a CNA this morning (couldn't recall name) if they could shave him, and he was told they would check with the CNA who normally shaved him.
A review of the medical record revealed that Resident #70 was admitted to the facility on [DATE] with diagnoses including traumatic intracranial hemorrhage, hemiplegia affecting the non-dominant left side, and seizure disorder.
A review of the ADL Task List revealed: Bathing/Shower/Bath schedule weekly variable/evenings, on Tuesdays, Thursdays, and Saturdays.
A review of the quarterly MDS assessment, dated 1/10/2023, revealed that the resident had a BIMS score of 12 out of a possible 15 points, indicating mild to moderate cognitive impairment. He required extensive assistance with personal hygiene (included shaving and bathing).
A review of the Care Plan (dated 11/13/2022) indicated the resident had an ADL Self-Care Deficit related to chronic medical conditions. Interventions included: Encourage and assist with ADL tasks as indicated, as tolerated by resident including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals. personal/oral hygiene, etc. Observe resident for changes in ADL capabilities.
On 02/02/2023 (Thursday) at 10:00 AM, Resident #70 was observed in bed. There were no changes to his facial hair. He was still unshaven. He stated he asked a CNA again this morning if someone could shave him, but they hadn't returned to do it yet.
In an interview on 02/02/2023 at 11:00 AM with CNA K, she stated she was assigned to Resident #70. She confirmed that the resident had asked her to shave him and she had not gotten to it yet. She added that residents were supposed to be shaved during their shower days. Resident #70 was scheduled to receive showers in the evenings, and therefore, she could not explain why the evening staff had not done it. She added that she would shave him before the end of the shift.
In an interview with LPN A on 02/02/2023 at 11:28 AM, she stated CNAs were expected to shave the residents during showers. If a resident refused a shower, the nurse should be notified. At least three attempts should be made at different times before documenting that the resident refused. When asked about Resident #70, she stated she was not aware of whether he refused showers. She added that this resident received showers in the evening, and she worked in the morning. She said she would ensure he was shaved.
A review of the facility's policy for Activities of Daily Living (Revised March 2018) revealed:
Policy Statement:
Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs.
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Policy Interpretation and Implementation:
Line 1. Resident will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADL's are unavoidable.
Line 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with;
a. Hygiene (bathing, dressing, grooming and oral care).
Page 2, Line 6. read: Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.
4. On 01/30/2023 at 2:00 PM, Resident #98 was observed with facial hair and stated she would like to be shaved.
On 01/31/2023 at 10:12 AM, Resident #98 was observed and appeared as she did on 01/30/2023 at 2:00 PM, with facial hair.
On 02/01/2023 at 2:22 PM, Resident #98 was observed with a shaved chin, but she still had hair above her upper lip. She stated, They shaved me yesterday.
A review of Resident #98's medical record revealed an admission date of 8/6/2022, and a re-entry on 10/25/2022. Resident #98's diagnoses included encephalopathy, major depressive disorder, fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, confusion, psychosis, and cataract extraction status, unspecified eye.
A review of the resident's quarterly MDS, dated [DATE], indicated Resident #98 had a BIMS score of 7 out of a possible 15 points, indicating severe cognitive impairment. Resident #98 had no behaviors , and required limited assistance with bed mobility, transfers, walking in room, locomotion on unit and corridor, limited assistance with dressing, supervision while eating, and she was totally dependent for bathing.
A review of the Care Plan, dated 10/18/2022, revealed that Resident #98 had an ADL Self-Care Deficit related to chronic medical conditions. Goal: Resident will maintain and/or improve ADL functioning through next review date. Resident will not have a decline in ADL functioning through next review date.
Interventions:
Assistive devices as ordered/indicated.
Encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc.
On 01/30/2023 at 10:18 AM, an interview was conducted with CNA P. He stated female residents had their facial hair removed during their shower day, which for resident #98, was every Friday during the day shift.
On 01/31/2022 at 2:18 PM, an interview was conducted with CNA Q. She stated some female residents refused facial hair removal, but they provided the service on shower days.
A review of the facility's policy and procedure for Activities of Daily Living (ADL) (effective 2001, revised in March 2018) revealed: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to assist five (Residents #115, #65, #37, #98, and #70) of 55 sampled residents, reviewed for activities of daily living (ADLs), necessary to maintain grooming and personal hygiene for dependent residents.
The findings include:
1. On 01/30/2023 at 12:10 PM, Resident #115 was observed in her room, sitting up in a wheelchair, dressed in day clothing. Her fingernails were elongated with brown debris under each nail.
On 01/31/2023 at 10:02 AM, Resident #115 was observed in her room, sitting up in a wheelchair, dressed in day clothing. Her fingernails were elongated with brown debris under each nail.
On 02/01/2023 at 8:55 AM, Resident #115 was observed in her room, awake in bed. Her fingernails were elongated with brown debris under each nail.
On 02/01/2023 at 2:50 PM, Resident #115 was in her room, awake in bed. Her fingernails were elongated with brown debris under each nail. The resident was asked if she preferred her nails to be trimmed and clean. She stated yes. She was asked if she was able to trim and clean her nails herself. She stated no. She was asked if staff trimmed and cleaned her nails. She stated, No, I don't remember the last time that happened. Her fingernails were observed with chipped pink nail polish, most nails were elongated, and two nails were jagged.
A medical record review for Resident #115 revealed diagnoses including right femur fracture, muscle weakness, need for assistance with personal care.
A review of the Minimum Data Set (MDS) annual assessment, conducted on 12/28/22 for Resident #115 revealed:
Section C: Brief Interview for Mental Status (BIMS) score was 05 out of a possible 15 points, indicating severe cognitive impairment.
Section E: Behaviors exhibited: None; Rejection of Care: Behavior not exhibited.
Section G: Personal Hygiene: Extensive staff assist/one person physical assist provided.
The Care Plan for Resident #115 was reviewed and revealed:
Focus (1/13/21, last revised 10/21/21) Self-Care Performance Deficit related to cognitive deficit, right femur fracture, impaired judgement/decision making, impaired mobility.
Goal: Customer will be assisted with ADLs daily by staff through next review.
Interventions: Assist as needed with daily dressing and grooming. Ensure neat and clean appearance daily.
2. On 01/30/2023 at 12:20 PM, Resident #65 was observed in her room, sitting up in a wheelchair, dressed in day clothing. She was nonverbal aside from some nonsensical mumbling. All of her fingernails were elongated with brown debris observed under each nail.
On 01/31/2023 at 2:06 PM, Resident #65 was observed in her room, sitting up in a wheelchair, dressed in day clothing. She was nonverbal aside from some nonsensical mumbling. All of her fingernails were elongated with brown debris observed under each nail.
On 02/01/2023 at 8:45 AM, Resident #65 was observed in her room, sitting up in a wheelchair, dressed for the day. She was nonverbal. All of her fingernails were elongated with brown debris under each nail.
On 02/01/2023 at 3:00 PM, Resident #65 was observed in her room, sitting up in a wheelchair, dressed for the day. She was nonverbal. All of her fingernails were elongated with brown debris under each nail.
A medical record review for Resident #65 revealed diagnoses ubcluding dementia, history of falling, polyosteoarthritis, major depressive disorder, and blindness in one eye.
A review of the MDS annual assessment, dated 10/25/22 for Resident #65 revealed:
Section C: Brief Interview for Mental Status (BIMS) score was 02 out of a opssible 15 points, indicating severe cognitive impairment.
Section E: Behaviors exhibited: None; Rejection of Care: Behavior not exhibited.
Section G: Personal Hygiene: Eextensive staff assist/one person physical assist provided.
The Care Plan for Resident #65 was reviewed and revealed:
Focus (8/8/14, last revised 2/8/21) Resident has a Self-Care Performance Deficit related to dementia, impaired judgement/decision making.
Goal: (revised 1/25/23) Resident will complete and/or maintain self-care tasks with moderate assistance through next review.
Interventions: Ensure neat and clean appearance daily.
3. On 01/31/2023 at 10:00 AM, Resident #37 was observed lying in bed, awake, conversant, and pleasant. She was asked if staff had assisted her with her activities of daily living this morning. She stated yes. Her fingernails were elongated with debris under each nail. She was asked if staff cared for her fingernails. She stated. Sometimes, but not recently. I need to get them repainted. She was asked if she could trim and clean her fingernails herself. She stated, No, I can't do that myself. I've had a stroke; I can't manage things like that with my hands.
On 02/01/2023 at 8:45 AM, Resident #37 was observed in her room, lying in bed, awake, and eating breakfast. Her fingernails were elongated with brown debris under each nail.
A medical record review for Resident #37 revealed diagnoses including COPD (Chronic Obstructive Pulmonary Disease), type II diabetes, CVA (Cerebral Vascular Accident), and glaucoma.
A review of the MDS quarterly assessment, dated 12/18/2022 for Resident #37 revealed:
Section C: Brief Interview for Mental Status score was 11 out of a possible 15 points, indicating moderate cognitive impairment.
Section E: Behaviors exhibited: None; Rejection of Care: Behavior not exhibited.
Section G: Personal Hygiene: Extensive staff assist/one person physical assist provided.
The Care Plan for Resident #37 was reviewed and revealed:
Focus: (6/10/22) Resident requires assistance with ADL functions.
Goal: Resident will maintain current level of function til next review.
Interventions: Grooming: someone must assist the resident to groom self. Grooming: The resident depends entirely upon someone else for grooming needs.
On 02/02/2023 at 11:50 AM, in an interview with Certified Nursing Assistant (CNA) U, she was asked if she was caring for Residents #37, #65, and #115 today. She stated, I have [Residents #65 and #115] on my assignment today, but I have cared for [Resident #37] before too. This is usually my unit to work, so I've cared for most of the residents over here. She was asked who cleaned and trimmed the residents' fingernails. She stated, We do, if they let us. Not the diabetics, though, only the nurses trim the diabetics' nails. She was asked if CNAs could clean under the diabetics' fingernails. She stated, I think so, yes, we can clean them, we just can't trim them. She was asked when residents' fingernails were cleaned and trimmed. She stated, Anytime, just with their ADL care. It's not something that's scheduled. We just clean them when they need to be cleaned, if they let us. She was asked what she did if a resident refused to have their fingernails trimmed and cleaned. She stated, I'll try to ask them again later, and then I let my nurse know if they still refuse. She was asked if she was able to chart anywhere if a resident refused care. She stated, Yes, we chart on the computer and we can put in refusals. She was asked who cleaned and trimmed the residents' toenails. She stated, That would be the foot doctor. We don't touch their toenails. She was asked what she did if she observed a resident's toenails to be elongated or in need of cleaning. She stated, I'll let my nurse know so they can get them a foot doctor appointment. They come into the facility to see the residents.
On 02/02/2023 at 12:00 PM, Licensed Practical Nurse (LPN) E was asked who cleaned and trimmed the residents' fingernails. She stated, The activities staff does that as an activity. They clean and trim them and give manicures, and they'll paint their nails. She was asked who trimmed fingernails for diabetic residents. She stated, Oh the nurses do that. We do the the trimming for the diabetic residents. She was asked how often fingernails for diabetic residents were cleaned and trimmed. She stated, I'm not sure. I think there's a schedule. She was asked how often she cleaned and trimmed her diabetic residents' nails. She replied, If I see they need it done or if one of the CNAs let me know it needs to be done.
On 02/02/2023 at 12:10 PM, the Director of Nursing (DON) was asked who cleaned and trimmed the residents' fingernails. She stated, Activity staff cleans, trims and paints residents' nails, but if a resident is a diabetic, only nurses can trim those nails. She was asked if CNAs provided fingernail care. She stated, Yes, as long as they are not a diabetic. She was asked if there was a schedule for fingernail care. She stated, No, they just do it when it needs to be done, or if the CNA lets the nurse know that a diabetic needs their nails trimmed. She was asked if CNAs and activities staff cleaned under all residents' nails, including diabetics. She stated, Yes, they can soak their nails and use an orange stick to clean under them. She was asked when this should be done. She stated, As needed, usually on shower days or in-between if it's needed, as long as a resident is agreeable and doesn't refuse the care. She was asked what the procedure was if a resident refused to have their fingernails trimmed and cleaned. She stated, The staff would reapproach them again later, and if they still refused, they would chart the refusal of care.
A review of the facility's policy for Activities of Daily Living (ADLs) revealed:
Policy statement: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
Policy Interpretation and Implementation:
2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:
a. Hygiene (bathing, dressing, grooming, nail care, and oral care).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #517's medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #517's medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, adult failure to thrive, severe protein-calorie malnutrition, and dementia. On 12/12/2022, Resident #517 was discharged to the hospital for dehydration and acute kidney failure.
A review of the Medicare 5-Day MDS (Minimum Data Set) assessment, dated 11/14/2022, revealed that Resident #517 had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points, indicating moderate cognitive impairment. She required extensive assistance with bed mobility and locomotion, limited assistance with transfers, and she was totally dependent on two staff members for bathing. Resident #517 was frequently incontinent of urine and always incontinent of bowel.
