AVIATA AT VENICE
For profit - Corporation
120 Beds
AVIATA HEALTH GROUP
Data: November 2025
Trust Grade
30/100
#473 of 690 in FL
Photo by David Hongsermeier
Photo by David Hongsermeier
Photo by Aviata at Venice
1 / 5 photos
Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Aviata at Venice has received a Trust Grade of F, indicating poor performance with significant concerns. It ranks #473 out of 690 facilities in Florida, placing it in the bottom half, and #15 out of 30 in Sarasota County, meaning there are more favorable options nearby. The facility is showing improvement, having reduced issues from 5 in 2024 to just 1 in 2025. Staffing is a relative strength with a 4 out of 5-star rating, but the turnover rate of 59% is concerning, as it is higher than the state average. There are also financial issues, with fines totaling $28,009, which is more than 75% of other Florida facilities, suggesting ongoing compliance problems. Specific incidents of concern include a failure to use the appropriate mechanical lift for transferring residents, putting their safety at risk, and a lack of monitoring for staff competency in using these lifts. Additionally, the kitchen was found to be unsanitary, with issues such as uncleanable surfaces and outdated food items. While there are strengths in staffing and some signs of improvement, the overall situation at Aviata at Venice raises several red flags for families considering this facility.
- Trust Score
- F
- In Florida
- #473/690
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $28,009 in fines. Lower than most Florida facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 51 minutes of Registered Nurse (RN) attention daily — more than average for Florida. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 32%
Needs review
5 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Florida average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 59%
13pts above Florida avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $28,009
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: AVIATA HEALTH GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Florida average of 48%
The Ugly 37 deficiencies on record
2 actual harm
Mar 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, review of clinical records and staff interviews the facility failed to provide the necessary care and services to maintain urinary catheters in a safe and sanitary manner for 3 (...
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Based on observation, review of clinical records and staff interviews the facility failed to provide the necessary care and services to maintain urinary catheters in a safe and sanitary manner for 3 (Resident #900, #899 and #800) of 4 residents reviewed with indwelling urinary catheters.
The findings included:
During the initial facility tour on 3/4/25 at 9:47 a.m., Resident #900's indwelling catheter drainage bag was observed on the floor.
Photographic evidence obtained.
On 3/4/25 at 9:52 a.m., Registered Nurse (RN) Staff A verified Resident #900's catheter drainage bag was on the floor.
On 3/4/25 at 10:00 a.m., an observation from the 100 hall revealed Resident #899's catheter drainage bag was located on the side of the bed facing the doorway to his room and was very full. There was no privacy cover and the drainage bag and urine were visible by staff, other residents and visitors, passing by the room.
On 4/4/25 at 10:05 a.m., in an interview RN Staff A confirmed Resident #899's catheter drainage bag was very full and visible to anyone passing by the residents room.
Photographic evidence obtained.
On 4/4/25 at 2:56 p.m., in an interview Certified Nursing Assistant (CNA) Staff G said the urinary catheter drainage bag of residents who have indwelling urinary catheters was to be attached to the bed frame on the side away from the door so no one can see it. CNA Staff G said if the resident was up in a wheelchair or walking you have a leg bag or a privacy bag. The CNA said, Always privacy, cover them, and keep the drainage bag off the floor.
On 3/4/25 at 3:15 p.m., during an observation from the 200 hallway Resident #800's catheter drainage bag was noted to be on the floor and visible from the hallway.
Photographic evidence obtained.
On 3/4/25 at 3:20 p.m., RN Staff C said Ok when informed that Resident #800's catheter drainage bag was on the floor. RN Staff C did not remove the resident's urinary catheter bag from the floor.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident and staff interviews, the facility failed to ensure adequate supervision to prevent the elopement of 1 (Resident #2) of 1 sampled resident who left the fa...
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Based on observation, record review, resident and staff interviews, the facility failed to ensure adequate supervision to prevent the elopement of 1 (Resident #2) of 1 sampled resident who left the facility without staff knowledge.
The findings included:
Facility policy Elopement/Wandering Risk Guidelines Document Name N-1031, Revision date 8/1/2020 indicated: Patient/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly, with a significant change in condition, and elopement event using the risk tool.
Review of the clinical record for Resident #2 revealed a re-admission date of 10/2/24 post hospitalization. Diagnoses included alcohol withdrawal and delirium.
The admission Minimum Data Set (MDS) Assessment with a target date of 10/7/24 noted the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 10.
The care plan initiated on 9/20/24 noted the resident was an elopement risk/wanderer related to disorientation to place, history of attempts to leave the facility unattended, and impaired safety awareness. The care plan noted Resident #2 wandered aimlessly and attempted to exit the front door and attempted to remove the wander alert device (alerts staff when a resident attempts to leave a designated safe area).
Review of facility notes revealed a note from the Speech Therapist which read: Last encounter with patient on 10/24/24. Brief Cognitive Assessment Tool (BCAT) completed with score 47/50. Errors in orientation/day of week: alternating /divided attention. Significant improvement with confusion. According to BCAT scoring, pt (patient) presents without functional deficits and potential independent living. Patient anticipated going home so he could return to work and pay the bills. Improvement of cognitive skills was discussed with rehab manager.
A score of 47 on the Brief Cognitive Assessment Tool (BCAT) indicates normal cognitive functioning.
The Social Worker documented in a progress note for 10/24/24 an Interdisciplinary Team meeting was held. Resident #2 reported he was doing well but wanted to be discharged . She discussed that she would need to verify where he was going first due to initial confusion when he was admitted to the facility.
The Social Worker documented in a progress note for 10/25/24 Resident #2 was at the Administrator's office discussing discharge.
On 10/26/24 at 2:04 p.m., a nursing progress note documented Resident #2 was missing. He left the premises without authorization. Resident #2 was last seen around 11:30 a.m. when the nurse was passing medication. The nurse noted the resident had a wander alert device to the right leg and was at risk for elopement. The facility was locked in for head count. The manager on duty and Administrator were aware.
Review of the facility investigation revealed on 10/26/24 between 8:00 a.m., to 9:30 a.m., Resident #2 asked a staff member to remove his wander alert bracelet. He was redirected to talk to the nurse.
On 10/26/24 around 9:30 a.m., or 10:00 a.m., Resident #2 was seen on the facility phone making calls with his credit card in hand. Resident #2 was later seen walking in the hallways around 11:30 a.m. When staff went in to retrieve his tray after lunch he was noted to be missing. The sign-out log indicated Resident #2 had not signed out of the building. Search ensued including notifying the police but Resident #2 was not found. On Sunday 10/28/24 the Social Worker (SW) was able to contact a friend of Resident #2 who explained he had spoken to Resident #2 on Friday. Resident #2 told him he was being discharged on Saturday.
On 10/28/24 Resident #2's emergency contact called the Social Worker and told her Resident #2 had a storage unit where he stores a Recreational Vehicle (RV).
On 10/31/24 Resident #2 called the Social Worker and told her he was under the impression that he was discharged per his conversation with the Administrator on 10/28/24. He reported he was picking up a friend from the airport, getting his RV and driving to Virginia.
On 11/5/24 at 11:30 a.m., in a telephone interview Resident #2 said he was fine, he was safe and was in Virginia where he lives. He said he thought he was discharged and wasn't sure if the miscommunication was on his part or the facility. He said he had no complaints against the facility, and they had been absolutely wonderful.
On 11/5/24 at 11:45 a.m., in an interview the Social Worker said Resident #2 came to her several times wanting to be discharged . She explained on initial admission he was confused and couldn't give information on his family but they were able to look through his phone and found family in Virginia. She said at the time he was confused and thought he was in Virginia and was not ok to discharge at that time. She said the Friday before he left, he again asked about discharge, he was calm, stable, and his overall confusion level was significantly improved. He wasn't making confusing statements. She said she came in on Sunday, the day after he left, and was trying to contact family/friends to verify where he was. When she did finally speak with him, he told her he was picking up a friend from the airport, then going to get his RV and driving to Virginia. She said a family member did call to confirm that he did have an RV in a public storage facility and all the things he had told her was accurate. The Social Worker said they found the wander alert bracelet; Resident #2 had taken it off. He told her he had been waiting outside her door on Saturday to tell her he was leaving, but she didn't come in and he left.
On 11/5/24 2:00 p.m., in an interview the receptionist on duty on 10/26/24 said Resident #2 came to her that day around 10:00 a.m., to 10:30 a.m. He asked who he may see to remove the wander alert bracelet. She advised him to talk to a nurse. She said he walked away and came back up front about 20-30 minutes later and asked for the Director of Nursing (DON), but she wasn't working. He said he was told it was the DON that was who removes it, and he went back into the facility. The Receptionist said she never saw him leave out the front door and she would have had to buzz him out. She said she would have recognized him as a resident as he had been up to the desk twice that morning. She said she was aware of the elopement book kept at the front desk.
On 11/5/24 at 11:40 a.m., in an interview the Administrator said Resident #2 was very close to being discharged from the facility but had his own plan and followed his own plan. The Administrator said Resident #2 was his own person and did not lack capacity. He had an order for leave of absence with responsible party and he was his own responsible party. The only thing he did wrong was not signing out. The Administrator said he cut off the wander alert bracelet. He said the facility doors are alarmed. During the day the receptionist hits a button to let a person out. He said they did not know but maybe the receptionist let him out. Resident #2 was younger than most of the residents and looked like a regular person. He said it was possible the resident tailgated another person out of the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, the facility failed to sufficient nursing staffing to ensure timely response to request for assistance for 3 (Residents #5, #6 and #7) of 3 sampled...
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Based on observation, resident and staff interviews, the facility failed to sufficient nursing staffing to ensure timely response to request for assistance for 3 (Residents #5, #6 and #7) of 3 sampled residents.
The findings included:
On 11/6/24 at 10:54 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said the facility is often short staffed and Residents complain about call lights not being answered.