A review of the Care Plan, dated 12/1/2022, revealed that the resident was at Risk for Alteration in Nutrition/Hydration r/t overweight status, therapeutic diet, advanced age, adult failure to thrive (AFTT), malnutrition, dementia, hypertension (HTN - high blood pressure), gastroesophageal reflux disease (GERD), and anemia.
A review of the Physician's Orders revealed:
11/10/2022 Carvedilol tablet 6.25 mg (milligrams), give 1 tablet by mouth two times a day for HTN.
11/10/2022 Valsartan Tablet 80 mg, give 1 tablet by mouth at bedtime for HTN.
12/2/2022 Pink Bismuth Suspension 262 mg/15ml (milligrams per milliliter) (Bismuth Subsalicylate), give 30 ml by mouth every 4 hours as needed for diarrhea.
12/3/2022 CBC & BMP (laboratory tests) one time only for 1 day.
12/3/2022 Vital signs every shift for 10 days.
12/11/2022 Dextrose-NaCl Solution 5-0.9% (Dextrose-Sodium Chloride), 60 ml/hour intravenously every shift for dehydration for 3 days.
12/11/2022 CBC&CMP (laboratory tests) one time only for dehydration.
12/12/2022 20:04 (8:04 PM) Send to ER (emergency room) for critical lab results STAT (immediately).
A review of Vital Signs forms for December 2022 revealed:
12/5/2022 17:14 (5:14 PM) blood pressure 82/53 mmHg (millimeters of mercury)
12/6/2022 16:44 (4:44 PM) blood pressure 94/68 mmHg
12/6/2022 20:03 (8:03 PM) blood pressure 90/70 mmHg (Copies obtained)
A review of the medical record revealed that on the 5th and 6th of December 2022, the records contained no documentation of physician notification about the resident's hypotension or the withholding/provision of blood pressure medication during those times.
A review of the electronic Medication Administration Record (eMAR) for December 2022, revealed no blood pressure (BP) or pulse (P) recorded for the medication Valsartan (blood pressure medication), nor was it administered on 12/05/2022 at 20:00 (8:00 PM). Code 4 outside parameter was documented, however, no parameters were indicated on the eMAR. On 12/6/2022 at 20:00 (8:00 PM), a BP of 90/70 and a P of 70 were recorded on the MAR under the medication Valsartan, and the medication was signed by the nurse as having been administered.
Further review of the eMAR for December 2022, revealed a BP of 82/53 and a P of 91 recorded for the medication Carvedilol (blood pressure medication) at 4:00 PM on 12/5/22. The medication was withheld and Code 4 outside parameter was documented, however, no parameters were indicated on the eMAR. On 12/6/22 at 8:30 AM, no BP or P were recorded for Carvedilol and the medication was administered. At 4:00 PM, a BP of 94/68 and a P of 70 were recorded for Carvedilol and the medication was administered.
Pink Bismuth Suspension (diarrhea medication), ordered as needed every 4 hours on 12/2/22 for diarhhea and discontinued on 12/19/22, was never administered.
Dextrose-NaCl Solution 5-0.9%, 60 ml/hr intravenously every shift x3 days for dehydration, starting on the night shift on 12/11 and to be administered through the evening shift on 12/14, was not signed off by the assigned nurse as having been administered at all on 12/13, or during the day shift or evening shifts on 12/14/22. (Copies obtained)
A review of the Laboratory Results reported on 12/13/2022 at 12:43 PM and reviewed by Registered Nurse (RN) W on 12/13/2022 at 5:38 PM, revealed critical high levels of Blood Urea Nitrogen (BUN) - 134 mg/dL (milligrams per deciliter) with a normal range of 7 to 25 mg/dL, and Creatinine - 9.17 mh/dL with a normal range of 0.60 to 1.20 mg/dL, indicating increased renal insufficiency. There was no documentation on the form to indicate that the resident's physician was notified. (Copy obtained)
A review of the Laboratory Results (BMP and CBC) reported on 12/15/2022 at 11:51 AM, and reviewed by the Assistant Director of Nursing (ADON)/LPN C on 12/15/2022 at 1:14 PM, revealed a collection date of 12/05/2022 at 5:20 AM, a received date of 12/05/2022 at 16:27 (4:27 PM), and a reported date of 12/15/2022 at 11:51 AM: Status invalid. Tests not performed. There was no documentation on the form to indicate that the resident's physician was notified. (Copy obtained)
Further review of Resident #517's medical record revealed that between 12/05/2022 and 12/12/2022 (Resident #517's discharge date ), the record contained no documentation of the facility having followed up on the resident's status invalid - tests not performed laboratory results.
A review of the resident's physician's Cardiology Progress Note, dated 11/11/2022, revealed the following recommendations for the resident: Monitor vital signs, avoid overcorrection of blood pressure, plan to check laboratory tests.
A review of the Progress Note dated 12/02/2022, revealed that the resident's family was concerned that she was lethargic and her appetite had not improved. The family was also concerned about diarrhea, and staff not cleaning her, dressing her, or or putting her hearing aids in.
A review of the Progress Note dated 12/11/2022, revealed that the resident had not been taking fluids or eating, and her blood pressure (BP) was 90/60.
A review of the Progress Note dated 12/12/2022, showed that the resident's chief complaint was low blood pressure (hypotension).
On 2/1/23 at 2:00 PM, an interview was conducted with LPN O. He stated after sending a sample from the resident to the laboratory for tests like a CMP (complete metabolic panel) and/or a CBC (complete blood count), it usually took one to two days to receive results. After two days, if no results were received, the nurse should call the laboratory to inquire about results. LPN O stated he would not give Valsartan or Carvedilol to the resident with a blood pressure of 82/53, 94/68, or 90/70 mmHg.
On 2/1/23 at 2:11 PM, an interview was conducted with LPN B. She stated the results from the laboratory usually came at 4:00 AM, 5:00 AM, or in the afternoon or evening time. She would call the laboratory if no results had been received within two days. If a resident's blood pressure was 82/53, 94/68, or 90/70, for a systolic blood pressure of 90 or less, she would not administer Valsartan or Carvedilol, and she would call the physician.
On 2/2/23 at 1:28 PM, an interview was conducted with the Director of Nursing (DON). She was asked to explain the process for following up on laboratory test results and who was responsible for the follow up. She stated a nurse was responsible (or a unit manager) for follow up calls to the laboratory. She stated if there were no blood pressure parameters in the MAR for blood pressure medications Valsartan and Carvedilol, she would call the physician for blood pressures of 82/53, 94/68, and 90/70 before administering those medications. The DON was asked to explain and show evidence that the facility followed up on the aforementioned laboratory results for Resident #517. She stated she needed time to investigate the problem. No explanation was provided before the survey exit.
A review of the facility's policy and procedure for Administering Medications (effective 2001 and revised in December 2022) revealed: If medication has been identified as having potential adverse consequences for the resident or is associated with adverse consequences, the person administering the medication will contact the prescriber. Notify physician of changes in resident/patient. (Copies obtained)
A review of the facility's policy and procedure for Change in a Resident's Condition or Status (effective 2001 and revised in May 2017) revealed: The nurse will notify the resident's attending physician or physician on call when there has been an adverse reaction to medication or a significant change in the resident's physical condition. (Copies obtained)
A review of the facility's policy and procedure for Laboratory Services (effective 2005 and revised in September 2012) revealed: A nurse will review all results. Before contacting the physician/designee, the nurse will gather and organize information and coordinate any telephone communications with physician and/or designee. (Copies obtained)
A review of the National Kidney Foundation at kidney.org (Accessed 2/2/23 at 3:00 PM) revealed:
What causes acute kidney injury (AKI)?
Acute kidney injury can have many different causes. AKI can be caused by the following: Decreased blood flow. Some diseases and conditions can slow blood flow to your kidneys and cause AKI. These diseases and conditions include: Low blood pressure (called hypotension) or shock, and blood or fluid loss (such as bleeding or severe diarrhea).
Based on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, by failing to 1) Carry out physician's orders for consultations for Resident #30, and 2) Promptly identify and intervene for a change in condition (dehydration), report low blood pressures (hypotension) to the physician, consult the physician about low blood pressures prior to the administration of blood pressure medications for a resident with hypotension, and follow physician's orders for laboratory tests, for Resident #517, two residents reviewed from a total sample of 55 residents.
The findings include:
1. On 1/31/22 at 10:00 AM, Resident #30 was observed lying in bed. He stated he had spoken to his physician multiple times related to his pain and vision. He had pain in his left lower back that radiated to his left foot. He stated when he told the nursing staff about his pain, they only gave him Tylenol and it did not help. He further stated he was worried about losing his vision, and would also like to see a dentist. When asked if the facility staff were aware of this, he said he had spoken to the staff. I have told the nurses over and over again and they ignore me. I just stopped telling them because they don't seem to care.
A review of the resident's Electronic Medical Record (EMR) revealed that Resident#30 was admitted to the facility on [DATE] and had a re-entry on 12/15/22. His admitting diagnoses included hemiplegia, hemiparesis, diabetes mellitus, retinopathy, and peripheral neuropathy.
A review of the active physician's orders revealed the following: Cardiology consult dated 12/16/22. Pain consult dated 12/30/22. Ophthalmology consult dated 1/27/23.
A review of the resident's Care Plan, with a review date of 2/3/23, revealed that the resident had pain and/or was at risk for pain related to chronic pain and physical disability. Interventions included administration of analgesia (pain medication) as ordered and review pain medication as needed. The care plan also indicated that the resident had oral/dental health problems related poor hygiene, missing teeth, and the facility would assist with arrangements for dental care. He was also at risk for altered respiratory status/difficulty breathing related shortness of breath (SOB).
A review of the Medicare 5-Day Minimum Data Set (MDS) assessment, dated 12/21/22, revealed that the resident had adequate vision and no corrective lenses. The Brief Interview for Mental Status (BIMS) score was recorded as 14 out of 15 possible points, indicating intact cognition. He required extensive assistance for bed mobility and toilet use, and limited assistance for transfers. He was independent for eating. He had no broken or loosely fitting full or partial dentures and no mouth discomfort or difficulty chewing. The assessment further indicated that the resident was not on any scheduled or as needed (PRN) pain management, and reported that he experienced pain almost constantly. Pain was described as severe. The resident was also noted as experiencing shortness of breath (SOB).
A Physician's Progress Note, dated 12/16/22, indicated the resident had poor dentition, and an electrocardiogram (EKG) performed at the acute care facility was reflective of stable ischemic cardiomyopathy. The resident was at risk for sickle cell disease (SCD). The plan included an in-house cardio consult and weekly weights.
A Nursing Progress Note, dated 1/1/23, indicated that the resident was in minimum pain but refused pain relief. (A review of the active physician's orders as of 02/02/23, revealed current orders for pain medication.)
A review of the Optometry Consult form, dated 11/03/22, revealed the resident was not examined due to COVID isolation. (Copy obtained)
On 2/1/23 at 12:00 PM, Resident #30 was observed seated in a wheelchair in the hallway. He again stated he had requested pain medication and the nurse gave him Tylenol, which did not help. When he was asked his level of pain on a scale of 1-10, 10 being the most severe pain, he replied that his pain level was a 10. He touched his left lower back and added that he also had nerve pain down through his left leg. He mentioned that he previously received stronger pain medication, but he was no longer offered that. He confirmed that he had not seen anyone about his dental concerns, pain or cardiology concerns.
In an interview on 2/2/23 at 11:28 AM, Licensed Practical Nurse (LPN) A stated if a resident was in pain, the nurse should complete a pain assessment and administer pain medication. If a resident did not have pain medication ordered, the nurse should call the physician and obtain an order. She stated medication should not be given without an order. She added that when an order was received, the facility had a medication bank where nurses could obtain medication while awaiting delivery from the pharmacy. When asked about consultation orders, she stated the nurse receiving the orders should contact the necessary department related to the consult. He/she should then fax the orders, and place the referral to the appropriate binder located at the nurses' station. She added that communication for follow up was also done during change-of-shift report. When asked about Resident #30's ordered consultations, she confirmed the resident had orders for cardiology, pain and ophthalmology consults, and there was no evidence that these orders were carried out. She stated she would follow up with the unit manager.
A review of the Pain Management binder, which was kept at the nurses' station, revealed all the residents' names under pain management as of 11/16/22. Resident #30 was on the list.
A review of the Cardiology binder, which was at the nurses' station, revealed that the consults had not been updated since 2019.
In an interview on 2/2/23 at 12:07 PM, LPN B confirmed that Resident #30 had no pain medication and was not under pain management. She reviewed the orders and stated the resident was previously on Norco (narcotic pain medication), 5/325 milligrams every 6 hours as needed (PRN) for pain, and the medication was discontinued on 11/3/22 when Resident #30 was transferred to an acute care facility. She also confirmed that the orders for the cardiology, pain and ophthalmology consultations were not carried out.
In an interview with LPN C/Assistant Director of Nursing (ADON) on 2/2/23 at 12:30 PM, she stated the facility should keep a list of residents who were receiving cardiology and/or pain consultations. She confirmed that the facility failed to maintain a list of residents who were on pain management or cardiology and therefore, she could not confirm whether Resident #30 was on the case load. She further stated there were no visit notes, so most likely, the resident was not on case load for either the cardiology or pain physicians.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observations, staff and resident interviews, medical record review, and policy and procedure review, the facility failed to ensure that two (Residents #37 and #74) of a total sample of 55 res...
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Based on observations, staff and resident interviews, medical record review, and policy and procedure review, the facility failed to ensure that two (Residents #37 and #74) of a total sample of 55 residents were provided with foot care consistent with professional standards of practice, including assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists.
The findings include:
1. On 01/31/23 at 10:00 AM, Resident #37 was observed lying in bed, awake and conversant. The resident stated she had not seen a podiatrist. She pulled back her covers and both feet were observed to have significantly thickened toenails, which were elongated and curled. She stated her left great toe hurt. She was asked when she had last seen a podiatrist. She stated, I don't know, but I haven't seen one since I've been here. She was asked if staff trimmed or cleaned her toenails. She stated, No. I don't think they will, because I'm a diabetic. She was asked if she had asked staff for a podiatry appointment. She replied, Yes, I've asked more than once. I haven't heard anything.
On 02/01/23 at 8:45 AM, Resident #37 was observed in her room, lying in bed, awake, eating breakfast. She was asked if her left great toe was still painful. She stated, Yes. I haven't heard a thing about the foot doctor. Can you put a fire under them?
A medical record review for Resident #37 revealed diagnoses including type II diabetes and Cerebral Vascular Accident (CVA).
A review of her quarterly Minimum Data Set (MDS) assessment, dated 12/18/22, revealed:
Section C: (Brief Interview for Mental Status) BIMS score of 11 out of 15 possible points, indicating moderate cognitive impairment.
Section E: Behaviors: None exhibited. Rejection of care: Not exhibited
Section G: Personal hygiene: Extensive assist/1-person assist
A review of Resident #37's Physician's Orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.
A review of the comprehensive person-based Care Plan revealed:
Focus Area: 6/10/22 (revised 10/11/22) Resident has potential for complications including hypo/hyperglycemia related to diabetes mellitus.
Goal: Resident will have no complications related to diabetes through the review date.
Interventions: (10/11/22) Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long toenails.
Focus Area: 6/10/22 Resident requires assistance with Activities of Daily Living (ADL) functions.
Goal: Resident will show improvement in ADLs through next review.
Interventions: Grooming: resident depends entirely upon someone else for grooming needs.
Further review of the medical record revealed no notes/consults from a podiatrist.
2. On 02/01/23 at 9:30 AM, Resident #74 was observed in her room. Licensed Practical Nurse (LPN) D pulled back the resident's bed covers to apply lotion to her legs. Her toenails were elongated and curled. The resident stated, I wish I had some nail clippers to cut my toenails. She was asked if she was diabetic. She stated yes. She was asked if she had seen a podiatrist. She stated no. LPN D stated, We'll have to get a foot doctor for you.
A medical record review for Resident #74 revealed diagnoses including type II diabetes and Cerebral Vascular Accident (CVA).
A review of her annual MDS assessment, dated 11/14/22, revealed:
Section C: BIMS score of 11 out of 15 possible points, indicating moderate cognitive impairment.
Section E: No behaviors exhibited. Rejection of care: Not exhibited.
Section G: Personal hygiene: Extensive assistance/1-person assist.
A review of the Physician's Orders revealed that no order (current, past, or discontinued) was found for podiatry care/visit/referral.
A review of the comprehensive person-based Care Plan revealed:
Focus Area: (3/1/219) Resident is at risk for alteration in skin integrity related to diabetes mellitus.
Goal: Resident will receive appropriate services and treatments to minimize potential skin breakdown, and will implement interventions to minimize the risk of skin impairment through the next review.
Interventions: (revision 5/9/21) Dry skin well between toes and other surfaces where skin rubs together. File/trim nails. Podiatry consult as indicated/ordered.
In an interview with the Administrator on 02/02/23 at 8:40 AM, she was asked who provided podiatry services for the residents. She stated, We use a service called [name of provider]. They come to the facility. She was asked how the residents were seen by podiatry. She stated, A podiatrist comes here about every 6-8 weeks; they have struggled with getting a doctor here. Residents are added to the list to be seen. We will send over a referral so they know who needs to be seen.
She was asked if she could provide any foot care notes from podiatry for Resident #37. She stated, She was just seen yesterday.
She was asked if this resident had been seen by a podiatrist any other time since her admission date of 6/10/22. She stated, No she hadn't.
She was asked if this resident had a diagnosis of diabetes. She stated yes.
She was asked how often a diabetic resident should be seen by a podiatrist. She stated, I would say as needed, but I'm a social worker by trade, so that may be a more clinical question.
She was asked if Resident #74 been seen by a podiatrist. She stated yes, and provided podiatry notes from 8/22/22 and 11/18/21.
She was asked if these were the only times this resident had been seen by a podiatrist. She stated, Yes, that's all we have for documentation. She was asked if this resident was diabetic.
She stated, Yes she is.
In an interview with Certified Nursing Assistant (CNA) U on 2/2/23 at 11:50 AM, she was asked who cleaned and trimmed the residents' toenails. She stated, We don't do that. They have a podiatrist do that. She was asked how the podiatrist knew which residents needed their toenails trimmed. She stated, We'll tell the nurse, or the nurse will see them and the nurse adds them to a list, I guess.
In an interview with LPN E on 2/2/23 at 12:00 PM, she was asked who cleaned and trimmed the residents' toenails. She stated, The foot doctor does that. Especially if they're a diabetic, but I think they do all the toenails for all the residents. She was asked how residents were seen for foot care. She stated, I think there's a list, and the list gets sent to the foot doctor. I think they come in once a month to see residents.
In an interview with the Director of Nursing on 2/2/23 at 12:10 PM, she was asked how often podiatry services were provided for the residents. She stated, We have a company called [name of provider]that comes in; I think they come in monthly. They have a schedule, but social services also deals with that and makes the appointments. They were here yesterday and saw seven residents. She was asked
if there was a set schedule for diabetics to be seen by podiatry. She stated, I don't know how often they are seen, but if we see any needs for a foot doctor, then we can call over to the podiatry service and they will add the resident to their schedule for their next visit. She was asked who trimmed the residents' toenails. She stated, The podiatrist. She was asked how often diabetics' toenails were assessed. She stated, Nursing should be assessing them on shower days. The CNAs will let them know if there is anything that needs to be looked at, and they have weekly skin checks that the nurses do.
A review of the facility's Policy and procedure for Foot Care (revised 3/2018) revealed:
Policy Statement: Residents will receive appropriate care and treatment in order to maintain mobility and foot health.
1. Residents will be provided with foot care and treatment in accordance with professional standards of practice.
2. Overall foot care will include the care and treatment of medical conditions associated with foot complications (i.e.: diabetes, PVD (peripheral vascular disease) etc.)
3. Residents will be assisted in making transportation appointments to and from specialists as needed.
4. Trained staff may provide routine foot care (eg: toenail clipping) within professional standards of practice for residents without complicating disease processes. Residents with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, staff and resident interviews, and facility policy review, the facility did not ensure the resident environment remained as free of accident hazards as is possible for one (Resi...
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Based on observations, staff and resident interviews, and facility policy review, the facility did not ensure the resident environment remained as free of accident hazards as is possible for one (Resident #106) of a total sample of 55 residents. The facility, which is responsible for resident safety, had no protocol for verifying the safety of individual resident refrigerators and/or maintaining safe temperatures inside to ensure foodborne illness did not result from temperatures that were too warm to keep foods properly cooled.
The findings include:
On 1/30/23 at 12:15 PM, Resident #106 was observed lying in bed, dressed in day clothes. A personal refrigerator was observed in her room beside her bed. No temperature log was observed in the area. The resident was asked what she kept inside the refrigerator. She stated, Usually leftovers if I get some take out food. She was asked permission to look inside the refrigerator. She agreed. Three coffee creamers were observed, and a thermometer which read 48 degrees.
On 1/31/23 at 10:49 AM, Resident #106 was not observed in her room. Her personal refrigerator was observed. Three creamers were observed inside the refrigerator. No temperature log was observed in the area. The thermometer inside indicated the temperature was 47 degrees Fahrenheit (F). (Photographic evidence obtained).
On 2/1/23 at 11:46 AM, Resident #106 was observed lying in bed, awake. She was asked if she had any food in her personal refrigerator. She stated, No, not right now. She was asked what type of food she kept in there. She stated, Sometimes my family will bring me some fried chicken, and I put drinks and sodas in there. My family will bring me other stuff, too, and I'll put the leftovers in there. She was asked how often she kept food in her refrigerator. She stated, Oh, a couple times a week, sometimes more, sometimes less. She was asked permission to look inside the refrigerator. She agreed. Three creamers were observed, and the thermometer read 47 degrees F. (Photographic evidence obtained) No temperature log was observed in the room. The resident was asked if staff checked the temperature of her refrigerator daily or at any time. She stated, No, no one checks it.
On 2/1/23 at 4:00 PM, during an interview with the Administrator, and after requesting a facility policy for personal refrigerators kept in residents' rooms, she stated the facility did not have a policy.
On 2/2/23 at 8:39 AM, in an interview with the Administrator, she was asked at what temperature a resident's refrigerator should be kept to safely store food. She stated, We don't monitor the temps, so it's what the resident deems safe.
She was asked if temperatures were monitored by staff and recorded for residents' personal refrigerators to ensure safe food storage. She stated, No, if the resident is alert and oriented, we'll check the fridge and we educate the resident on what they should and shouldn't keep inside the fridges. The resident or their family has to be able to maintain their personal fridge and the temperature.
She was asked what if the resident is not alert and oriented. She stated, Well, we try to keep an eye on the residents and make sure they are still competent to take care of the fridge themselves.
She was asked who monitored and cleaned the refrigerators to ensure safety. She stated, Housekeeping checks them to clean them, but not to monitor the temps.
She was asked if any temperature logs were maintained by staff, resident, or families for the personal refrigerators. She stated no.
On 2/2/23 at 9:37 AM, during an interview with Resident #106 with the Administrator present, the resident was asked permission to look inside her refrigerator. She agreed. The thermometer inside read 48 degrees F. Three creamers were observed inside. The Administrator asked the resident if she kept food inside her refrigerator. The resident said yes. The Administrator asked the resident what type of food she kept inside. The resident stated, Oh, cookies, chicken, drinks, whatever my family brings in for me.
On 2/2/23 at 12:10 PM, during an interview with the Director of Nursing (DON), she was asked who monitored the temperatures and cleaned the residents' personal refrigerators. She stated, They or their families have to be able to clean them themselves. She was asked what a safe temperature for a personal refrigerator was. She stated, I suppose the same temperature as your fridge at home, but we don't monitor the temps here because it's their fridge. We actually didn't even know anyone had a personal fridge until you told us. We're not allowing personal fridges; we're going to remove them.
A review of the facility's policy for Food Brought in by Family/Visitors (revised 10/2017), revealed:
Policy statement: Food brought in by family/visitors is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of the resident.
A review of the facility's policy for Refrigerators and Freezers (revised 12/2014), revealed:
Policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.
Policy interpretation and implementation:
1. Acceptable temperature ranges are 35 degrees F to 40 degrees F and less than 0 degrees for freezers.
2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.
3. Monthly tracking sheets will include: temperature, initials, and action taken. The last column will only be completed if temperatures are not acceptable.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one resident (#35) who required blood pressure and pain medication, out of four residents reviewed for unnecessary medication, from a total sample of 55 residents.
The findings include:
A medical record review revealed that Resident #35 was admitted to the facility on [DATE] with a primary diagnosis of pneumonia. Secondary diagnoses included anxiety and pulmonary hypertension.
A review of a Physician's Order, dated 3/4/22, revealed Tramadol 50 milligrams (mg) every 6 hours for non-acute pain, Lisinopril 2.5 mg, give 2 tablets one time a day for hypertension (high blood pressure).
A review of the electronic Medication Administration Record (eMAR) for January 2023, revealed that on 1/30/23 and 1/31/23 lisinopril was not administered. The eMAR notes indicated that the drug was on order. Tramadol was not administered on the following days: 1/10/23, 1/16/23, 1/17/23, 1/19/23, 1/20/23, 1/21/23, or 1/29/23. eMAR notes indicated that the medication was on order. (Copies obtained) On 1/25/23, the resident's blood pressure was 113/47 mm Hg (millimeters of mercury) and her Lisinopril was held. An eMAR note, dated 1/25/23, read, Medication was held due to low BP of 113/47. There was no indication that the physician was contacted. (Copies obtained)
A review of the Care Plan dated 11/13/22, revealed that the resident had a potential for Altered Cardiovascular Status related to hypertension. Interventions included observation for side effects such as orthostatic hypotension. The Care Plan further indicated that the resident had a potential for generalized pain related to immobility.
A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/11/22, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment. The assessment also indicated that the resident required limited assistance with bed mobility; extensive assistance for transfers and toilet use; supervision for eating; and was receiving scheduled pain medication.