On 11/6/24 at 12:45 p.m., Registered Nurse (RN) Staff B said she didn't think residents were getting the care they need. She said she felt the CNAs just didn't care.
On 11/6/24 at 12:30 p.m., in an interview RN Staff C said the facility could always use more staff. She said she gave Administration credit as they are trying to hire, but the people stay two weeks and they leave.
On 11/6/24 at 1:15 p.m., in an interview Resident #5 said when he presses his call bell there had been times no one comes and he's had to scream out in order to get someone to come. He said it had happened just within the last few days. He said it can be over an hour, if they come at all.
On 11/6/24 at 12:15 p.m., Resident #6 and her husband were in her room. Both said even though Resident #6 had only been there a short time, it could take quite a bit of time for someone to answer the call light.
On 11/6/24 at 2:50 p.m., Resident #7's daughter came out of the room requesting assistance for her father. She was redirected to a staff member near the nurse's station whom she was observed speaking with.
On 11/6/24 at 2:55 p.m., in an interview Resident #7's daughter said her mother and father shared a room at the facility. She said her father was receiving hospice services and needed to be repositioned every two hours. A friend had been with them since 8:00 a.m., and no one came in to change her father until 1:00 p.m. The daughter also complained her mother's call light was not working and the light did not turn on when pressed. She said her mother suffered from dementia. A month she fell and had to crawl on the floor to get help. The daughter said the staff were overwhelmed and it can take up to 1.5 hours for someone to come and assist. The daughter said she was still waiting for someone to come and assist her father.
On 11/6/24 at 3:02 p.m., four staff members wearing scrubs were observed speaking to each other in the hallway. The staff members walked away and did not enter Resident #7's room to provide the assistance requested.
On 11/6/24 at 3:07 a staff member dressed in scrubs was observed coming down hall to retrieve supply cart near Resident #7's room. The staff member did not enter the resident's room.
On 11/6/24 at 3:10 p.m., Registered Nurse (RN) Staff C was observed pushing her medication cart down the hall, past Resident #7's room. She placed the cart one door away from Resident #7's room and began passing medications.
On 11/6/24 at 3:11 p.m., an aide walked slowly down hall past Resident #7's room and conversed with Staff C, then returned down hallway past Resident #7's room again.
On 11/6/24 at 3:24 p.m., The Director of Nursing (DON) was observed entering the hallway. She spoke with Staff C. When the DON walked past Resident #7's room, the resident's daughter called her in the room. When the DON exited room, she was heard saying, I have to find (Maintenance Director's name)
On 11/6/24 at 3:27 p.m., the Activity Director was observed entering and exiting Resident #7's room. The DON, Activity Director and Maintenance Director were observed in the hallway having a short discussion then leave.
On 11/6/24 at 3:33 p.m., a Certified Nursing Assistant was observed going into Resident #7's room and provided the requested assistance.
On 11/6/24 at 4:00 p.m., the DON said she had been employed at the facility about two weeks. She said she felt a good response time for call lights would be within five minutes. She said waiting 43 minutes for assistance was excessive. She said when she went in the room, the daughter told her the call light wasn't working and she contacted maintenance. She explained when pressed it would go off at the desk but the light outside the room was not working. She agreed then that when the daughter pressed the call light button it alerted at the nurses station, and no one responded. She said she would begin doing call light response audits.
Jun 2024
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to protect the residents' right to be free from neglect by failure to ensure staff used the appropriate mechanical lift, and failure to follow safety protocol when using a mechanical lift to transfer 2 (Residents #1 and #2) of 3 sampled residents who use mechanical lifts for transfers.
The findings included:
Review of the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift with and effective date of 11/30/2014 and a revision date of 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift. Lift status will be indicated on the resident's care plan and [NAME] [Provides instructions for care]. The completed evaluation will be filed in the medical record.
Review of the facility's skills competency assessments for CNA (Certified Nursing Assistant) Staff noted, Skills competency is your ability to apply your skill, knowledge, and experience to perform a duty correctly .
The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in:
1. [NAME] [document that provides instructions for care]: Transfer status is verified prior to transferring.
2. Two staff members are used during transfer .
1. Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness.
The Quarterly Minimum data Set (MDS) with a target date of 4/11/24 noted Resident #1's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #1 had functional limitation in range of motion of upper and lower extremities on one side. The resident was dependent (helper does all of the effort) for chair to bed or bed to chair transfer.
The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces.
Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) sit to stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local Emergency Room.
Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m.
Resident #1 was admitted to the hospital and returned to the facility on 6/8/24.
The hospital discharge summary noted imaging studies showed no evidence of fracture.
The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1.
The statement from CNA Staff A read, I transferred him in the [brand name sit to stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name sit to stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain.
The statement did not note CNA Staff A verified the transfer status before using the (sit to stand) mechanical lift to transfer Resident #1.
Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competence in the use of the Sit to Stand lift.
The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly].
The statement from Resident #1 read, I heard a pop when I was being transferred in the [sit to stand] lift.
The facility documented CNA Staff A was immediately suspended pending investigation.
Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis:
CNA failure to use the correct mechanical lift and following policy for 2 person assist.
Care plan and [NAME] did not have the updated transfer status.
On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills. The resident said he did not trust the staff to use the mechanical lift to transfer him. As a result, he has not taken a shower since the incident and only receives bed baths.
Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5.
A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift .
The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days.
The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24.
On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. PT Staff C said he counseled the resident about only using a full body mechanical lift.
Review of the sling reference guide for the stand up patient lift used by the facility showed, standing lift requirements include, Standing slings are for residents who are partially dependent, have at least 60% weight bearing capacity, have head and neck control, are cooperative, can sit up on the edge of the bed (with or without assistance), and are able to bend at the hip, knees and ankles.
On 6/20/24 at 2:01 p.m., in a telephone interview CNA Staff B said on 6/4/24 he was in a room assisting a resident when CNA Staff A told him Resident #1 was sliding out of a sit to stand lift and asked for his help. He said CNA Staff A was using the lift by herself. When he walked into the shower room, Resident #1 was sliding from the sit to stand lift and holding onto the lift. Resident #1 was saying, My knee, my knee. Staff B said Staff A brought the chair while he was holding Resident #1 from behind. Staff A used the sit to stand mechanical lift to lower the resident into the chair. He reported the incident to Registered Nurse (RN) Staff J and told her to remind staff never to use a mechanical lift alone.
Review of RN Staff J statement dated 6/7/24 read, Around 1050 [10:50 a.m.] CNA [Certified Nursing Assistant] [Staff A] informed me [Resident #1] had pain in his knee D/T [due to] his shower. I went and assessed [Resident #1] and he was in 10/10 [10 of 10 Severe] pain and his Left knee was swollen. ARNP [Advanced Registered Nurse Practitioner] was contacted and a new order for stat [immediately] Xray of left knee was completed. When I assessed [Resident #1] he stated these idiots had him in the sling wrong and He was slipping out of it B/C [because] She left a pillow behind him. He said he was sliding down to the ground and heard his knee pop and was asking them to stop and just lay him on the ground B/C [because] it hurt so badly.
2. Review of the clinical record for Resident #2 revealed an admission date of 6/1/21. Diagnoses included muscle weakness, unsteadiness on feet, and seizures.
Review of the Significant Change in Status MDS assessment with a target date of 6/7/24 noted the resident's cognition was moderately impaired with a BIMS score of 12. The assessment noted Resident #2 was dependent on staff (Helper does all of the effort) to move from sitting on the side of the bed to lying flat on the bed, and transfers (Chair/bed-to-chair).
Review of the CNA [NAME], and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary.
On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room.
On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident.
On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling.
On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great.
Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring.
On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, residents and staff interviews, review of facility's policy and procedure, the facility fai...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, residents and staff interviews, review of facility's policy and procedure, the facility failed to ensure ongoing monitoring of staff competency for use of mechanical lifts to ensure the safety of residents during transfers for 2 (Residents #1 and #2) of 3 sampled residents of 16 residents who use mechanical lifts for transfers.
The findings included:
The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and [NAME] [provides instructions for care].
Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by:
Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job.
1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation.
Review of the hospital record dated 6/4/24 noted Resident #1 arrived at the hospital via ambulance with concerns for left lower extremity pain after slipping from his wheelchair onto his left knee at approximately 10:00 a.m.
Resident #1 was admitted to the hospital and returned to the facility on 6/8/24.
The hospital discharge summary noted imaging studies showed no evidence of fracture.
Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness.
The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces.
The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1.
The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain.
Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift.
The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, [NAME]: Transfer status is verified prior to transferring. Two staff members are used during transfer.
The statement from CNA Staff B read, [CNA Staff A] came to get me when I was in [room number]. She said that [Resident #1] was sliding and to come help her. She was by herself. He was in the [brand name sit to stand] lift, and he was holding onto the [brand name sit to stand] lift and sliding. He said, my knee my knee. I told [CNA Staff A] to get the shower chair and we used the [sit to stand] lift to transfer him into the shower chair. She showered him and came to me again to help her transfer him back to the wheelchair. I don't think she had the [brand name sit to stand lift] pad on correctly.
The statement from Resident #1 read, I heard a pop when I was being transferred in the [Sit to Stand] mechanical lift.
On 6/19/24 at 9:15 a.m., in an interview Resident #1 said CNA Staff A was not listening when he told her his foot needed to be on the step of the Sit to Stand mechanical lift. He said while he was in the mechanical lift, CNA Staff A left him in the shower room with Staff B. He told Staff B he was slipping out of the sling. Staff B said they knew what they were doing. Resident #1 said he slipped and hyperextended his knees and started having terrible pain. He was begging Staff B to let him down to the floor. When Staff A returned, they transferred him to the shower chair using the sit to stand mechanical lift. Staff A and B also used the sit to stand mechanical lift to transfer him back to bed after the shower. Resident #1 said since the incident, he's been experiencing on-going pain requiring the use of pain pills.
On 6/19/24 at 10:00 a.m., in an interview Physical Therapist (PT) Staff C said Resident #1 could not bear weight on his legs and was not a candidate to use a sit to stand (Stand up ) lift. He said prior to the incident, staff had come to him and said Resident #1 wanted to use the sit to stand lift. PT Staff C said he counseled the resident about only using a full body mechanical lift.
On 6/20/24 at approximately 3:00 p.m., in a joint interview the Director of Nursing and the Regional Nurse said PT Staff C did not report to them Resident #1 requested to use the Stand up lift.
Review of all discontinued and current electronic physician's orders in the electronic record shows Resident #1 had not used Opioid pain medications since being admitted to the facility until 6/9/24.
Review of the clinical record from 3/3/24 through 6/3/24 showed documentation on one occasion (5/28/24) Resident #1 experienced a pain level of 5.
A progress note dated 6/9/24 at 5:01 a.m. read, [Resident #1's] pain situation s/p [status post] fall in the shower before going to the hospital for eval from which he returned today-with no pain meds ordered despite his c/o [complains of] 10/10 pain, esp [especially] when moving. LLE [left lower extremity] is more swollen than at the start of the shift .
The Medication Administration Record (MAR) for June 2024 showed a physician's order dated 6/9/2024 for Percocet 5-325 milligrams one tablet by mouth every eight hours as needed for moderate pain (Pain level of 4 to 10) for 14 days.
The MAR showed the resident received 15 doses of the Percocet from 6/9/24 through 6/18/24.
Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis:
CNA failure to use the correct mechanical lift and following policy for 2 person assist.
Care plan and [NAME] did not have the updated transfer status.
The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies.
2. Review of the list of residents who use a mechanical lift for transfer revealed Resident #2 used a full body mechanical lift for transfer.
On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room.
On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident.
On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer. An unlabeled stand-up lift sling was observed being brought out of Resident #2's room. The sling was observed to have frayed edges in which the cloth could be spread apart on the side of the sling.
On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great.
Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring.
On 6/20/24 at 9:45 a.m., Resident #2 said staff had not been using a full body mechanical lift to transfer him from the bed to the chair. He said staff used the stand-up lift to transfer him. Resident #2 said he could not bear complete weight on his legs, and he could not sit on the side of the bed by himself without tipping over.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure 4 (Staff A, Staff E, Staff F, Staff G) of 4 sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure 4 (Staff A, Staff E, Staff F, Staff G) of 4 sampled Certified Nursing Assistants (CNAs) were knowledgeable and competent to ensure the safe use of mechanical lifts to transfer residents.
The findings included:
The facility policy Transfer/Mobility Evaluation Low Lift, Document Name N-907, Effective Date 11/30/2014, Revised 11/1/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individual needs . Two staff members are required when using a mechanical lift . Lift status will be indicated on the resident's care plan and [NAME] [provides instructions for care].
Review of the facility's Skills Competency Assessments for C.N.A [Certified Nursing Assistant] Staff revealed the facility utilizes Skills Competency Assessments to ensure you are able to fulfill your duties as required by state and federal regulations. We follow the minimal regulatory requirements for assessment of competency. Our practice is a Tell, Show, Do, Practice, Review training method followed by:
Direct observations of your performance while conducting the tasks . Monitoring and recording of your Skills Competency Assessment results. All employees have the responsibility to sustain the competencies represented in the assessments and any other procedures/responsibilities for performing their job.
The Skills Competency Assessment for the Sit to Stand lift included the employee demonstrates skills and competencies in:
1. [NAME] [document that provides instructions for care]: Transfer status is verified prior to transferring.
2. Two staff members are used during transfer .
1. Review of the facility's incident investigations showed on 6/4/24 the facility initiated an investigation for an allegation of neglect with serious bodily injury involving Resident #1. The investigation noted on 6/4/24 Certified Nursing Assistant (CNA) Staff A transferred Resident #1 with a (Brand name) Sit to Stand mechanical lift in the shower room without assistance. CNA Staff A left the resident alone in the mechanical lift in the shower room to request assistance from CNA Staff B. When they both walked back into the shower room, Resident #1 was sliding out of the lift. He stated, My knee my knee. They transferred the resident in the shower chair and CNA Staff A showered him. When the resident was transferred to the bed, he complained of pain in the left knee with swelling assessed. The Advanced Practice Registered Nurse ordered an X-Ray which showed a fracture of the left femur. The resident was transferred to a local emergency room for evaluation.
The facility provided a typewritten document as part of their investigation which included statements from CNA Staff A, CNA Staff B and Resident #1.
The statement from CNA Staff A read, I transferred him in the [brand name Sit to Stand lift] to wheelchair and he started to slide out. His left leg so we put his legs back in place. We transferred resident to the shower chair. I showered the resident then took him back to his room. I used the [brand name Sit to Stand] lift to transfer him back to bed. He c/o [complained of] pain with the transfer. States he always c/o pain even with brief pain.
Review of skills competency assessments revealed on 4/23/24 CNA Staff A had an annual refresher skills competency assessment which noted the CNA demonstrated skills and competency in the use of the Sit to Stand lift.
The skills competencies for CNA Staff A noted on 4/23/24 Staff A demonstrated skills and competencies in use of the Sit to Stand mechanical lift which included, [NAME]: Transfer status is verified prior to transferring. Two staff members are used during transfer.
Review of the clinical record for Resident #1 revealed an admission date of 12/4/2019. Diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, morbid obesity and muscle weakness.
The care plan initiated on 1/3/20 and revised on 11/16/23 noted the resident had self-care performance deficit in activities of daily living related to a history of CVA (cerebrovascular accident) with left hemiplegia, impaired balance, limited mobility. The interventions for transfer as of 1/3/2020 specified, The resident requires [brand name full body mechanical lift] by 2 staff to move between surfaces.
Review of the facility's Ad Hoc (unplanned) Quality assurance and Performance Improvement Meeting dated 6/14/24 noted the following root cause analysis:
CNA failure to use the correct mechanical lift and following policy for 2 person assist.
Care plan and [NAME] did not have the updated transfer status.
The Plan included CNA education regarding proper techniques when utilizing mechanical lift along with competencies.
2. On 6/19/24 at 10:00 a.m., CNA Staff E was observed pushing a Sit to Stand Lift out of Resident #2's room.
Review of the CNA [NAME], and the care plan (as of 11/14/23) revealed Resident #2 required two staff and a (brand name) full body mechanical lift to move between surfaces every day and as necessary.
Review of the skills competency assessments revealed on 6/5/24 the DON assessed CNA Staff E's skills competency to use the Sit to Stand Lift. The DON documented 2 (fully meet standards) for the level of competency which included [NAME]: Transfer status is verified prior to transferring.
On 6/19/24 at 10:15 a.m., in an interview the Assistant Director of Nursing (ADON) said she had just counseled Staff E earlier that day that Resident #2 could not use a Stand-up Lift, and she needed to read the resident's [NAME] before transferring the resident.
On 6/19/24 at 11:35 a.m., in an interview CNA Staff E said Resident #2 uses a Stand-up (sit to stand) Lift to transfer.
On 6/19/24 at 3:25 p.m., in an interview the ADON said when she spoke with Staff E that morning she asked her if she was aware Resident #2 was required to use a (brand name) full body mechanical lift. The ADON said the CNA's exact words were, No, but the standing lift works great.
3. Review of the user manual for the Stand up lift used by the facility revealed, Warning: The legs of the stand up lift MUST be in the maximum open position for optimum stability and safety. If it is necessary to close the legs to maneuver the stand up lift under a bed, close the legs only as long as it takes to position the stand up lift over the patient and lift the patient off the surface of the bed. When the legs of the stand up lift are no longer under the bed, return the legs to the maximum open position. [Manufacturer name] does not recommend locking the rear casters of the stand up lift when lifting and transferring an individual. Doing so could cause the lift to tip and endanger the patient and assistants. [Manufacturer name] recommends that the rear casters be left unlocked during lifting and transferring procedures to allow the stand up lift to stabilize itself when the patient is initially lifted from and transferred to a chair, bed or any stationary object.
Review of the skills competency assessment for CNAs for the Sit to Stand (Stand up) mechanical lift revealed, Lock the rear swivel casters only when positioning or removing the stand assist sling from the patient. Unlock the rear casters while lifting/transferring the resident .
On 6/19/24 at 12:43 p.m., CNAs Staff F, and Staff G were observed transferring Staff H with a Stand up mechanical lift to demonstrate the proper use of the mechanical lift. The Assistant Director of Nursing (ADON) was present during the observation.
After placing the transfer sling around Staff H, Staff F was observed to place the lift next to the chair without completely opening the base of the lift. Staff F locked the rear casters and attempted to lift Staff H with the Stand Up mechanical lift. The lift did not respond. Staff changed the battery twice and lifted Staff H off the chair. The lift stopped in the middle of the lift and would not respond. Staff F was observed trying to wiggle the wires on the bottom of the lift to get the lift to respond. When the lift would not respond Staff F and G were observed transferring Staff H to the chair without ensuring Staff H was fully standing. Staff F was observed to unlock the casters and move Staff H without fully extending the base of the lift. Staff F then locked the rear casters before lowering Staff H.
On 6/19/24 at 1:45 p.m., in an interview the ADON verified she instructed all staff both verbally and by observation on the use of the facility's mechanical lifts after the incident on 6/4/24.
Oct 2023
12 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on record review, review of facility's policy and procedure, and staff interview the facility failed to ensure the baseline care plan was developed within 48 hours of admission for 1(Resident #2...
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Based on record review, review of facility's policy and procedure, and staff interview the facility failed to ensure the baseline care plan was developed within 48 hours of admission for 1(Resident #283) of 3 newly admitted residents reviewed.
The findings included:
The facility policy, Plan of Care effective 11/30/14 (revised 9/25/17 documented, An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Develop and implement an individualized plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the comprehensive plan of care is completed.
Review of the clinical record for resident #283 revealed an admission date of 9/1/23.