In an interview on 2/2/23 at 11:28 AM, Licensed Practical Nurse (LPN) A stated if a resident was in pain, nurses should complete a pain assessment and then administer pain medication. She added that if medication was not available in the medication cart, the facility had a medication bank where nurses could obtain medication while awaiting delivery from the pharmacy.
In an interview on 2/2/23 at 12:30 PM, LPN C/Assistant Director of Nursing (ADON), was asked about the missed medication doses. She stated nurses had access to the medication bank, and they should check there to see whether the medication was available. She added that nurses should re-order medications when there were at least three days worth of medications left. Additionally, they should also contact the pharmacy if medication was not available, because medications were delivered to the facility twice daily and there was no reason the residents should miss medications for two consecutive days. When she was asked to explain the facility's protocol for administering blood pressure medication, she stated her expectation was that nurses should obtain the resident's blood pressure before administering any blood pressure medication (with or without parameters), hold the medication if the blood pressure was below 110/50 millimeters of mercury (mm Hg), and notify the physician. When asked about Resident #35, LPN C confirmed that that blood pressure was low, the medication should have been held, and the physician should have been notified.
A review of the facility's policy and procedure for Pharmacy Services Overview (revised in April 2019), revealed: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medication and biologicals and the services of a licensed consultant pharmacist.
Policy interpretation and implementation:
3. Pharmacy services are available to residents 24 hours a day, seven days a week.
4. Residents have sufficient supply of their prescribed medication and receive medications (routine, emergency or as needed) in a timely manner.
5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.
A review of the facility's policy and procedure titled Administering Medication (revised April 2020), revealed:
Policy interpretation and implementation:
5) If a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potentially adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the attending physician or the facility's Medical Director to discuss the concerns.
10) The following information is checked/verified for each resident prior to administering medication:
a. Allergies to medications; and
b. Vital signs, if necessary.
According to Mayoclinic. org 2023 (https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-causes/syc-20355465 - accessed on 2/3/23 at 4:00 PM), Low blood pressure is generally considered a blood pressure reading lower than 90 millimeters of mercury (mm Hg) for the top number (systolic) or 60 mm Hg for the bottom number (diastolic). Extreme low blood pressure can lead to a condition known as shock.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, staff interview, and facility policy review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedul...
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Based on observations, staff interview, and facility policy review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse.
The findings include:
On 2/2/23 at 9:20 AM, Licensed Practical Nurse (LPN) N was observed retrieving a Clonidine 0.1 mg (milligram) tablet from the Emergency Medication Supply Machine (Medbank). The Medbank was observed located in the hallway of the Beachside Unit. The Medbank was observed to be self-standing in the common area hallway, not enclosed or within a medication room. No secondary locking system was observed. The nurse was asked if narcotic medications were also contained in the machine. She stated, Yes, all the back-up medications are kept there, including narcotics. (Photographic evidence obtained) A list of all current medications kept in the Medbank was requested, as well as the facility's policy for storage of controlled narcotic medications.
A review of the policy for Storage of Medications (last revision 4/2019), revealed: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation:
13. Schedule II-IV controlled medications are stored in separately locked, permanently affixed compartments. Security access to controlled medications is separate from access to non-controlled medications.
A review of the inventory for all on-hand medications contained in Medbank storage, revealed that the following Schedule II-IV medications were housed inside the Medbank, and were not in separately locked, permanently affixed compartments:
Xanax 0.25 mg (milligrams) (15 tablets)
APAP/Codeine 300-30 mg (10 tablets)
Klonopin 0.5 mg (7 tablets)
Valium 5.0 mg (10 tablets)
Fentanyl Patch 25 mcg (micrograms) (2 patches)
Fentanyl Patch 50 mcg (2 patches)
Hydrocodone/APAP 5/325 mg (12 tablets)
Hydrocodone/APAP 10/325 mg (11 tablets)
Dilaudid 2 mg (10 tablets)
Ativan 0.5 mg (15 tablets)
Methadone 5 mg (10 tablets)
Morphine Sulfate IR 15 mg (20 tablets)
Morphine Sulfate ER 15 mg (20 tablets)
Morphine Sulfate 10 mg/0.5 ml (milliliters) (10 vials)
Oxycodone/APAP 10/325 mg (18 tablets)
Oxycodone/APAP 5/325 mg (19 tablets)
Oxycodone/APAP 7.5/325 mg (14 tablets)
Oxycodone ER 10 mg (10 tablets)
Oxycodone 5.0 mg (15 tablets)
Ultram 50 mg (14 tablets)
Temazepam 7.5 mg (7 capsules)
Ambien 5 mg (10 tablets)
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy and procedure review, the facility failed to ensure that resident meals were serv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and policy and procedure review, the facility failed to ensure that resident meals were served at a safe and appetizing temperature, for five (Residents #478, #467, #104, #31, and #184) out of 55 sampled residents. Failure to provide palatable, attractive, and appetizing food in accordance with professional standards for food service, can decrease the amount of food all residents eat and drink. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline.
The findings include:
During a facility tour on 1/30/23 at 12:50 PM, Resident #468, who had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition), reported, The food is always cold. The food sits in the hallway for 30 minutes before being served.
On 2/1/23 at 2:00 PM, Resident #467, with a BIMS score of 10 out of a possible 15 points (moderate cogntive impairment) reported, Today the food was cold all the way through. When asked if she requested that her tray be warmed, she replied no, she had never requested that staff warm her food. When asked if she requested an alternate meal, she replied No, I didn't feel like eating after that.
On 2/2/23 at 11:50 AM, a food cart holding lunch trays for the 100 hallways was observed in front of the nursing station. Twenty-nine minutes later at 12:19 PM, Certified Nursing Assistant (CNA) T, assigned to rooms 114-122, arrived on the nursing unit and began passing lunch trays from the food cart in front of the nursing station to her residents on the 100 hallways.
On 2/2/23 at 12:32 PM, CNA T was asked what time the lunch meals were delivered to the 100 hallways. She replied, sometime between 12:00 PM and 12:30 PM. When asked if she had received any complaints from the residents in rooms 114-122 related to cold food, she replied no. She stated, If a resident complained of cold food I would warm the food, but that has never happened. If a resident did not want a meal they received, they could request an alternate meal.
On 2/2/23 at 1:20 PM, Dietary Director V confirmed that the lunch meal cart for the Beachwalk Nursing Unit (rooms 114-122) was scheduled to arrive from the kitchen between 12:15 PM and 12:40 PM. She confirmed that the tray line finished early, so the Beachwalk Nursing Unit received their lunch food cart earlier today, between 11:30 AM and 11:45 AM.
A review of Resident Council minutes, dated 1/16/2023, revealed food trays had not been not passed timely upon arrival at the nursing units.
A review of the In-Service Education Roster, dated 1/18/2023, revealed the Topic: Resident Council, 1. Please pass trays timely.
A review of the Resident Council minutes dated 11/21/2022, revealed trays were not passed timely, so an in-service training was provided by Dietary Director V.
A review of the Food Committee Form dated 11/21/2022, revealed the coffee was served cold.
A review of the Resident Council minutes dated 11/7/2022, revealed in the discussion of Old Business: Would like trays delivered timely. Meeting facilitated by [Dietary Director V]. Ad hoc meeting on tray delivery timeliness - staff in-serviced.
A review of the Food Committee Form dated 11/7/2022, revealed eggs were served cold, but the rest of the food was hot.
A review of the Resident Council minutes dated 10/3/2022, revealed in the discussion of New Business: Resident stated food carts get to the unit, but are not passed out right away and visual cues are not provided. Resolutions/Need for Assistance - New Business revealed: Would like food trays passed promptly and appropriate notifications given. Meeting facilitated by [Dietary Director V]. Team members in-serviced.
A review of the facility's policy and procedure for Food Preparation and Handling, dated: 1/15/2021, revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the current Federal and State Food Codes and HACCP guidelines.
On 01/31/2023 at 12:57 PM, Resident #104 reported the food was cold. Resident #104 was admitted on [DATE]. His quarterly Minimum Data Set (MDS) assessment, dated 01/11/2023, reported a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition.
On 01/31/2023 at 10:20 AM, Resident #31 reported, The food is often cold because they leave the doors to the food cart open and don't use hot plates. The resident's medical record was reviewed and noted an MDS assessment, dated 12/10/2022, with a BIMS score of 15 out of a possible 15 points.
On 02/02/2023 at 1:16 PM, an interview was conducted with Resident #184. He reported that the food was not hot. He stated, The food is usually warm to cool but not hot. It sits on the cart too long. Resident #184 was admitted on [DATE]. His quarterly MDS assessment, dated 11/10/2022, reported a BIMS score of 12 out of a possible 15 points, indicating mild to moderate cognitive impairment.
An observation of the kitchen was conducted on 02/01/2023. At 11:28 AM, an observation of the tray line was conducted and food temperatures were obtained by the cook. The temperatures were as follows: Enchilada: 135 °F, pureed enchilada: 135°F. The Regional Certified Dietary Manager (CDM) confirmed that 135°F was adequate, even though the tray line had just started service. At 12:50 PM on 02/01/2023, a full food cart was observed with no plastic bottoms for plates to match the plastic doomed tops. The CDM confirmed they had run out of plastic bottoms at this time. A test tray of regular diet was requested to be put on the last lunch cart to be served. The test tray was removed from the food delivery cart after residents' trays from same cart were served. The food was taste tested and it was noted with a luke warm enchilada with warm rice and warm corn. The foods were not hot. The test tray was noted as having no plastic bottom to match the plastic domed top to help keep the food warm.
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Jan 2023
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0578
(Tag F0578)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedures, and interviews with staff, the facility failed to a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedures, and interviews with staff, the facility failed to act in accordance with a resident's Advance Directives as per her Do Not Resuscitate (DNR) status (the desire not to be resuscitated in the event her heart or breathing stopped) after finding her unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's DNR status, prolonged her dying process, and deprived her of the right to experience a natural death.
Immediate Jeopardy at a scope of J (isolated) was identified at 12:00 p.m. on [DATE].
On [DATE] at 6:00 p.m., the Immediate Jeopardy began.
On [DATE] at 6:45 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE].
The facility remained out of compliance, and the scope and severity were reduced to a D.
The findings include:
Cross reference F678
A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] (expired). She had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease that damages the lungs in ways that make it hard to breathe).
A review of the physician's order dated [DATE], revealed that the resident had executed Advanced Directives including a Do Not Resuscitate Order (DNRO). The State of Florida DO NOT RESUSCITATE ORDER was signed on [DATE]. (Copy obtained)
The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview for Mental Status score of 1 out of a possible 15 points, indicating severe cognitive impairment. She also required extensive assistance for bed mobility and toilet use, total assistance for transfers, and supervision for eating.
A review of the resident's Care Plan, dated [DATE], revealed that the resident/representative had executed a DNRO (do not resuscitate order), indicating CPR measures were not to be performed in the event of respiratory/cardiac arrest.
A Health Status note authored by Licensed Practical Nurse (LPN) B and dated [DATE] at 10:52 p.m., read, During medication pass, CNA (Certified Nursing Assistant) notified nurse supervisor that resident seemed to not be breathing. Nurse supervisor checked resident chart and seen [sic] no visible DNR paperwork. Cardiopulmonary Resuscitation (CPR) was initiated. 911 was called. Upon arrival of the Emergency Medical Technicians (EMTs), CPR was taken over. Nurse on standby in case needed. During resuscitation by EMT, DNR paperwork was noted in the middle of the chart. All activities on the resident was [sic] ceased. Resident was cleaned up and awaiting arrival of pick up from morgue. Resident family was contacted, and physician contacted.
On [DATE] at 11:11 a.m., the Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) were interviewed jointly regarding the incident on [DATE]. The Administrator stated she was contacted by LPN A on [DATE] at 6:59 p.m., notifying her that Resident #1 had expired. Emergency Medical Services (EMS) had been contacted and pronounced the resident's death in the facility. She stated LPN A had not mentioned that Resident #1 had a DNRO, but CPR had been provided. The DON stated on [DATE], as she was reviewing Resident #1's chart, she noted the progress note indicating that the resident had a DNRO, but CPR had been provided. She immediately contacted the Administrator, and an investigation was initiated. Per the investigation, it was identified that on [DATE] at approximately 6:00 p.m., CNA C was picking up dinner trays when she noticed that Resident #1 was unresponsive. CNA C called the supervisor because the assigned nurse was in another resident's room. The supervisor initiated CPR, and a Code Blue (cardiac/respiratory arrest) was called, as well as EMS. Upon the arrival of EMS, it was noted that Resident #1 had a DNRO and CPR was stopped. They each stated that their expectation was that staff check the paper chart, the electronic medical record (EMR), and contact the DON or the Administrator per facility policy. They stated LPN A was suspended pending investigation, the physician and family were contacted, and facility-wide education was provided.