The admission data collection form with an effective date of 9/2/23 noted diagnoses including chronic obstructive pulmonary disease, anemia, presence of cardiac pacemaker, heart failure, and muscle weakness.
Resident #283 was dependent on continuous oxygen and was frequently incontinent of bowel and bladder. Resident #283 had dark discoloration, redness, and open area to the sacrum (Bone in the lower back).
The clinical record lacked documentation of a baseline care plan to promote continuity of care, increase the resident's safety, and safeguard against adverse events.
On 10/5/23 at 12:06 p.m., the Regional Assistant Director of Nursing confirmed a baseline care plan was not completed for Resident #283.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to ensure they applied and removed an AFO (ankle-fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to ensure they applied and removed an AFO (ankle-foot orthosis) device for 1 (Resident #66) of 1 out of 6 residents coded as having an AFO. The use of an AFO is to improve standing, transfers, and/or walking patterns by reducing, preventing, or limiting the movement of the lower leg and foot and by supporting weak muscles.
The findings included:
On 10/03/23 at 9:10 a.m., Resident #66 was observed sitting in her wheelchair in the doorway to her room. During the observation, Resident #66 was noted to be dragging her right foot and her right arm and her hand appeared to be contracted. Resident #66 stated she had a cerebral vascular accident (CVA) causing her weakness on the right side of her body. She said she used to have a right foot splint, but therapy took it away a long time ago and she didn't know why.
Review of Resident #66's medical record revealed diagnoses included a medical history of Multiple Sclerosis (disorder marked by decreased nerve function), Hemiplegia (paralysis of one side of the body), and Hemiparesis (weakness of one side of the body) following a Cerebral Infarction affecting the Right Dominant Side, Weakness, Unsteadiness on Feet, and a History of Falls.
Resident #66's plan of care, dated 1/9/23 and revised 9/7/23, noted the resident had an activity of daily living (ADL) self-care performance deficit related to the disease process of Multiple Sclerosis, Vision Impairment, and Right Lower Leg/Extremity (RLE) Impairment and wore an AFO. Under interventions, it stated staff was to assist the resident with applying and removing the RLE AFO daily. The Certified Nursing Assistant (CNA)'s plan of care ([NAME]) for Resident #66, noted in the Resident Care section to assist Resident #66 with applying and removing her RLE AFO daily and observe for discoloration and bruising at least daily.
On 10/4/23 at 9:15 a.m., CNA Staff K, said she was normally assigned to work with Resident #66. She said Resident #66 was independent but due to CVA she was very weak on her right side and had an unsteady gait. She said she had never seen or applied any splinting device to Resident #66's right foot. She said she was never told or aware the CNA's [NAME] stated they had to assist Resident #66 with applying and removing her RLE AFO daily and check for any discoloration to her leg.
On 10/4/23 at 9:30 a.m., the Rehabilitation Director, said she had conducted an Occupational Therapy (OT) evaluation on Resident #66 on 9/7/23 because the resident was referred to them due to worsening vision, falls, decreased strength, impaired endurance, anxious behaviors and decreased quality of life. She said via her OT evaluation of Resident #66, she determined to start OT sessions with Resident #66, four times a week for four weeks. She said during her evaluation of Resident #66 on 9/7/23 she noted the resident did not have any splinting devices. The Rehabilitation Director said on 9/11/23 the Minimal Data Set (MDS) Coordinator gave her a list of 11 residents that had a splint/orthotics device and asked her to determine if the residents were using their splints/orthotics and to determine if they still needed them. The Rehabilitation Director confirmed Resident #66 was on the list for a right AFO to be worn out of bed. She said she did not have any documentation the therapy department had conducted the evaluation of Resident #66's RLE for use of AFO as requested by the MDS Coordinator on 9/11/23.
By observation of Resident #66 and a search of Resident #66's room, the Rehabilitation Director confirmed Resident #66 was not wearing the RLE AFO as ordered, and she was unable to find the RLE AFO in Resident #66's room.
On 10/4/23 at 10:06 a.m., the MDS Coordinator, said Resident #66 was admitted on [DATE] and the physician had ordered on 12/13/22 for a RLE AFO to be worn daily when Resident #66 was out of her bed. She said Resident #66 had a care plan created on 1/09/23 and revised on 9/7/23 for her to wear the RLE AFO because of her vision impairment, history of Multiple Sclerosis, and falls. The MDS Coordinator said she had given the therapy department a list of residents on 9/11/23 to conduct an evaluation of their splints/orthotics to determine if the residents still needed the splints/orthotics, including Resident #66. The MDS Coordinator said she had no documentation the therapy department had conducted an evaluation of Resident #66's RLE AFO as requested on 9/11/23.
By observation the MDS Coordinator confirmed Resident #66 was not wearing the RLE AFO and the AFO was not in Resident #66's room. Resident #66 told the MDS Coordinator she had not worn the AFO in months. The MDS Coordinator said she was not informed Resident #66 was not wearing the RLE as ordered by the physician and written in Resident #66's ADL plan of 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policies and procedures, and staff interviews, the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility policies and procedures, and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Resident #19, and #68) of 3 residents reviewed for activities of daily living (ADLs).
The findings included:
The facility policy, N-1130 Bathing/Showering effective 11/30/2014 (revised 9/1/17) documented, Assistance with showering and bathing will be provided at least twice a week and as needed to cleanse and refresh the resident. The resident shall be asked on admission to establish a frequency schedule for bathing.
1. Review of the clinical record revealed Resident #19 had an admission date of 2/4/23 with diagnoses including Alzheimer's disease, paranoid schizophrenia, and major depressive disorder.
The Quarterly Minimum Data Set (MDS) assessment (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 8/16/23 documented Resident #19 required extensive physical assistance of one person for personal hygiene and was dependent on staff for bathing. The MDS assessment noted Resident #19's cognitive skills for daily decision making were severely impaired.
On 10/2/23 at 3:08 p.m., Resident #19 was observed sitting at a table in the dining room of the secured Memory Care Unit. Her fingernails were very long extending approximately half inch in length and had a brown substance under the nail beds. Resident #19's hair was flat, uncombed, and greasy.
On 10/3/23 at 8:06 a.m., Resident #19 was observed being assisted from her room dressed in her own clothing. Her hair was combed and appeared greasy. Resident #19's fingernails remained untrimmed with a brown substance under the nail beds.
Review of the Certified Nursing Assistant (CNA) documentation for August 2023 and September 2023 revealed Resident #19 was scheduled for showers on the day shift on Tuesdays and Fridays.
The CNA documentation lacked evidence Resident #19 received her scheduled shower on 8/8/23, 8/15/23, 8/18/23, 8/25/23, 9/1/23, 9/15/23, 9/22/23 and 9/29/23. On 9/12/23 the documentation reported a partial shower was provided.
There was no documentation Resident #19 received assistance with personal hygiene during the day shift on 8/6/23, 8/8/23, 8/10/23, 8/11/23, 8/25/23, 8/28/23, 9/1/23, 9/2/23, 9/3/23, 9/15/23, 9/17/23, 9/22/23, 9/23/23, 9/24/23 and 9/29/23.
There was no documentation Resident #19 received assistance with personal hygiene during the evening shift on 8/3/23, 8/4/23, 8/5/23, 8/9/23, 8/11/23, 8/18/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/28/23, 8/31/23, 9/1/23, 9/3/23, 9/7/23, 9/8/23, 9/10/23, 9/15/23, 9/17/23, 9/19/23, 9/22/23, 9/23/23, 9/24/23, 9/26/23, 9/27/23, 9/28/23 and 9/29/23 .
The clinical record lacked documentation of assistance with personal hygiene for the night shift on 8/9/23, 8/12/23, 8/16/23, 8/19/23, 8/21/23, 8/22/23, 8/26/23, 8/27/23, 9/3/23, 9/6/23.
2. Review of the clinical record revealed Resident #68 had an admission date of 12/23/22 with diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety.
The Quarterly MDS assessment dated [DATE] documented Resident #68 required extensive physical assistance of one person with dressing, personal hygiene and was dependent on staff for bathing. The MDS noted Resident #68's cognitive skills for daily decision making were severely impaired.
Review of the CNA documentation for August 2023 and September 2023 revealed Resident #68 was scheduled for showers on the 3-11 shift on Mondays and Thursdays.
There was no documentation Resident #68 received her scheduled shower on 8/3/23, 8/28/23, 8/31/23, 9/11/23, and 9/14/23. A bed bath was provided on 9/7/23.
The CNA documentation showed Resident #68 received no assistance with personal hygiene as follows:
The day shift on 8/6/23, 8/8/23, 8/10/23, 8/11/23, 8/14/23, 8/15/23, 8/25/23, 8/28/23, 9/1/23, 9/2/23 , 9/7/23, 9/17/23, 9/18/23, 9/22/23 and 9/29/23.
The evening shift on 8/3/23, 8/4/23, 8/5/23, 8/9/23, 8/11/23, 8/18/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/28/23, 8/31/23, 9/2/23 9/5/23, 9/8/23, 9/9/23, 9/11/23, 9/15/23, 9/16/23, 9/22/23, 9/23/23, and 9/30/23.
The night shift on 8/9/23, 8/12/23, 8/16/23, 8/17/23, 8/19/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 9/3/23, 9/6/23, 9/7/23, 9/11/23, 9/17/23, 9/18/23, 9/21/23, 9/23/23, 9/26/23 and 9/29/23.
On 10/02/23 at 12:14 p.m., Resident #68 was observed in the dining room at the table for the noon meal, dressed in a hospital gown. The gown was opened on the left side exposing her incontinent brief, upper thigh, and abdomen as she sat eating lunch. Three staff members were present in the dining room and did not adjust the resident's gown to cover her thigh, abdomen, and exposed brief.
On 10/2/23 at 3:16 p.m., Resident #68 was observed sitting at a table in the dining room dressed in her own clothing. Her fingers nails were long with a brown substance under the nail beds. Her hair was messy and uncombed.