In an interview with CNA C on [DATE] at 12:00 p.m., she stated on [DATE], she had been assigned to Resident #1 on the 3-11 (evening) shift. At 5:00 p.m., she went to the resident's room and delivered her dinner tray. She set the tray up for the resident to eat and no concerns were identified. At 6:00 p.m., when she went back to pick up the tray, she found the resident slumped to the right side and unresponsive. She shouted for help, but no one came. She then stepped outside of the resident's room and saw the evening supervisor (LPN A). She summoned him for help. Upon entering the room, Supervisor/LPN A assessed the resident, then left the room. When he returned, he was accompanied by other nurses and CPR was initiated. After approximately 10 minutes, EMS arrived, and as the supervisor was gathering the transfer paperwork, he found the DNRO and gave it to EMS. CPR was stopped at approximately 6:15 p.m. When asked if LPN A was the resident's assigned nurse, CNA C replied no. She stated the assigned nurse was providing care to another resident and came to Resident #1's room after CPR had already been initiated.
In an interview with Supervisor/LPN A on [DATE] at 12:36 p.m., he stated he was notified by CNA C on [DATE] at 6:00 p.m., that Resident #1 was not looking well. Upon entering the resident's room, Supervisor/LPN A found Resident #1 unresponsive and slumped to her right side on the bed. Upon assessment, she had no pulse or respirations. Supervisor/LPN A left the room and went to the nurses' station to check the resident's code status and did not find the DNRO form in the chart, so he instructed the assigned nurse (LPN B) to call a code (per facility protocol) and then call EMS. He went back to the resident's room and initiated CPR. EMS arrived at 6:10 p.m. and took over the CPR. At approximately 6:15 p.m., as he was gathering the paperwork for the resident's transfer to the hospital, he found the DNRO form toward the middle of the resident's medical record. He took the document to the EMS chief and CPR was stopped. He notified the resident's family of the resident's status. The physician was called, did not pick up the phone, and therefore a message was left. Supervisor/LPN A added that he forgot to notify the facility's Administration. When he was asked about the facility's policy and procedure for CPR, he stated he needed to check the code status in the EMR and the paper chart. He mentioned that he was not the assigned nurse at the time, and therefore did not think about checking the EMR. When asked if he had received education prior to the incident regarding the facility's policy for CPR, he stated he could not remember.
In a telephone interview with the Medical Director (also Resident #1's physician) on [DATE] at 2:30 p.m., he stated he was notified by the DON and the Administrator about the incident involving Resident #1. He confirmed that the resident had comorbidities and Advanced Directives on file upon her admission to the facility. He stated it was unfortunate that the incident occurred despite the facility's having spelled-out pathways and policies for CPR and code status verification. He added that an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE], and he agreed with the facility's plan of correction to ensure that all staff were re-educated about code status verification and Advanced Directives.
In an interview with LPN B (Agency nurse) on [DATE] at 2:44 p.m., she stated she was assigned to Resident #1 on the [DATE] evening shift, and when she started the shift, the resident had no concerns. At approximately 6:00 p.m., as she was coming out of another resident's room, she saw the nursing supervisor at the nursing station frantically going through Resident #1's paper chart. Supervisor/LPN A told her that Resident #1 was unresponsive, and he instructed her to call a Code Blue and EMS. Shortly after calling the Code Blue, LPN B proceeded to Resident#1's room and found LPN A and Registered Nurse (RN) D performing CPR. LPN B initiated the use of oxygen and suctioning the resident, as she had some secretions. At approximately 6:15 p.m., EMS arrived, and she stayed at the bedside in case she was needed. The other nurses left the room, and the Supervisor/LPN A went to gather the transfer paperwork. Supervisor/LPN A returned to the resident's room and provided the EMS chief the DNRO form. At this time, Resident #1 was already intubated. CPR was stopped, the resident was extubated, and was pronounced dead by EMS at approximately 6:35 p.m. When asked if she verified the EMR for the resident's code status, LPN B stated she did not remember to check at the time. She said, I trusted the supervisor, because he has been here for a while and was more familiar with facility protocol. She was then asked whether she had received any training about the facility's policies and procedures for CPR when she started working in the facility. She replied, No, however, I was provided with in-service training after the incident and also participated in a mock code.
A review of the facility's policy and procedure titled Advance Directives (revised [DATE]), revealed the following policy statement: Advanced Directives will be respected in accordance with the state law and the facility policy. The policy interpretation and implementation further indicated that upon admission, the resident would be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advanced Directive if he or she chose to do so. Information about whether or not the resident had executed an Advanced Directive should be displayed prominently in the resident's medical record. The plan of care would be consistent with his or her documented treatment preferences and/or Advanced Directives.
A review of the facility's policy and procedure titled Code Status Verification Process (revised on [DATE]), revealed:
Code Status: Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident's heart stop beating and/or should the resident stop breathing.
DO NOT RESUSCITATE (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally if the heart stopped beating and/or they stopped breathing.
Verification of code status -
A resident's code status must be verified by the physician's order under the orders tab in [electronic medical record]. If the resident is a DNR, the yellow DNR document should be visualized in the document tab in [electronic medical record]. The resident's code status will appear on the resident profile with the picture and in the orders tab in [electronic medical record].
Document storage -
DNRs are kept electronically (in [electronic medical record]) and on paper (hard chart or secured binder).
DNRs must be scanned by a designated facility representative into the documents tab and appropriately labeled.
DNR Paper copies (storage) -
Facilities with hard charts: Yellow DNR form is placed in front of chart with a copy of the [electronic medical record] order.
Facilities with paperless charts: Yellow DNR form is placed in the binder which is secured (non-removable, i.e. binder similar to MSDS binder) at nurses' station. Yellow DNR forms are filed alphabetically by last name.
DNR form must be filed immediately in Hard Chart or Binder.
Rescinded DNR Yellow Forms must be removed immediately and marked as revoked with the date and two staff signatures (nurses, social services, APRN (advanced practice registered nurse), physician etc.).
Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows:
On [DATE], a review of Resident #1's medical records was completed by the Director of Nursing.
An Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held on [DATE], to review the results of the facility-wide quality reviews that were completed. The following team members were in attendance: Executive Director, Regional Nurse Consultant, Director of Nursing, Medical Director, Activities Director, and Social Services Assistant. The Ad Hoc QAPI committee approved the recommendations. The Ad Hoc meeting included a Performance Improvement Plan developed and initiated based on a Root Cause Analysis. As part of the quality review, the Advanced Directives discussion document was completed for current residents. Based on the wishes of the resident/resident's responsible party, the below measures were completed:
o
Florida Yellow DNRO form for those who wish CPR to be withheld.
o
Order for Full Code obtained for those residents who wish to receive CPR.
o
Electronic Medical Record (EHR) audited to ensure order accuracy of each current resident's code status.
o
Care Plan audit for current residents completed to ensure accuracy of individualized code status wishes.
As of [DATE], an Advanced Directives quality review for current residents was completed by the Regional Nurse Consultant, the Director of Nursing, and the Social Services Assistant. There were 203 residents at the time the audit was conducted, and there were no other residents identified as having been affected by the deficient practice.
LPN A was suspended as of [DATE] pending investigation.
The Director of Nursing and the Administrator were educated by the Regional Nurse Consultant on [DATE] regarding Advanced Directives Consents, Florida yellow DNRO forms, and two-nurse validation of code status. A review of the education sign-in sheet revealed the signatures for the Director of Nursing and the Administrator.
Supervisor/LPN A received 1:1 education on [DATE] from the Director of Nursing regarding Advanced Directives consents, Florida yellow DNRO forms, and two-nurse validation of code status.
All staff present during the code on [DATE] received 1:1 education on [DATE] from the Director of Nursing on Advanced Directive consents, Florida yellow DNRO forms, and two-nurse validation of code status. There were four nurses present and all had signed as having received the education.
On [DATE], current licensed nursing staff received education from the Director of Nursing and the Unit Manager regarding the procedure for obtaining Advanced Directives consents and Florida yellow DNRO forms, as well as education about a two-nurse validation of code status. The education was completed on [DATE] for 39 of 39 current licensed nurses.
New hire education was updated on [DATE] by the facility's Staff Educator. A review of the new hire package revealed the education for Advanced Directives, two-nurse code status verification, and CPR. There were no newly hired staff since the incident occurred.
As of [DATE], there were 76 residents who had Advanced Directives, including a DNRO, who were at risk. The facility made a yellow DNRO folder, and copies of the yellow DNRO forms were alphabetically organized in the folder for easier access. This was added to the electronic medical record and paper medical chart process already in place. The unit manager would ensure that the folder is kept current.
On [DATE], the Advanced Directives discussion form was implemented, and a quality review was completed for current residents to ensure that their code status was honored. Orders were reviewed to ensure accuracy and presence in the electronic medical record. Florida yellow DNRO forms (if applicable) were checked to ensure they were present in the medical record, and resident's care plans were reviewed to ensure they were current and accurate.
In an interview with CNA C on [DATE] at 12:00 p.m., she stated after the incident the facility had conducted multiple mock code drills and she had received in-service training on Advanced Directives and the facility's expectations for verifying a resident's code status and CPR.
In a [DATE] interview with LPN B at 2:44 p.m., she stated after the incident, she received in-service training on Advanced Directives and the facility's expectations for verifying a resident's code status and CPR, and she participated in a mock code. She added that the facility had created a new DNRO binder.
In a [DATE] interview with RN D at 2:26 p.m., he stated he had received in-service training about Advanced Directives and the facility's expectations for verifying a resident's code status and CPR in addition to participating in a mock code drill. He stated he understood that the resident's code status had to be checked by two nurses in both the electronic and paper medical record.
In a [DATE] interview with the facility's scheduler (also a CNA) at 4:46 p.m., she stated she was required by the facility to maintain a current CPR card however, nursing was to initiate CPR when necessary. She knew to look in the resident's paper chart, electronic medical record and now the new DNRO binder to verify a resident's code status. She added that she had participated in a mock code drill.
In a [DATE] interview with the Assistant Director of Nursing at 4:50 p.m., she stated she had been assisting with the mock code drills and staff education since the incident. After every mock code drill there was a debriefing moment, and all participants were provided with feedback. Mock code drills were conducted on every shift and no further concerns had been identified.
In a [DATE] interview with CNA E at 5:08 p.m., she stated she had received education about Advanced Directives and the facility's expectations for verifying a resident's code status and CPR since the incident. She had also participated in a mock code drill.
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CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports and staff interviews, the facility staff failed to withhold cardiopulmonary resuscitation (CPR) per the resident's Do Not Resuscitate Order (DNRO) and Advanced Directives, when she was discovered unresponsive and without a pulse or respirations. CPR was initiated by facility staff, and Emergency Medical Services (EMS) was called. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's DNRO status (the desire for no resuscitation in the event of respiratory or cardiac arrest), prolonged her dying process, and deprived her of the right to experience a natural death.
Immediate Jeopardy at a scope of J (isolated) was identified at 12:00 p.m. on [DATE].
On [DATE] at 6:00 p.m. the Immediate Jeopardy began.
On [DATE] at 6:45 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective [DATE].
The facility remained out of compliance, and the scope and severity were reduced to a D.
The findings include:
Cross reference F578
A medical record review revealed that Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] (expired). She had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease that damages the lungs in ways that make it hard to breathe).
A review of the physician's order dated [DATE], revealed that the resident had executed Advanced Directives including a Do Not Resuscitate Order (DNRO). The State of Florida DO NOT RESUSCITATE ORDER was signed on [DATE]. (Copy obtained)
The Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview for Mental Status score of 1 out of a possible 15 points, indicating severe cognitive impairment. She also required extensive assistance for bed mobility and toilet use, total assistance for transfers, and supervision for eating.
A review of the resident's Care Plan, dated [DATE], revealed that the resident/representative had executed a DNRO (do not resuscitate order), indicating CPR measures were not to be performed in the event of respiratory/cardiac arrest.
A Health Status note authored by Licensed Practical Nurse (LPN) B and dated [DATE] at 10:52 p.m., read, During medication pass, CNA (Certified Nursing Assistant) notified nurse supervisor that resident seemed to not be breathing. Nurse supervisor checked resident chart and seen [sic] no visible DNR paperwork. Cardiopulmonary Resuscitation (CPR) was initiated. 911 was called. Upon arrival of the Emergency Medical Technicians (EMTs), CPR was taken over. Nurse on standby in case needed. During resuscitation by EMT, DNR paperwork was noted in the middle of the chart. All activities on the resident was [sic] ceased. Resident was cleaned up and awaiting arrival of pick up from morgue. Resident family was contacted, and physician contacted.
On [DATE] at 11:11 a.m., the Administrator, Director of Nursing (DON), and Regional Nurse Consultant (RNC) were interviewed jointly regarding the incident on [DATE]. The Administrator stated she was contacted by LPN A on [DATE] at 6:59 p.m., notifying her that Resident #1 had expired. Emergency Medical Services (EMS) had been contacted and pronounced the resident's death in the facility. She stated LPN A had not mentioned that Resident #1 had a DNRO, but CPR had been provided. The DON stated on [DATE], as she was reviewing Resident #1's chart, she noted the progress note indicating that the resident had a DNRO, but CPR had been provided. She immediately contacted the Administrator, and an investigation was initiated. Per the investigation, it was identified that on [DATE] at approximately 6:00 p.m., CNA C was picking up dinner trays when she noticed that Resident #1 was unresponsive. CNA C called the supervisor because the assigned nurse was in another resident's room. The supervisor initiated CPR, and a Code Blue (cardiac/respiratory arrest) was called, as well as EMS. Upon the arrival of EMS, it was noted that Resident #1 had a DNRO and CPR was stopped. They each stated that their expectation was that staff check the paper chart, the electronic medical record (EMR), and contact the DON or the Administrator per facility policy. They stated LPN A was suspended pending investigation, the physician and family were contacted, and facility-wide education was provided.
In an interview with CNA C on [DATE] at 12:00 p.m., she stated on [DATE], she had been assigned to Resident #1 on the 3-11 (evening) shift. At 5:00 p.m., she went to the resident's room and delivered her dinner tray. She set the tray up for the resident to eat and no concerns were identified. At 6:00 p.m., when she went back to pick up the tray, she found the resident slumped to the right side and unresponsive. She shouted for help, but no one came. She then stepped outside of the resident's room and saw the evening supervisor (LPN A). She summoned him for help. Upon entering the room, Supervisor/LPN A assessed the resident, then left the room. When he returned, he was accompanied by other nurses and CPR was initiated. After approximately 10 minutes, EMS arrived, and as the supervisor was gathering the transfer paperwork, he found the DNRO and gave it to EMS. CPR was stopped at approximately 6:15 p.m. When asked if LPN A was the resident's assigned nurse, CNA C replied no. She stated the assigned nurse was providing care to another resident and came to Resident #1's room after CPR had already been initiated.
In an interview with Supervisor/LPN A on [DATE] at 12:36 p.m., he stated he was notified by CNA C on [DATE] at 6:00 p.m., that Resident #1 was not looking well. Upon entering the resident's room, Supervisor/LPN A found Resident #1 unresponsive and slumped to her right side on the bed. Upon assessment, she had no pulse or respirations. Supervisor/LPN A left the room and went to the nurses' station to check the resident's code status and did not find the DNRO form in the chart, so he instructed the assigned nurse (LPN B) to call a code (per facility protocol) and then call EMS. He went back to the resident's room and initiated CPR. EMS arrived at 6:10 p.m. and took over the CPR. At approximately 6:15 p.m., as he was gathering the paperwork for the resident's transfer to the hospital, he found the DNRO form toward the middle of the resident's medical record. He took the document to the EMS chief and CPR was stopped. He notified the resident's family of the resident's status. The physician was called, did not pick up the phone, and therefore a message was left. Supervisor/LPN A added that he forgot to notify the facility's Administration. When he was asked about the facility's policy and procedure for CPR, he stated he needed to check the code status in the EMR and the paper chart. He mentioned that he was not the assigned nurse at the time, and therefore did not think about checking the EMR. When asked if he had received education prior to the incident regarding the facility's policy for CPR, he stated he could not remember.
In a telephone interview with the Medical Director (also Resident #1's physician) on [DATE] at 2:30 p.m., he stated he was notified by the DON and the Administrator about the incident involving Resident #1. He confirmed that the resident had comorbidities and Advanced Directives on file upon her admission to the facility. He stated it was unfortunate that the incident occurred despite the facility's having spelled-out pathways and policies for CPR and code status verification. He added that an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE], and he agreed with the facility's plan of correction to ensure that all staff were re-educated about code status verification and Advanced Directives.
In an interview with LPN B (Agency nurse) on [DATE] at 2:44 p.m., she stated she was assigned to Resident #1 on the [DATE] evening shift, and when she started the shift, the resident had no concerns. At approximately 6:00 p.m., as she was coming out of another resident's room, she saw the nursing supervisor at the nursing station frantically going through Resident #1's paper chart. Supervisor/LPN A told her that Resident #1 was unresponsive, and he instructed her to call a Code Blue and EMS. Shortly after calling the Code Blue, LPN B proceeded to Resident#1's room and found LPN A and Registered Nurse (RN) D performing CPR. LPN B initiated the use of oxygen and suctioning the resident, as she had some secretions. At approximately 6:15 p.m., EMS arrived, and she stayed at the bedside in case she was needed. The other nurses left the room, and the Supervisor/LPN A went to gather the transfer paperwork. Supervisor/LPN A returned to the resident's room and provided the EMS chief the DNRO form. At this time, Resident #1 was already intubated. CPR was stopped, the resident was extubated, and was pronounced dead by EMS at approximately 6:35 p.m. When asked if she verified the EMR for the resident's code status, LPN B stated she did not remember to check at the time. She said, I trusted the supervisor, because he has been here for a while and was more familiar with facility protocol. She was then asked whether she had received any training about the facility's policies and procedures for CPR when she started working in the facility. She replied, No, however, I was provided with in-service training after the incident and also participated in a mock code.
In an interview with Registered Nurse (RN) D on [DATE] at 2:26 p.m., he stated he had worked in the facility for about two years. He stated on [DATE], he responded to a Code Blue. Resident #1 was observed slumped over on her right side, was unresponsive, had vomited and appeared blue. The nurse supervisor (LPN A) initiated CPR while RN D assisted with suctioning. After five minutes, he switched with the supervisor and did compressions. EMS arrived about 15 minutes later and took over CPR. When asked about CPR training prior to the incident, he stated he was hired during the COVID-19 pandemic, and there were very few in-service trainings provided. He stated he couldn't recall receiving any training on the facility's CPR or Advanced Directives policy training. He added that after the incident, he received training on code status verification, Advanced Directives, and he participated in a mock code drill. He stated code status should be checked in the electronic medical record (EMR) and the paper chart.
A review of the facility's policy titled Cardiopulmonary Resuscitation (revised 11/2022), revealed: If an individual (resident, visitor, member) is found unresponsive with no pulse and not breathing, a licensed staff member who is certified in CPR/BLS (cardiopulmonary resuscitation/basic life support) shall initiate CPR immediately unless, its is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exists for that individual. Instructions were as follows:
-If an individual is found unresponsive and sudden cardiac arrest is likely . verify or instruct a staff member to verify the DNR or code status of the individual.
A review of the facility's policy and procedure titled Code Status Verification Process (revised on [DATE]), revealed:
Code Status: Obtained upon admission and reviewed at least quarterly and/or upon resident/representative's request. Identifies resident's wishes for medical intervention should the resident's heart stop beating and/or should the resident stop breathing.
DO NOT RESUSCITATE (DNR): A DNR code status would indicate that the person would not want CPR performed and would be allowed to die naturally if the heart stopped beating and/or they stopped breathing.
Verification of code status -
A resident's code status must be verified by the physician's order under the orders tab in [electronic medical record]. If the resident is a DNR, the yellow DNR document should be visualized in the document tab in [electronic medical record]. The resident's code status will appear on the resident profile with the picture and in the orders tab in [electronic medical record].
Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows:
On [DATE], a review of Resident #1's medical records was completed by the Director of Nursing.
An Ad Hoc Quality Assurance Performance Improvement (QAPI) committee meeting was held on [DATE], to review the results of the facility-wide quality reviews that were completed. The following team members were in attendance: Executive Director, Regional Nurse Consultant, Director of Nursing, Medical Director, Activities Director, and Social Services Assistant. The Ad Hoc QAPI committee approved the recommendations. The Ad Hoc meeting included a Performance Improvement Plan developed and initiated based on a Root Cause Analysis. As part of the quality review, the Advanced Directives discussion document was completed for current residents. Based on the wishes of the resident/resident's responsible party, the below measures were completed:
o
Florida Yellow DNRO form for those who wish CPR to be withheld.
o
Order for Full Code obtained for those residents who wish to receive CPR.
o
Electronic Medical Record (EHR) audited to ensure order accuracy of each current resident's code status.
o
Care Plan audit for current residents completed to ensure accuracy of individualized code status wishes.
LPN A was suspended as of [DATE] pending investigation.
The Director of Nursing and the Administrator were educated by the Regional Nurse Consultant on [DATE] regarding two-nurse validation of code status. A review of the education sign-in sheet, revealed the signatures for the Director of Nursing and the Administrator.
Supervisor/LPN A, received 1:1 education on [DATE] from the Director of Nursing regarding two-nurse validation of code status.
All staff present during the code on [DATE] received 1:1 education on [DATE] from the Director of Nursing on two-nurse validation of code status. There were four nurses present and all had signed as having received the education.
On [DATE], current licensed nursing staff received education from the Director of Nursing and the Unit Manager regarding the procedure for a two-nurse validation of code status. The education was completed on [DATE] for 39/39 current licensed nurses.
New hire education was updated on [DATE] by the facility's Staff Educator. A review of the new hire package revealed the education for two-nurse code status verification and CPR. There were no newly hired staff since the incident occurred.
On [DATE], a mock code drill was conducted on all shifts, then on various shifts/various days to include the weekends, mock code drills were and will be conducted until all staff have participated at least once. As of [DATE], 86 nurses and CNAs had signed as having participated in at least one drill. A review of the facility employee roster revealed that as of [DATE], the facility had a total of 156 CNAs and nurses. Orders were reviewed to ensure accuracy and presence in the electronic medical record. Florida yellow DNRO forms (if applicable) were checked to ensure they were present in the medical record, and resident's care plans were reviewed to ensure they were current and accurate.
In an interview with CNA C on [DATE] at 12:00 p.m., she stated after the incident the facility had conducted multiple mock code drills and she had received in-service training on the facility's expectations for verifying a resident's code status and CPR.
In a [DATE] interview with LPN B at 2:44 p.m., she stated after the incident, she received in-service training on the facility's expectations for verifying a resident's code status and CPR, and she participated in a mock code.
In a [DATE] interview with RN D at 2:26 p.m., he stated he had received in-service training about the facility's expectations for verifying a resident's code status and CPR in addition to participating in a mock code drill. He stated he understood that the resident's code status had to be checked by two nurses in both the electronic and paper medical record.
In a [DATE] interview with the facility's scheduler (also a CNA) at 4:46 p.m., she stated she was required by the facility to maintain a current CPR card, however, nursing was to initiate CPR when necessary. She knew to look in the resident's paper chart, electronic medical record and now the new DNRO binder to verify a resident's code status. She added that she had participated in a mock code drill.
In a [DATE] interview with the Assistant Director of Nursing at 4:50 p.m., she stated she had been assisting with the mock code drills and staff education since the incident. After every mock code drill there was a debriefing moment and all participants were provided with feedback. Mock code drills were conducted on every shift and no further concerns had been identified.
In a [DATE] interview with CNA E at 5:08 p.m., she stated she had received education about the facility's expectations for verifying a resident's code status and CPR since the incident. She had also participated in a mock code drill.
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Jun 2021
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to maintain a clean living environment for one (Resident #251) of five resid...
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Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to maintain a clean living environment for one (Resident #251) of five residents receiving enteral feedings through a gastrostomy tube (g-tube), from a total of 54 sampled residents. Food product was splattered on the wall adjacent to the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand beside the resident's bed. Failure to provide a clean living environment can present the potential for infection and illness for the residents.
The findings include:
Resident #251 was observed on 06/14/2021 at 12:35 PM lying in bed with her eyes closed. She did not respond to requests to enter the room. An enteral feeding pump was observed next to her bed. The pump was not on. Enteral feeding product was splattered on the wall beside the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand beside the bed. (Photographic evidence obtained)
A review of Resident #251's clinical record revealed an active physician's order, which read: Enteral Feed. In the evening for feeding Glucerna 1.5 @65ml/hr (milliliters/hour) until 1000 ml infused. Start date: 04/14/2021.
A review of the resident's care plan, dated 06/10/2021, revealed: [Resident #251] has feeding tube. At risk for complications.
During an interview with the Registered Dietician (RD) on 06/16/2021 at 12:10 PM, she stated [Resident #251] is getting all of her nutrition through enteral feedings. She is not verbal or responsive. Her cognition is severely impaired, and she cannot make her needs known.
Resident #251 was observed on 06/17/2021 at 12:04 PM lying in her bed. She was not alert or responsive. The G-tube pump was infusing. Enteral food product was splattered on the wall beside the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand next to the bed, and did not appear to have been cleaned since the first observation on 06/14/2021 at 12:35 PM.
During an interview with Employee J, Licensed Practical Nurse (LPN), on 06/17/2021 at 12:09 PM, she stated, Everyone is responsible for cleaning up the food product if it splatters. She was unaware that there was food splattered on the floor, the bed frame, the feeding pump pole, the wall and the food pump in Resident #251's room. She went to look.
During an interview with the Director of Housekeeping Services on 06/17/2021 at 1:14 PM, he was shown the food splatter on the floor, the bed frame, the feeding pump pole, the wall, and the food pump. He stated the housekeeper was responsible for cleaning the food splatters in the rooms. He was informed the food splatter had not been cleaned up and was first observed on 06/14/2021 at 12;35 PM. (Photographic evidence obtained)
During a second interview with Employee J on 06/17/2021 at 1:21 PM, she stated, I saw the splatter. I tried to get it off, but it was really stuck on.