On 10/4/23 at 8:12 a.m., Resident #68 was observed seated at the dining room table dressed in her own clothing. Her nails remained long with a brown substance under the nails.
On 10/4/23 at 11:00 a.m. in an interview, CNA Staff A said if a resident refuses a shower, she will leave and approach the resident again. She said, I have a three-time process, if they decline after 3 times, I ask another staff member to try. If the resident continues to refuse a shower, I document it and I notify the nurse.
Review of the Resident Council Minutes showed the following repeated concern with residents not receiving showers as scheduled.
On 4/15/23, 14 residents attended the meeting and reported showers were not given.
On 6/18/23, eight residents attended the meeting and reported the shower schedule was not being kept.
On 7/11/23, nine residents attended the meeting and reported showers were getting better.
On 8/12/23, nine residents attended the meeting and reported showers are sometimes being provided.
On 10/5/23 at 10:00 a.m., Registered Nurse Staff J said the nurse was responsible to ensure the residents showers are completed. Staff J said sometimes, if the resident doesn't want to take a shower, she goes and ask them to please take a shower. She will try three times and if they say no, she documents the resident refused.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide care and services to prevent reduction in ra...
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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 care and services to prevent reduction in range of motion (ROM) for 1 (Resident #78) of 2 residents reviewed for limitation in ROM.
The findings included:
Review of the facility policy for Contracture Prevention revised 8/22/17 revealed the purpose is to prevent contracture of extremities for those residents who no longer have full use of their extremities. Each resident must be evaluated for the need of contracture prevention procedure on admission and readmission as needed.
Review of the clinical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including paralysis of right side due to cerebral vascular accident (CVA).
The physician's orders dated 8/12/23 included an Occupational and Physical Therapy evaluation and treatment.
The physician's History and Physical progress note dated 8/14/23 at 5:47 p.m., noted Resident #78 had a right hand contracture. Physical Therapy (PT) and Occupational Therapy (OT) to assess and treat.
The clinical record lacked documentation of an Occupational Therapy evaluation and treatment as per the physician's order.
On 10/02/23 at 10:37 a.m., Resident #78 was observed in his room. The resident's right hand was in a closed fist. The resident was not wearing an orthotic device such as a splint to the right hand.
Resident #78 was not able to speak and shook his head no when asked if the facility had evaluated and was treating his right hand.
On 10/4/23 at 11:35 a.m., observed Resident #78 in his room, nothing in the right hand, closed fist position.
On 10/4/23 at 1:09 p.m., Resident #78 was observed in his room with his daughter. The daughter said Resident #78 had a CVA on 2/14/23. His right hand became paralyzed. She retrieved a splint from a box in the closet which she said was for Resident #78's right hand.
On 10/4/23 at 1:29 p.m., the Director of Rehabilitation Services said Resident #78 was not evaluated or treated by Occupational Therapy and was not receiving services to prevent a decline in the range of motion of the right hand. The Director of Rehabilitation said Resident #78's payor source was Private Pay, the daughter wanted to start with Physical Therapy, therefore, he did not receive Occupational Therapy.
On 10/4/23 at 2:16 p.m., Certified Nursing Assistant (CNA) Staff X said she takes care of the resident regularly, no one told her to do any range of motion (ROM) for Resident #78.
On 10/4/23 at 3:58 p.m., the Minimum Data Set (MDS) Coordinator said the Rehabilitation Department should have addressed the right-hand fist and applied a rolled-up towel or something to keep the hand from closing. After reviewing the clinical record, she said Resident #78 was not receiving restorative nursing for his right hand to prevent a decline in the range of motion.
On 10/5/23 at 9:11 a.m., the Director of Rehabilitation Services attempted to open Resident #78's right hand. The Rehabilitation Director said she cannot open the fist. She said she could not tell if the hand was contracted or hypertonia (abnormal muscle tone), both of which indicate a ROM decline. She said without treatment the hand would get worse. She said that is what happens when the hand is paralyzed.
On 10/5/23 at 9:29 a.m., the Director of Nursing (DON) went to the room and confirmed the right hand was closed in a fist, and she could not open it.
On 10/5/23 at 9:48 a.m., the Business Office Manager (BOM) said OT should have evaluated and treated per the physician's orders, regardless of the payor source.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/5/23 at 4:10 p.m., Resident #24's dialysis communication book located in the dialysis bag in the resident's room was re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/5/23 at 4:10 p.m., Resident #24's dialysis communication book located in the dialysis bag in the resident's room was reviewed. The dialysis communication form dated 10/5/23 did not document the resident's name and was not filled out by the facility prior to going to dialysis at 6:30 a.m.
On 10/05/23 at 4:18 p.m., Registered Nurse (RN) Staff J stated when she received the resident back from dialysis today, the pre dialysis part of the form dated 10/5/23 was not filled out, and the form did not have the resident's name.
Based on record review, and staff interviews the facility failed to ensure they maintained communication between the nursing facility and the dialysis center related to the ongoing assessment of dialysis resident before and after each dialysis treatment for 2 (Residents #7 and #24) of 2 residents receiving dialysis.
The findings included:
The facility policy titled, Coordination of Hemodialysis Services N-1359, with an effective date of 11/30/2014 and a revision date of 7/2/2019, stated residents that required an outside ESRD (End Stage Renal Disease) facility would have services coordinated by the facility. The Dialysis Communication form would be initiated by the facility and sent to the ESRD center. The nurse would collect and complete the information regarding the resident to send to the ESRD center and upon the resident's return to the facility, the nurse would review the Dialysis Communication form and the information sent by the ESRD center and complete the post dialysis information on the Dialysis Communication form and file it in the resident's medical record.
1. Review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with a medical diagnosis of End Stage Renal Disease. Resident #7 had a physician's order for hemodialysis (Treatment to filter wastes and water from the blood) every Tuesday, Thursday and Saturday related to ESRD.
On 10/4/23 at 4:38 p.m., Licensed Practical Nurse (LPN) Staff F confirmed Resident #7 went to the dialysis center every Tuesday, Thursday and Saturday. She said the nurses were responsible to fully fill out the prior to dialysis section on the Dialysis Communication Record form and send it to the dialysis center. When the resident returned from the dialysis center, the receiving nurse was required to review the Dialysis Communication Record form for any new orders and/or concerns the dialysis center documented on the form. The receiving nurse then was responsible to complete the return from dialysis section of the form to show they had completed a full assessment of the dialysis port site to check for any bleeding and/or possible infection and to complete a full set of vital signs to indicate the resident was stable and not in any distress. Staff F searched Resident #7's dialysis communication logbook and Resident #7's medical record and she said she was unable to find any of Resident #7's Dialysis Communication Record forms.
On 10/4/23 at 5:00 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed Resident #7 went to the dialysis center every Tuesday, Thursday and Saturday. They said the nursing staff were required to complete the pre and post assessment on the Dialysis Communication Record form. The ADON said all of Resident #7's Dialysis forms were kept in the medical records office. Resident #7's Dialysis Communication Records forms for September and October 2023 were reviewed with the ADON. The ADON verified the post return section of the dialysis communication form was not completed on September 2, 19 and 21. The ADON said she was not able to find the dialysis communication form for September 7, 9, 14, 16, 23, 26, 30, and October 2, 2023.
On 10/5/23 at 8:30 a.m., in an interview, the Charge Nurse at the Dialysis Center confirmed Resident #7 came to their facility every Tuesday, Thursday and Saturday for hemodialysis service. She said the facility did not always send the Dialysis Communication Record form with Resident #7 as required. She said even though the facility did not always send the Dialysis Communication Record form, they always faxed their Information Exchange form to the facility for their records. She said their main concern was Resident #7 came to their facility without a dressing covering the left chest dialysis port site which could lead to an infection. She said they had written this information on the Dialysis Communication form as required but Resident #7 still came to the facility without a dressing to his dialysis port site.
On 10/5/23 at 10:00 a.m., the ADON said she was unable to find Resident #7's Dialysis Communication form for September 7, 9, 14, 16, 23, 26, 30, and October 2, 2023. The ADON confirmed the dialysis center had written on their Information Exchange form dated 9/19/23 Resident #7's dialysis port dressing was missing. She said she had identified on 9/26/23, the nursing staff were not completing the pre and post assessments on the Dialysis Communication form but had not conducted staff education with the nursing staff to ensure they completed the required components on the Dialysis Communication Record form and making sure Resident #7's dialysis dressing remained intact at all times.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to have documentation of alternatives attempted prior to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to have documentation of alternatives attempted prior to use of side rails, review the risks and benefits of side rails, and obtain consent prior to the use of side rails for 1 (Resident #44) of 1 resident observed with side rails on the bed.
The findings included:
Review of the facility policy for Side Rail/Bed Rail dated 4/19/18 indicated the facility will attempt alternative interventions and document in the medical record, prior to the use of side rail/bed rail. 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risks and benefits with residents. 3. Obtain consent from the resident. 4. Obtain physician order for side rail/bed rail.
Review of Resident #44's Quarterly Minimum Data Set assessment dated [DATE] Section P for restraints, documented side rails used for 0 days.
Review of the Order Summary Report that included physician orders revealed there was no order for side rails/bed rails.
Review of the Care Plan for activities of daily living (ADLs) self-care performance revealed interventions for bilateral quarter rails used for bed mobility and turning and repositioning initiated on 6/15/23.
On 10/2/23 at 10:41 a.m., observed Resident #44's bed with quarter side rails in the up position.
On 10/04/23 at 5:51 p.m., the Nursing Home Administrator (NHA) said it is necessary to obtain consents for side rails and then the therapy department evaluates for appropriateness. She said Resident #44's evaluation for appropriateness was completed on 10/4/23 and that was the only one she could find in the medical record. She acknowledged Resident #44 was using side rails prior to evaluation for appropriateness and attempts for alternatives.
On 10/05/23 at 2:00 p.m., review of the resident's medical record including paper chart and electronic health record revealed a side rail evaluation form completed on 10/4/23. The clinical record lacked documentation of a consent for side rail use, and no alternative interventions attempted prior to the use of side rails as initiated in the care plan on 6/15/23.
On 10/5/23 at 3:27 p.m., the Director of Nursing acknowledged the facility lacked the proper documentation including consents, evaluations, and attempts for alternative interventions prior to the use of side rails.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on staff interviews and staff record reviews, the facility failed to ensure 3 Certified Nursing Assistants (CNA) (Staff A, H, and I) of 3 sampled records reviewed had a performance review comple...
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Based on staff interviews and staff record reviews, the facility failed to ensure 3 Certified Nursing Assistants (CNA) (Staff A, H, and I) of 3 sampled records reviewed had a performance review completed at least once every 12 months. The facility failed to ensure staff had in-service education based on the outcome of the employee annual performance/competency evaluations.
The findings included:
On 10/3/23, a review of the facility's Employee Guidebook stated on page 25 and 26, all employees would have a performance evaluation completed upon hire, and on their yearly anniversary date or on their promotion date.
On 10/3/23, a review of CNA Staff A's employee file revealed a hire date of 11/2/1992. There was no documentation Staff A had an employee performance/competency review in 2022 or 2023. The last performance/competency review in the employee record was dated 11/26/13.
On 10/3/23, a review of CNA Staff H's employee file revealed a hire date of 4/11/1991. There was no documentation Staff H had an employee performance/competency review in 2022 or 2023. The last performance/competency review in the employee record was dated 4/30/13.
On 10/3/23, a review of CNA Staff I's employee file revealed a hire date of 7/11/1995. There was no documentation Staff I had an employee performance/competency review in 2022 or 2023. The last performance/competency review in the employee record was dated 7/29/13.
On 10/5/23 at 3:17 p.m., the Administrator confirmed their Employee Guidebook stated all employees would have a performance evaluation completed upon hire, on their yearly anniversary date or on their promotion date. The Administrator said prior to 10/3/23 the last time Staff A, Staff H and Staff I completed their annual performance/competency evaluation was in 2013. The Administrator confirmed she was unable to find documentation Staff A, Staff H and Staff I had their annual competencies/performance review completed on an annual basis and in-service education based on the outcome of their competency/performance reviews.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and record review, the facility failed to ensure 1 (Resident #282) of 5 sampled residents was free of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and record review, the facility failed to ensure 1 (Resident #282) of 5 sampled residents was free of significant medication errors. Medications not given as ordered can have a significant impact on resident health and welfare.
The findings included:
1. Review of the clinical record for Resident #282 revealed the resident was admitted to the facility on [DATE] with diagnoses including End Stage liver failure (cirrhosis of the liver) and Hepatic Encephalopathy (Damaged liver does not remove toxins from the blood). The physician's orders dated 7/21/23 included Lactulose 20 grams twice a day with meals. The Lactulose was scheduled for 9:00 a.m., and 9:00 p.m.
Lactulose is a medication used to treat hepatic encephalopathy. It works by decreasing the amount of toxins in the blood, which is a common cause of hepatic encephalopathy. Lactulose helps trap ammonia in the colon and bind to it. This reduces the amount of ammonia that is absorbed into the bloodstream and helps improve symptoms of hepatic encephalopathy.
Review of the Medication Administration Record (MAR) for July 2023 revealed on eight different occasions the Lactulose was not documented as administered as follows:
7/22/23, 7/24/23, 7/26/23, and 7/27/23 at 9:00 a.m.
7/22/23, 7/23/23, 7/25/23, and 7/26/23 at 9:00 p.m.
For each dose not administered, the nurse entered 9 (Other/See progress notes).
Review of the progress notes revealed the following Medication Administration entries:
7/22/23 at 2:18 p.m., and 5:09 p.m., On order from pharmacy, ARNP (Advanced Registered Nurse Practitioner) aware.
7/23/23 at 8:31 p.m., No supply, pharmacy MD (physician) notified.
7/24/23 at 10:00 a.m., Unfound.
7/25/23 at 8:12 p.m., No supply here yet pharmacy aware.
7/26/23 at 10:14 a.m., and 10:17 a.m., na [sic] (not applicable).
7/26/23 at 8:29 p.m., No supply pharmacy notified.'
7/27/23 at 8:38 a.m., Awaiting delivery.
Review of the pharmacy proof of delivery for Resident #282 revealed the Lactulose was received on 7/28/23 at 7:35 am, seven days after it was ordered.
2. The physician's orders dated 7/21/23 included to administer Phosphorus (K-Phos) 250 milligrams (mg) twice a day with meals for abnormal labs. The medication was scheduled for 9:00 a.m. and 5:00 p.m.
K-Phos Neutral is a combination medicine that contains potassium phosphate and sodium phosphate. It is used to make the urine more acidic to help prevent kidney stones. It can also be used as a phosphorus supplement to prevent and/or treat a phosphorus deficiency.
Review of the MAR for July 2023 revealed the Phosphorus was not documented as administered at 9:00 a.m. and 5:00 p.m., on 7/22/23, 7/24/23, 7/26/23 and 7/27/23.
For each missed dose of Phosphorus 250 mg, the nurse entered 9 (Other/See progress notes).
Review of the progress notes revealed several Medication Administration entries noting,
On order from pharmacy, ARNP aware.
No supply pharmacy MD notified.
Order.
Unfound.
no.
No supply here yet.
Pharmacy aware.
Awaiting delivery.
No supply pharmacy notified.
Review of the pharmacy proof of delivery record noted the K-Phos neutral was received on 7/29/23 at 5:39 am, eight days after it was ordered.
On 10/05/23 at 10:37 a.m., Resident #282's Physician stated she was not made aware Resident #282 did not receive the Lactulose or K-Phos as ordered. The physician said no one notified her. She stated it is serious for the resident to not receive these medications with the diagnosis she had. The physician said she did not feel in the long run it made much of a difference in her end stage process.
On 10/05/23 at 11:30 a.m., the Advanced Registered Nurse Practitioner (ARNP) stated the facility never notified her the resident was not receiving the Lactulose or the Phosphorus (K-Phos) until 7/27/23. She said she had the medication sent to the facility right away and had ammonia level drawn. When she received the results, she gave the resident an extra dose of Lactulose. The ARNP said she feels the mistake happened because of having agency staff who do not know how to do certain things.
On review of Lab results for Ammonia (Plasma) level drawn on 7/26/23 was noted to be 141 and reference range in (16.0 - 57.0). Ammonia level on 7/31/23 was noted to be 128 and reference range (11-32).
On 10/05/23 at 1:56 p.m., the Director of Nursing (DON) said if a medication is not available, she expects the nurses to call the pharmacy and ask where the medication is; Notify the physician or ARNP; Let the resident or family know that the medication unavailable and they are working on getting it; and document every step they took to get the medication. The DON said she also expected the nurses to call her. The DON said the nurses wrote a few notes about notifying the pharmacy, the physician and the ARNP of the missing medications. The DON did not answer when asked if the nurses had followed the process for the missing medications. The DON did not answer when asked about the doses of Lactulose and K-phos documented as given when the medication was not available.
During an interview on 10/5/23 at 1:58 p.m., Administrator stated that her expectation was the same as the DON, but she would have the nurse check the emergency drug kit (EDK) before they would call the pharmacy. The administrator said no one informed her Resident #282 went without the Lactulose and K-Phos for six days.
On 10/5/23 at 2:20 p.m., the DON stated an agency nurse told her she could not find the Lactulose in the cart. The DON said she called the ARNP who gave a lab order to test the resident's ammonia levels. The Ammonia level was 141.2 (Reference range 16.2-57). The ARNP ordered the Lactulose to be given twice a day. The DON stated she did not go back and investigate the situation and see how long the resident had been without the medications. She said she did not have a formal program yet for reviewing new admission charts to double check all the orders.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on staff interview, and record review, the facility failed to maintain clinical records that were complete and accurate for 1 (Residents #282) of 2 resident records reviewed. Incomplete or inacc...
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Based on staff interview, and record review, the facility failed to maintain clinical records that were complete and accurate for 1 (Residents #282) of 2 resident records reviewed. Incomplete or inaccurate clinical records could result in residents receiving improper care.
The findings included:
A review of the clinical record for Resident #282 revealed the resident was admitted to the facility with a diagnosis of End Stage liver failure (cirrhosis of the liver) and Hepatic Encephalopathy. A review of the July 2023 Medication Administration Record (MAR) revealed two medications were not given as ordered. A review of the physician's orders on admission to the facility indicated that on 7/21/2023 the resident was ordered Lactulose 20 gram twice a day with meals and Phosphorus (K-Phos) 250 mg twice a day with meals.
A review of Resident #282's Medication Administration Record (MAR) revealed the resident did not receive the ordered Lactulose a total of eight (8) times that was documented that the medication was not available and four (4) times the nurse documented it was given.
A review of Resident #282's Medication Administration Record (MAR) revealed the resident did not receive the ordered Phosphorus (K-Phos) a total of eight (8) times with documentation that the medication was not available and four (4) times the nurse documented it was given.
A review of pharmacy proof of delivery for Resident #282 revealed that shipments of the medication Lactulose was not received into the facility until 7/28/23 at 7:35 am, seven (7) days after it was ordered. The pharmacy proof of delivery record also indicates that the medication K-Pho was not received into the facility until 7/29/23 at 5:39 am, eight (8) days after it was ordered.
During an interview on 10/05/23 at 10:37 a.m., Resident #282's Physician stated that she was not made aware that Resident #282 went without her Lactulose or K-Pho's medication for 6 days. The physician said that no one had called her and notified her of this. MD stated it is serious for the resident not to receive these medications with the diagnosis that she had.
During an interview on 10/05/23 at 11:30 a.m., Resident's Advanced Registered Nurse Practitioner (ARNP) stated that the facility never notified her that the resident was not receiving the Lactulose or the Phosphorus (K-Phos).
On review of Lab results for Ammonia (Plasma) level drawn on 7/26/23 was noted to be 141 and reference range in (16.0 - 57.0). Ammonia level on 7/31/23 was noted to be 128 and reference range (11-32).