A review of the facility's policy and procedure entitled Environmental Services Customer Room Cleaning (effective May 1, 2003, revised October 23, 2017) revealed: All customer rooms should be cleaned as needed or on a daily basis. Purpose: To maintain a clean, safe, and hygienic environment for all customers, visitors, and team members. Process: The following equipment and supplies should be used: 2. Mop 7. Clean rags. 9. Putty knife. 13. Germicidal cleaner. 14. Multi-purpose cleaner. 17. Paper towels. Spot cleaning and surface sanitizing: 2.1 Utilize labeled germicidal spray bottle solution and cleaning cloths and/or glass cleaning solution. 2.2 Use glass cleaner to remove fingerprints and smudges from mirrors, walls, light switches, etc. 2.3 Wash all furniture, doors, ledges, etc. starting with the least soiled and starting at the top working toward the bottom. 6. Wet Floor Mopping: 6.2 Use germicidal solution, wet mop and 4 gallon bucket with wringer and a putty knife. 6.4 Start at farthest from the door using S stroke, avoiding base boards. Flip the mop over once and wipe out each corner.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to develop a baseline care plan for catheter care for one (Resident #252) of six newly admitted residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling Foley catheter and a urinary tract infection (UTI). Failure to develop a plan of care for catheter care could potentially exacerbate the urinary tract infection.
The findings include:
Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. He was attempting to get out of bed by himself. Both of his feet were on the floor. His catheter bag was not contained in a dignity bag but was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained)
During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if needed. She confirmed she had not provided catheter care since his admission. She stated the staff would wipe the tubing and the bag off if they became soiled. The catheter bag was hung on the bed frame when the resident was in bed. He was new to the facility, and she was not that familiar with him yet. He was a pleasantly confused man, and so far, she had not seen any problems with him. She did not look up his physician's order for catheter care or review the Treatment Administration Record (TAR) during this time.
A review of Resident #252's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) and his Order Summary Report, indicated he was admitted on [DATE] with diagnoses including: Dementia without behavioral disturbance, major depressive disorder, atrial flutter, tachycardia, hypertension, muscle weakness, unspecified protein malnutrition, constipation, retention of urine and urinary tract infection.
A review of the active physician's orders, revealed no order for catheter care. (Photographic evidence obtained)
A review of the care plan revealed no care plan for catheter care (Copy obtained).
A review of the Nursing Assessment, dated 06/10/2021, revealed Resident #252 was admitted with an indwelling Foley (urinary) catheter and hematuria (blood in his urine). His last urology consult was on 06/03/2021. He had a UTI upon admission (Copy obtained).
A review of the current Medication Administration Record (MAR) and TAR revealed no place for catheter care documentation.
A review of the nursing notes from 06/10/2021 through 06/17/2021 revealed no documentation regarding catheter care. (Photographic evidence obtained)
During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 06/17/2021 at 2:50 PM, they both looked in the electronic medical record for nursing documentation of catheter care. They reviewed the Initial Nursing Assessment and saw that the resident was admitted on [DATE] with an indwelling urinary catheter. They both reviewed the nursing notes and could not find any notes related to catheter care. They confirmed they did not see a physician's order or care plan for catheter care. The Minimum Data Set (MDS) Coordinator joined the interview on 06/17/2021 at 3:01 PM. She did not see orders for catheter care in Resident #252's chart. She looked at the Initial Nursing Assessment to see if the nurse documented the presence of the catheter upon admission. She saw that the nurse noted it. She reviewed the physician's orders, the care plan and the nursing notes, but did not find any documentation regarding the urinary catheter. The DON stated the old electronic system transferred the information from the assessment to the initial care plan, however the new electronic system did not do that. The MDS Director concurred. They stated they needed to make sure the nurses who reconciled the medications and treatments upon admission carried over all of the care to the initial care plan. The DON confirmed that if the care was not documented, then there was no evidence that it was done.
A review of the facility's policy and procedure entitled Care Plan: Customer (effective 05/01/2003, revised 02/08/2019) revealed: An individualized, interdisciplinary baseline care plan may be initiated within 48 hours of admission or readmission for each customer as part of the Service Location delivery process. It is a working tool that is reviewed and revised at specific intervals and as needed to reflect response to care and changing needs and goals. Purpose: To structure and guide therapeutic interventions, services, and treatments to meet customer's needs an achieve clinical outcomes. Process: Baseline care plan must be revised as needed until the Comprehensive Care Plan has been developed. 2. Upon admission 1.1 A licensed nurse should evaluate the customer's needs and initiate person-centered care plan problems based on findings identified on the nursing admission assessment. 1.2 The assessment must include at least the following: Special treatments and procedures. 3. The initiation of the care plan is communicated to appropriate staff where indicated. (Copy obtained).
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and staff interviews, the facility failed to coordinate hospice services for one (Resident #57) of eigh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record reviews and staff interviews, the facility failed to coordinate hospice services for one (Resident #57) of eight residents receiving hospice services, from a total sample of 54 residents.
The findings include:
A record review for Resident #57 revealed a [AGE] year old female admitted on [DATE] with diagnoses including dementia, chronic kidney disease, asthma, rhabdomyolysis, and overactive bladder. She was alert with confusion, required limited assistance with activites of daily living (ADLs), and was ambulatory without assistance. She was ordered hospice services on 10/6/20 due to a decline in condition.
A review of the medical record found no hospice notes or plan of care after February 2021. An interview was conducted with the Unit Clerk on 6/17/21 at 9:05 AM. She was asked where the most recent hospice notes for Resident #57 were located. She stated this particular hospice was not good about putting notes in the charts. She said she would look in medical records. After looking in the files, she said none were found. She was then asked if the resident was still receiving hospice services. She said she would check the computer. After doing so, she stated according to the entry from the business office, the resident was discharged from hospice on 2/17/21. When asked if there was a discharge summary from hospice and physician's orders to discontinue services, the Unit Clerk said she could not find those documents. She said she would ask the Unit Manager.
An interview was conducted with the Director of Nursing (DON) and Employee L, Unit Manager (UM), on 6/17/21 at 9:40 AM. When asked how often the Hospice nurse visited Resident #57, the UM said weekly. She was asked if the hospice nurse communicated with her after the visits, and she replied, Not always, but they do communicate with the nurse assigned to the resident. The UM was asked if Resident #57 was still receiving hospice services, and she said she was aware that the family wanted to revoke hospice, so Resident #57 could receive physical therapy. She had not been notified that hospice had been discontinued. During the interview, the DON stated she had just spoken to the Business Office Manager (BOM) and Resident #57 was discharged from hospice in February 2021, however, nursing was never informed. She was asked if there were hospice discharge records, and she replied that none had been sent from hospice. The DON stated the hospice agency providing services never communicated with the nursing staff that services were discontinued.
A review of the hospice contract, dated 11/10/05, revealed the hospice responsibilities included:
Hospice Interdisciplinary Team Care Plan will develop a plan of care for the management of each hospice patient in collaboration with the facility. This plan is updated and reviewed routinely by hospice IDT (team and facility. The nursing and social components of this plan and all documentation including but not limited to progress notes, orders and discharge plans will be placed in patients medical record at hospice and facility.
The MDS/Care Plan Coordinator was interviewed on 6/17/21 at 11:10 AM. She was asked if hospice attended the care plan meetings for Resident #57. She said, not this particular hospice. She also said she was made aware just today that Resident #57 was no longer receiving hospice services.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, by failing to ensure medications were n...
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Based on observations, interviews and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, by failing to ensure medications were not left at residents' bedsides for one (Resident #47) of a total of 54 residents in the sample.
The findings include:
On 6/15/21 at 10:30 AM during an interview with Resident #47, a bottle of Systane eye drops, without a pharmacy label, and a plastic cup with an orange gel substance and spoon in it were observed on the resident's night table. The resident was asked if she was able to self-administer the eye drops on the table. She said no. She was asked if she knew what was in the cup with the orange substance in it, and she said, probably Metamucil. I told the nurse to leave it and I would take it later.
An interview was conducted with the Employee M, Agency Nurse, on 6/15/21 at 10:40 AM. She was asked if she had left medication and eye drops at Resident #47's beside. She stated she left the resident's Metamucil on the night table, as the resident didn't want it at that time, and she said she would take it later. The nurse stated she did not give the resident any eye drops, because she was to receive Visine and Visine was not available in the medication cart. She saw the Systane drops on the night table, but she did not put them there. She said she was from the Agency and was not aware she shouldn't leave medications at bedside.
A review of Resident #47's active physician's orders revealed an order for Metamucil, 1 packet every day at 8:00 AM. There was no order for Systane eye drops.
An interview was conducted with the Director of Nursing (DON) on 6/15/21 at 11:30 AM. She was asked what the policy was for leaving medications and eye drops at the beside. She stated medications could not be left at the resident's bedside. If a resident refused or wanted the medications at a later time, then the nurse must document refusal or why the medication was given at a later time than ordered.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews and staff interviews, the facility failed to provide urinary catheter care for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record reviews and staff interviews, the facility failed to provide urinary catheter care for one (Resident #252) of six sampled residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling urinary catheter and a urinary tract infection (UTI). Failure to provide catheter care could potentially exacerbate the urinary tract infection.
The findings include:
Resident #252 was observed on 06/14/2021 at 1:10 PM seated on the side of his bed. His catheter bag was was sitting directly on the floor. The catheter tubing was also lying on the floor. (Photographic evidence obtained)
During an interview with Employee F, Licensed Practical Nurse (LPN), on 06/17/2021 at 9:26 AM, she was asked about Resident #252's catheter care. She stated she would clean the catheter if needed. She confirmed she had not provided catheter care since his admission. She stated the staff would wipe the tubing and the bag off if they became soiled. The catheter bag was hung on the bed frame when the resident was in bed. He was new to the facility, and she was not that familiar with him yet. He was a pleasantly confused man, and so far, she had not seen any problems with him. She did not look up his physician's order for catheter care or review the Treatment Administration Record (TAR) during this time.
A review of Resident #252's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008) and his Order Summary Report, indicated he was admitted on [DATE] with diagnoses including: Dementia without behavioral disturbance, major depressive disorder, atrial flutter, tachycardia, hypertension, muscle weakness, unspecified protein malnutrition, constipation, retention of urine and urinary tract infection.
A review of the active physician's orders, revealed no order for catheter care. (Photographic evidence obtained)
A review of the care plan revealed no care plan for catheter care (Copy obtained).
A review of the Nursing Assessment, dated 06/10/2021, revealed Resident #252 was admitted with an indwelling Foley (urinary) catheter and hematuria (blood in his urine). His last urology consult was on 06/03/2021. He had a UTI upon admission (Copy obtained).
A review of the current Medication Administration Record (MAR) and TAR revealed no place for catheter care documentation.
A review of the nursing notes from 06/10/2021 through 06/17/2021 revealed no documentation regarding catheter care. (Photographic evidence obtained)
During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 06/17/2021 at 2:50 PM, they both looked in the electronic medical record for nursing documentation of catheter care. They reviewed the Initial Nursing Assessment and saw that the resident was admitted on [DATE] with an indwelling urinary catheter. They both reviewed the nursing notes and could not find any notes related to catheter care. They confirmed they did not see a physician's order or care plan for catheter care. The Minimum Data Set (MDS) Coordinator joined the interview on 06/17/2021 at 3:01 PM. She did not see orders for catheter care in Resident #252's chart. She looked at the Initial Nursing Assessment to see if the nurse documented the presence of the catheter upon admission. She saw that the nurse noted it. She reviewed the physician's orders, the care plan and the nursing notes, but did not find any documentation regarding the urinary catheter. The DON stated the old electronic system transferred the information from the assessment to the initial care plan, however the new electronic system did not do that. The MDS Director concurred. They stated they needed to make sure the nurses who reconciled the medications and treatments upon admission carried over all of the care to the initial care plan. The DON confirmed that if the care was not documented, then there was no evidence that it was done.
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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** 2. On 6/14/21 at 12:17 PM, Resident #102 was observed using a portable oxygen tank that was attached to the back of her wheelcha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/14/21 at 12:17 PM, Resident #102 was observed using a portable oxygen tank that was attached to the back of her wheelchair. The oxygen tank was empty. Upon entering the resident's room, an oxygen concentrator was observed at the resident's bedside. An oxygen cannula was observed on the floor.
A clinical record review for Resident #102 indicated that she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Physician's orders included an order for oxygen continuously at 3 LPM via nasal cannula to keep her oxygen saturation above 93%, and the use of Spiriva (a bronchodilator), inhale 1 puff one time a day for COPD.
The resident was care planned as At Risk for Alteration in Respiratory Status related to a diagnosis of COPD with an intervention to administer oxygen as ordered.
The admission Minimum Data Set (MDS) assessment, dated 5/6/21, indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 points, indicating the resident had severe cognitive impairment. She also required extensive assistance from staff for bed mobility and limited assistance for transfers and toileting.
In an interview with Employee C, Registered Nurse (RN)/Unit Manager on 6/16/21 at 1:41 PM, she stated oxygen tubing was changed every Thursday and was dated at that time. She also confirmed that Resident #102's cannula was not dated, nor was the tubing bagged per the facility's protocol.