During an interview on 10/05/23 at 1:56 p.m., the Director of Nursing (DON) stated that her expectations for a nurse that finds that a resident's medication is not available, should do the following:
* calls the pharmacy and ask where the medication is.
* Notify the physician or ARNP.
* Let the resident or family know that the medication available and they are working on getting it.
* Then document every step they took to get the medication.
DON stated that each time a nurse finds medication not in the medication cart they should take the same steps and document. She also stated that if they have a problem, they should also call DON and report it to her. When asked if she felt that the nurse followed the steps that she just said were her expectations she would not answer. When DON was asked if there was documented each time that the Lactulose and/or K-Phos medication that were not given she said nothing.
During an interview on 10/5/23 at 1:58 p.m., Administrator stated that her expectation was the same as the DON, but she would have the nurse check the emergency drug kit (EDK) before they would call the pharmacy. The administrator reports that she had not been informed that Resident #282 had gone without 2 of her medication for 6 days due to it not being available in the facility.
During an interview on 10/5/23 at 2:20 pm DON and Administrator were asked to review and explain how four (4) nurses recorded on the Medication Administration Record (MAR) between 7/22/23 and 7/27/23 that the Lactulose and K-Phos medication had been given even though the medication had not been delivered to the facility until 7/28/23 and 7/29/23. DON and Administrator did not have an answer and did not speak.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of the facility policies and procedures, and staff interviews the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of the facility policies and procedures, and staff interviews the facility failed to develop and implement a program of meaningful activities to meet the needs of 6 of 16 residents in the memory care unit. The facility failed to implement meaningful individualized activities to meet the interest and wellbeing of 1 (Resident #58) of 1 resident in the memory unit sampled for individualized activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration.
The findings included:
The facility policy, MC-200 Activity-Intensive Program effective date 11/30/14 (revised 3/19/19) documented, A structured activity intensive program shall be the focus of the memory care unit to minimize the confusion residents with dementia and related disorders experience as they attempt to cope with difficulties in short term memory, attention span, comprehension, learning, conceptualization, judgment, reasoning, abstract thought, perception and psychosocial well-being . Procedure: The activity intensive program shall provide a minimum of 12 hours per day, 84 hours per week of structured activity programming .
A review of the clinical record revealed Resident #58 was admitted on [DATE] with diagnosis including dementia, anxiety, and major depressive disorder.
The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 7/6/23 documented Resident #58's cognitive skills for daily decision making were severely impaired.
The care plan initiated on 9/30/21 and revised on 7/11/23 documented Resident #58 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. The goal for Resident #58 was to attend and participate in community life activities of choice three to five times. The care plan noted, She loves company. She loves music and BINGO, she loves chocolate. The interventions included assisting with arranging community activities. Ensure that the activities the resident is attending are compatible with physical and mental capabilities. Compatible with known interest and preferences, adapted as needed such as large print. Compatible with individual needs and abilities.
The activity calendar listed Exercise for 10/2/23 at 10:00 a.m.
On 10/2/23 at 10:20 a.m., Resident #58 was observed seated at the dining room table with her forehead resting on the table. No music was playing, and no activity program was in progress.
On 10/2/23 at 12:21 p.m., Resident #58 was observed at the same table in the dining room resting her forehead on the table.
The activity calendar for 10/3/23 listed News at 9:00 a.m., and Rosary at 10:00 a.m.
On 10/3/23 Resident #58 was observed sitting at a table in the dining room from 10:00 a.m. to 10:30 a.m., and on 10/3/23 at 11:21 a.m. During both observations, Resident #58 was staring at the wall. There was no activity in progress, no television or music playing. There were no staff in the dining room during the observations.
On 10/4/23 at 8:13 a.m., Resident #58 was observed in a wheelchair in the unit dining room. There was no group or individual activity in progress and no music playing.
On 10/4/23 at 8:23 a.m., Registered Nurse (RN) Staff D said there were no activities provided to the Memory Care Unit residents. Staff D said the unit used to have an activity aide who was wonderful, but she was no longer here. Staff D said, The CNAs (Certified Nursing Assistants) try to do little things for the residents, but they have patient care to do and can only do so much. I have not seen the Activity Director come back here to do any activities during the day when I am working.
On 10/4/23 at 8:36 a.m., CNA Staff A said, No one comes to the memory care unit to do activities. We have this large activity calendar on the wall and, if we have time, we do something with the residents. The residents back here are not able to do most of the things on the calendar, they use the same one as the main unit and the activities listed, most of the residents are not able to do. We are not allowed to take the residents from the unit for the general activities in the main area of the facility. The CNA said, The calendar says to do news at 9:00 a.m. The residents don't read the newspaper and if I try, they can't participate. Karaoke is at 10:00 a.m., today but they don't have the equipment here and the residents can't read along.
On 10/4/23 at 9:01 a.m., the Activity Director (AD) said she tries to go back to the unit as often as she can, but with the COVID outbreak on the unit it is harder. The AD said she was the only activity person for the facility and the CNAs were to provide the activities on the Memory Care Unit. The AD said she goes back to the unit daily to ensure the activities are being provided. The AD said she does not place individual activity calendars in resident rooms because the residents cannot read it. The AD said she only placed a large calendar on the unit wall by the television (TV). The AD said she had provided education to all the staff who work on the memory care unit on how to do each activity and said everything is on the unit for the activities. The AD said she makes sure the CNAs are providing the activities and completing the charting. The AD provided a copy of the same general population calendar for the Dementia residents, and said the calendar was the same one used for the Memory Care Unit residents.
On 10/4/23, during observation of the Memory Care Unit from 10:00 a.m. to 10:27 a.m., Resident #58 remained at the table facing a wall with no activity in progress. The Calendar specified Karaoke at 10:00 a.m. No music was playing. No activity of any kind was in progress.
On 10/4/23 at 10:20 a.m., CNA Staff B said there was no Karaoke machine on the unit. Staff B said she had not received in-service education on providing activities on the unit and said, The residents wander, and you have to stop and redirect them frequently, you can't be in two places at the same time, and we can't do our patient care and do activities at the same time.
On 10/4/23 at 10:31 a.m., during observation in the main dining room of the general population, Karaoke was in progress. No residents from the memory care unit were in attendance. The Activity Director was present.
On 10/4/23 at 11:03 a.m., an observation on the Memory Care Unit, one resident was wandering the halls, three residents were in the dining room unattended. Resident #58 was seated at the table, with crayons and a paper to color, but the resident had pushed them to the other side of the table. Resident #58 responded when greeted but did not respond appropriately to questions. There was no structured activity in progress and no music was playing. One CNA was observed in the TV area attending to other residents.
On 10/4/23 at 1:59 p.m., the activity calendar specified nails to be done at 2:00 p.m. Observation of the unit noted five residents sleeping in the TV area, while the TV was on. One resident was wandering in the dining room. The CNAs were observed providing toileting and care to the residents.
On 10/4/23 at 2:03 p.m., RN Staff D said, The Activity Director came back here this afternoon and told the staff they were to do nail care, I told her we had no supplies back here on the unit. The AD left and returned with a caddy that had a few nail polishes in it.
On 10/4/23 at 2:16 p.m., CNA Staff B said no one from activities had come to the unit to provide nail care. The CNA said, if we have time, we try and do an activity with the residents, but we are always busy.
On 10/4/23 at 2:22 p.m., CNA Staff A said, We toilet everyone back here every two hours, I take that very seriously. If they need to be changed or put to bed, I do it. My main concern is with the resident's care and if I have time, I don't mind doing the activity with them. I love to spend time with them doing appropriate activities for them but some days there is no time.
On 10/5/23 at 8:30 a.m., the Activity Director confirmed the activity calendar for the Memory Care Unit was the same as the general population and the residents did not leave the secured unit to attend activities in the main area of the facility. The Activity Director said the residents like Karaoke, and they sing along to it but confirmed the activity did not occur on the memory unit as listed on the calendar. The Activity Director said she was aware the residents on the Memory Care Unit required activities to meet their cognitive level and said she was doing her best, but she was the only person in the facility for activities. I used to have an assistant, but she left suddenly and had not been replaced yet. The Activity Director confirmed the activities on the general population calendar were not provided to the memory care residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders for 2 (Residents #18 and #30) of 4 residents observed f...
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Based on observation, clinical record review and staff interviews, the facility failed to administer medications according to physician's orders for 2 (Residents #18 and #30) of 4 residents observed for medication administration. Three licensed nurses on the morning shift with 29 opportunities were observed. Two medication errors were observed resulting in a 6.9% error rate.
The findings included:
The facility policy Administering Medications (revised 4/19) documented, Medications are administered in a safe and timely manner and as prescribed.Medications are administered in accordance with prescriber orders including any required time frame.
1. On 10/3/23 at 8:31 a.m., Registered Nurse (RN) Staff C was observed administering eight different medications to Resident #18.
RN Staff C said she was not able to administer Duloxetine 40 milligrams (mg) as ordered medications. She said the medication was not available and was not included in the emergency drug kit.
Review of the clinical record revealed a physician's order dated 9/3/23 to administer Duloxetine HCL (Hydrochloride) 40 milligrams (mg), one capsule by mouth daily related to Recurrent Major Depressive Disorder.
On 10/3/23 at 4:00 p.m., RN Staff C documented in a progress note she notified the Advanced Practice Registered Nurse the medication will be given late as it will be sent STAT (immediately) from the pharmacy.
On 10/4/23 at 12:15 p.m., Review of the Medication Administration Record failed to show documentation Resident #18 received the Duloxetine 40 mg as ordered on 10/3/23.
On 10/4/23 at 12:32 p.m., the Assisted Director of Nursing (ADON) said Resident #18 did not receive the Duloxetine on 10/3/23 because it was not here.
On 10/4/23 at 12:46 p.m., review of the Pharmacy Delivery Slip showed the Duloxetine 40 mg capsule was delivered and available on 10/3/23 at 12:48 p.m.