Another observation on 6/17/21 at 9:23 AM, revealed Resident #102 in the living area. Her oxygen flow rate was set at 2 LPM.
In an interview with Employee D, RN, on 06/17/21 at 9:31 AM, she stated Resident #102's oxygen order was for 2 LPM on an as-needed basis. She then checked the June 2021 MAR and stated the order was for 3 LPM continuously. The nurse went to the resident and confirmed that the resident was receiving 2 LPM instead of 3LPM. The nurse adjusted the flow rate to 3 LPM.
In an interview with the DON on 6/17/21 at 10:23 AM, she stated the nurses were supposed to follow the physicians' orders for oxygen flow rates. She added that oxygen tubing was to be changed weekly on Thursdays.
A review of the facility's policy and procedure titled Specific Procedure for all Medications, revealed: Process : Medication Occurrence
Examples of medication occurrence include, but not limited to:
1. Medication Omission - The failure to administer an ordered dose, unless refused by the customer or administered because of recognized contraindication.
2. Medication Occurrence Non-Significant - Medication administered without eliciting significant adverse effects.
2.3 Wrong rate.
Based on record reviews, staff and resident interviews and observations, the facility failed to ensure that residents requiring respiratory care, received appropriate care, consistent with professional standards of practice, by failing to follow physician's orders for the administration for oxygen for two (Residents #102 and #131) of two residents sampled for oxygen administration from a total sample of 54 residents.
The findings include:
1. On 6/15/21 at 10:27 AM, Resident #131 was observed coming out of the bathroom. Oxygen tubing was observed on the bed, the oxygen concentrator was on and the oxygen flow rate was set at 3.5 liters per minute (LPM). The resident was was asked if she knew how much oxygen flow she was ordered, and she replied 2 liters. When asked who set the flow rate, she said the device was set for 2 liters, so she didn't have to do anything except put the oxygen cannula back on.
An interview was conducted with Employee K, Licensed Practical Nurse (LPN), on 6/15/21 at 10:45 AM. She was asked what oxygen rate was ordered for Resident #131. She stated 2 liters via nasal cannula. She was asked if Resident #131 was able to regulate the flow rate on her own, and she replied no. On observation of the oxygen concentrator, she confirmed the oxygen flow was set at 3.5 LPM. She decreased the flow rate to 2 LPM as per the physician's order.
An observation of Resident #131 on 6/16/21 at 9:05 AM, found the oxygen concentrator's flow rate was set at 3 LPM.
During an interview with Resident #131 at 9:10 AM, she was asked if she had set the oxygen flow on the concentrator. She said, No, it always stays the same. Employee K was asked to observe the concentrator, and she confirmed the flow rate was set 3 LPM.
A review of the active physician's orders revealed: Monitor oxygen saturation levels every shift for shortness of breath, oxygen 2 liters via nasal cannula as needed for shortness of breath.
A review of the June 2021 Medication Administration Record (MAR) revealed oxygen administration was not documented.
During an interview with Employee K on 6/16/21 at 11:05 AM, she was asked where the nurses documented oxygen administration, and she replied, in the nursing notes.
During a review of the nursing notes with Employee K at 11:10 AM on 6/16/21, she confirmed oxygen administration was not documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record reviews, the facility failed to ensure that medications were properly stored/disposed of safely for two (Residents #138 and #61) of six residents observed ...
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Based on observations, interviews and record reviews, the facility failed to ensure that medications were properly stored/disposed of safely for two (Residents #138 and #61) of six residents observed during medication administration.
The findings include:
1. On 6/15/21 at 4:38 PM, medication administration was observed with Employee A, Registered Nurse (RN), for Resident #138. The nurse pulled two tablets of olanzapine (Zyprexa - antipsychotic), 7.5 milligrams (mg) from a blister pack. After review of Resident #138's Medication Administration Record (MAR), she noted that the order had changed from 7.5 mg to 10.0 mg. She took the two tablets of 7.5 mg olanzapine and discarded them in the trash can.
In an interview with Employee A on 6/15/21 at 5:00 PM, she was asked what the facility's protocol was for medication destruction. She stated that there was a destroyer liquid in the medication room. She admitted that medication should not be discarded in the trash can and stated she forgot.
2. On 6/16/21 at 9:03 AM, Employee B, Licensed Practical Nurse (LPN), was observed prepping medication for Resident #61. Employee B dropped the resident's furosemide (Lasix - diuretic) tablet. She picked it up and discarded it in the trash can. She performed hand hygiene and obtained another dose of Lasix 20 mg. After obtaining the Lasix 20 mg, she continued to pull other medication for the resident as ordered, and popped the pills in a medication cup. She then popped Entresto 24-25 mg (blood pressure medication) in a separate medication cup. Before administering the medication to the resident, Employee B obtained the resident's vital signs and stated her blood pressure (BP) was 116/59 millimeters of mercury (mmHg) and her pulse was 82 beats per minute. Employee B held the dose of Entresto that was in a separate cup and stated she would notify the physician that the resident's BP was below the parameters. After exiting the resident's room, Employee B took the blood pressure medication and discarded it in the trash can. During medication administration, other residents were observed wandering in the hallway with access to the trach receptacle on the nurse's medication cart. This placed them at risk of obtaining and possibly ingesting the medication in the trash.
On 6/16/21 at 10:00 AM, Employee B was asked what the facility's protocol was for medication destruction. She stated she was not sure and she normally threw medication that had been refused or not administered for other reasons in the trash. Employee B added that she would check with the Unit Manager for the correct protocol.
A review of Employee A's and Employee B's competencies revealed that neither employee had completed Medication Administration competencies.
On 6/17/21 at 3:37 PM, the Administrator stated the facility normally relied on the web-based training for employees who needed to complete required trainings. He added that the facility only required employees to complete medication administration competencies upon hire and when an issue was identified.
A review of the facility's policy and procedure titled Specific Procedures for all Medications (effective March 10, 2016 and revised July 28 2017) revealed: Process: Destruction of non-controlled medications
Purpose:
Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to do so after they have familiarized themselves with the medication.
Non - Controlled Medications:
Non-controlled medication may only be destroyed by a licensed professional at the center or by a pharmacist.
Non-controlled medications if dropped on the floor or refused and/or removed in error should be destroyed in a manner that would prevent consumption by other customers.
Disposing of the medication in a toilet, and or in another vessel that would be difficult to access.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) Failing to maintain the...
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Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) Failing to maintain the dishwasher at appropriate temperatures during the wash and final rinse cycles, 2) Failing to ensure kitchen employees wore face coverings and gloves appropriately, and 3) Failing to ensure three of three nourishment rooms were clean and stored/labeled food appropriately. The facility census was 154. All residents receiving food from the kitchen and/or nourishment rooms had the potential to be affected by this deficient practice.
The findings include:
1. On 6/15/2021 at 10:13 AM, during an observation of the dish room, the facility's dishwasher machine was observed to be a low temperature, chemical machine. (Photographic evidence obtained)
The dishwasher label read: Wash tank minimum temperature of 140°F, Pumped rinse tank minimum temperature of 120°F; Final rinse minimum temperature 120°F. The dishwasher was in use at the time of the observation; employees were cleaning dishes from the breakfast service. Temperatures at this time read: 120°F wash, 120°F rinse, 100°F final rinse. The Dietary Manager stated the last dial was not working properly and a technician was on his way. At this time, the Dietary Manager was asked if the machine was not up to temperature, what would she do to clean the dishes? She stated she would go to hand washing all dishes, and she pointed to the three-compartment sink. After observations of the dumpster were concluded at 10:25 AM, the Dietary Manager came back and directed the staff to start washing dishes by hand.
At 4:35 PM on 6/15/21, the Dietary Manager and the Administrator explained that a technician had been there, and the dishwasher was now working correctly.
A second observation of the dishwasher at 4:55 PM on 6/15/21, revealed the following: Wash cycle 130°F, rinse 120°F and final rinse 140°F. The Dietary Manager continued to run the dishwasher at least ten times with very little change in temperature to the wash cycle. At 5:10 PM, temperatures of 140°F/125°F/141°F were observed during the last two cycles respectively. At this time, the Dietary Manager was asked if employees knew to check temperatures and run the machine until temperatures were up. She stated, yes. She stated that the only employees who checked temperatures were the Dietary Manager, Assistant Culinary Director, and the cooks on the weekend. Observations of the June 2021 temperature logs for the dishwasher revealed the same initials and temperature every day, every shift. The Assistant Culinary Director was asked if these were all the same employee, and she stated yes, they were the Assistant Culinary Director's initials. No variations of initials or temperatures were observed over the entire month of June.
A third observation of the kitchen was made on 6/16/2021 at 11:05 AM. The dishwasher temperatures were observed. The Dietary Manager ran the machine and waited for the temperature to rise. She stated this morning she ran the dishwasher with no concerns, and she re-educated staff about appropriate temperatures for the dishwasher. At this time the dishwasher was given until 11:16 AM to get to temperature before observations were recorded. During this time between 11:05 and 11:16 AM, the Dietary Manager reset the washer, drained the water from dishwasher tank, and took out a cup that had been left in the machine before turning the dishwasher back on again and letting the dishwasher cycle run for another 10 times. At this time the temperatures were recorded at 134 °F / 134 °F /154°F respectively. The dishwasher was again turned on and off and drained again. A final observation of the dishwasher was made at 11:35 Am on 6/16/21, and temperatures of 148°F/ 138°F/ 148°F were recorded at this time. The total time it took for the dishwasher to meet the proper temperature was half an hour.
2. At 11:00 AM on 6/15/21 during an observation of the tray line, Employee O, Kitchen Employee, was observed with their face mask down below their face, and the following day on 6/16/2021 at 11:30 am, the same employee was observed with the mask below their nose.
On 6/15/21 at 5:15 PM, the Dietary Manager was interviewed about the PPE (personal protective equipment) that was required in the kitchen. She stated employees were required to wear face masks, gloves if handling dirty dishes or any ready to eat food or preparing food, and a hair net or hat. When asked if face masks were to be worn under or over the nose she stated, over the nose.
On 6/16/21 at 11:35 AM, Employee P, Kitchen Employee, was observed cleaning the counter, taking out trash and putting away seasonings all with the same gloves on. The employee took off the gloves and opened the door of the walk-in refrigerator to get items out of the refrigerator for the tray line without washing their hands first.
3. Three out of three nourishment rooms were observed on 6/17/21 with sanitation concerns as follows:
The nourishment room for the 200 hall was observed at 2:00 PM on 6/17/21. The refrigerator contained an open container of pudding with a date of 6/16/2021 on it. The microwave had spatters of liquid and paper towels in it. The ice machine had black specks of residue inside on the door and around the door hinge. (Photographic evidence obtained). One Styrofoam food container had food items in it dated 6/9/2021. Another Styrofoam container in the refrigerator had food items in it with no date and no name on it.
The nourishment room on the 100 hall was observed at 2:30 PM on 6/17/21. The microwave had crumbs and residue in it. A resident's food tray was sitting on top of the microwave with dirty dishes and used napkins on the tray. (Photographic evidence obtained)
During an observation of the nourishment room on the second floor for the 500 hall at 2:40 PM on 6/17/21, bits of paper towel were observed on the floor. An open package of cookies was lying out on the counter with no label or open date on the package.
An interview was conducted with Employee L, Unit Manager at 2:15 PM on 6/17/21. When asked who oversaw stocking and cleaning of the nourishment rooms, she stated each shift checked temperatures of the refrigerator and the staff on the 11pm to 7am shift on Sunday nights checked the dates of the food in the nourishment room refrigerators.
A facility policy for foods received from outside of the facility revealed that outside food should be labeled with resident's name and use by date on it.
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $57,854 in fines. Review inspection reports carefully.
- • 29 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $57,854 in fines. Extremely high, among the most fined facilities in Florida. Major compliance failures.
- • Grade F (11/100). Below average facility with significant concerns.
Bottom line: Trust Score of 11/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Riverwood Center's CMS Rating?
CMS assigns RIVERWOOD CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Florida, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Riverwood Center Staffed?
CMS rates RIVERWOOD CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 51%, compared to the Florida average of 46%.
What Have Inspectors Found at Riverwood Center?
State health inspectors documented 29 deficiencies at RIVERWOOD CENTER during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 26 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Riverwood Center?
RIVERWOOD CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ASTON HEALTH, a chain that manages multiple nursing homes. With 240 certified beds and approximately 211 residents (about 88% occupancy), it is a large facility located in JACKSONVILLE, Florida.
How Does Riverwood Center Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, RIVERWOOD CENTER's overall rating (2 stars) is below the state average of 3.2, staff turnover (51%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Riverwood Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Riverwood Center Safe?
Based on CMS inspection data, RIVERWOOD CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Florida. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Riverwood Center Stick Around?
RIVERWOOD CENTER has a staff turnover rate of 51%, which is 5 percentage points above the Florida average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Riverwood Center Ever Fined?
RIVERWOOD CENTER has been fined $57,854 across 4 penalty actions. This is above the Florida average of $33,657. 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 Riverwood Center on Any Federal Watch List?
RIVERWOOD 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.