2. On 10/3/23 at 9:39 a.m., Licensed Practical Nurse (LPN) Staff E was observed administering seven different medications to Resident #30, including one chewable tablet of Aspirin 81 mg. LPN Staff E crushed all the medications and administered them to the resident.
Review of the clinical record revealed a physician's order dated 1/20/23 to administer Aspirin EC (enteric coated) tablet delayed release, one tablet by mouth one time a day related to atrial fibrillation.
On 10/3/23 at 11:00 a.m., LPN Staff E said she did not know what enteric coated was. She verified Aspirin 81 mg enteric coated was not available in the medication cart.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure medications w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure medications were appropriately labeled in 3 (Carts #1, #2, and #3) of 3 medications carts reviewed. Without an open date on the medication there was no way to know when it would expire. This had the potential for residents to receive medications that could create hazardous health consequences. The facility also failed to secure medication and treatment carts were secured when not in view of the licensed nurse.
The findings included:
The facility policy, Administering Medications (revised 4/19) documented, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.
1. On 10/2/23 at 10:39 a.m., during an observation of medication cart identified by Licensed Practical Nurse (LPN) Staff F as cart #1 (rooms 204-208), the following was observed:
One Novolog insulin flex pen without an open date on the package. The directions on the pharmacy label instructed to discard 28 days after opening.
Photographic evidence obtained.
One Novolin R flex pen for without an open date recorded. The directions on the pharmacy label instructed to discard after 28 days.
The findings were verified by LPN Staff F.
2. On 10/2/23 at 11:30 a.m., during an observation of medication identified as Cart #3 with LPN Staff E, the following was observed:
One Levemir Flex Pen without an open date.
Photographic evidence obtained.
One Novolog Flex pen in a clear plastic bag with a date opened of 8/15/23. The plastic bag did not have a pharmacy label. The instructions specified to discard 28 days after opening. The Novolog flex pen should have been discarded on on 9/12/23.
Photographic evidence obtained.
One Levemir Flex Pen dated 8/15/23 on the insulin pen and a date of 9/1/23 on the pharmacy label. The label instructed to discard after 28 days.
LPN Staff E confirmed she did not know which date was the actual open date of the insulin.
Staff E confirmed the findings in the medication cart.
3. On 10/2/23 at 11:45 a.m., during an observation of medication cart identified as cart #2 with Registered Nurse (RN) Staff D the following was observed:
One Lispro Insulin Pen without an open date. The pharmacy label instructed to discard the medication 28 days after opening.
RN Staff D confirmed the findings in the medication cart.
On 10/4/23 at 1:38 p.m. in an interview, the Assistant Director of Nursing (ADON) said the expectation was when you open an insulin you date it. The ADON confirmed the opened insulin should be dated when the nurse opens the medication.
4. On 10/2/23 at 12:11 p.m., during an observation, RN Staff D unlocked medication cart #3 to retrieve medications. The cart was against the wall in front of the nursing station. RN Staff D walked away from the unsecured medication cart and went down the hallway to the other nursing unit. There were residents and staff in the hall. RN Staff D returned to the unit and confirmed the medication cart had been left unlocked and unattended.
Photographic evidence obtained.
5. On 10/2/23 at 1:17 p.m., on the secured Memory Care Unit the medication room was left unlocked and the door was open. The medication cart was in the room and was unlocked. There were residents wandering by past the open medication room. The nurse was not present for five minutes and the medication cart was unsecured. LPN Staff F returned to the open medication room and verified she had left the medication room and the medication cart unsecured and unattended.
Photographic evidence obtained.
6. On 10/3/23 from 8:56 a.m. to 9:06 a.m., a medication cart labeled cart #2 was observed unlocked at nursing station 1. A treatment cart located in the hallway across from nursing station 1 was unlocked. The treatment cart contained medications and wound care supplies. Residents and staff were observed walking by the unlocked medication and treatment carts.
On 10/3/23 at 9:06 a.m., LPN Staff E verified the medication and treatment carts were unlocked and unattended.
7. LPN Staff E walked away from an unlocked cart in the hallway in front of room [ROOM NUMBER]. On 10/3/23 at 9:11 a.m., LPN Staff E returned to the unsecured medication cart in front of room [ROOM NUMBER] and confirmed the medication cart was unlocked with the contents easily accessible.
Photographic evidence obtained.
On 10/4/23 at 11:08 a.m., the Director of Nursing said the carts were to be locked when not in view of the nurse.
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
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to refer for a Preadmission Screening and Resident Revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to refer for a Preadmission Screening and Resident Review Process (PASSR) Level II screening for 1 resident (#1) of 3 residents reviewed for mental illness. A PASRR Level II is required for individuals with mental disorders and intellectual disabilities to ensure proper placement in the nursing home and obtain additional services for the resident while in the nursing home.
The findings included:
Review of the facility Policy for PASRR dated 11/8/21: The center will assure all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure the residents with SMI or are ID receive the care and services they need in the most appropriate setting.
Review of Resident #1's Preadmission Screening Inclusionary and Exclusionary Checklist dated 9/26/07 revealed diagnoses included Anoxic Brain Damage and Recurring Depression. Resident #1 was admitted to the facility on [DATE] and did not have a PASRR Level II in the medical chart.
Review of the psychiatrist's note dated 6/12/23 revealed Resident #1 was [AGE] years old and admitted to the facility on [DATE]. The resident was being re-evaluated at the request of the facility because she was found outside of the building, crying, stating, I want to go away from this place. The psychiatrist noted Resident #1's past medical history included Major Depression, Mental Disorder, and Psychosis.
On 7/31/23 at 12:50 p.m., the Licensed Clinical Social Worker (LCSW) said she meets with Resident #1 twice a month for psychotherapy. She said Resident #1 was child-like, wants her stuffed animals, and never learned to read, or write. She said Resident #1 always lived with her mother until she passed away. Now Resident #1 has a state appointed guardian. The LCSW said she believes Resident #1 is mentally retarded/developmentally delayed (MRDD). She said she tried to get her into a program but all her money goes to the facility.
On 7/31/23 at 1:21 p.m., Resident #1 said she is not happy living at the facility. The resident became visibly upset and started to cry. She said she wants to go back to school and learn to read and write but the facility can't afford it.
On 7/31/23 at 3:01 p.m., the Social Services Director (SSD) said she is familiar with Resident #1, and the resident has lived at the facility since 2007. She said Resident #1 has Encephalopathy and Mental Illness/Mental Retardation. She confirmed Resident #1 had gone to a program in the past, but Resident #1 could not continue the program because her monthly income could not afford it. She said she is not sure the process for PASRR Level II and did not refer Resident #1 for the screening, so check with the Director of Nursing (DON).
On 7/31/23 at 3:18 p.m., during an interview with the administrator and the DON they acknowledged Resident #1 has been at the facility since 2007 and did not have a PASRR Level II. The DON confirmed she has access to Keppro but did not apply for a Level II for Resident #1. The DON and the administrator acknowledged Resident #1 should be referred for the Level II.
Feb 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to coordinate care and implement interventions to mi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to coordinate care and implement interventions to minimize the risk of avoidable fall and fall related injuries for 2 (Resident #1 and #2) of 4 residents reviewed with a history of multiple falls.
The findings included:
1. Review of the clinical record for Resident #1 revealed an admission date of 7/21/2021.
The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted diagnoses including heart failure, Depression and Dementia. Resident #1's cognition was severely impaired. The resident required limited physical assistance of one person for activities of daily living such as transfer, walking in room, personal hygiene and toileting. The resident was not steady and only able to stabilize with human assistance when moving from seated to standing position, walking, turning around and facing the opposite direction while walking. Resident #1 was frequently incontinent of bladder and occasionally incontinent of bowel.
The care plan initiated on 10/10/2021 and revised on 12/15/2022 noted Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, resident attempts to transfer and ambulate unassisted. Resident #1 did not always use the call light to ask for assistance. The goal was to minimize the risk for falls.
As of 10/20/21 the interventions included to anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; educate the resident/resident's representative about safety reminders and what to do if a fall occurs; Ensure that the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair.
The care plan was updated noting Resident #1 had an actual fall on 10/4/22. The care plan listed additional falls on 11/23/22, 12/9/22, 12/26/22, 2/7/23, and 2/10/23.
The nurse's note dated 11/23/22 at 2:27 p.m., noted Resident #1 was found sitting on the floor and sustained no apparent injury.
The care plan was not updated with interventions to prevent further falls.
On 12/9/22 at 4:30 p.m., a progress note documented Resident #1 was found on the floor in her bedroom. Resident #1 complained of severe pain to the face and right hip. Resident #1 was transferred to the hospital where she was diagnosed with a right hip fracture.
Review of the fall investigation form dated 12/9/22 at 4:30 p.m., noted Resident #1 was found on the floor in her room. Staff noted under Why they think the fall happened, Trying to be up unattended.
The investigation did not include if Resident #1 was wearing appropriate footwear. There was no documentation determining the root cause of Resident #1 Trying to be up unattended.
Resident #1 returned to the facility on [DATE] after a surgical repair of the right hip fracture sustained at the facility on 12/9/22.
Resident #1's fall care plan was updated on 12/15/22 to offer toileting after meals, upon rising and before bed.
On 12/26/22, a fall investigation form noted Resident #1 was found sitting on the floor next to the bed. Staff noted under Why they think the fall happened, Rolled out of bed onto floor. In the section Describe what the resident was doing prior to and at the time of the fall, Staff checked Wheelchair, Mechanical lift. The fall investigation form noted the resident was confused, had unsteady/poor gait and had a surgical incision.
The investigation did not document the root cause for Resident #1 falling out of bed.
The form noted an updated intervention for a larger mattress.
The care plan was updated on 12/28/22 to put the bed in low position, and a perimeter mattress (mattress with built-in bolsters defining the edges of the bed and aid in preventing falls). On 1/4/23 floor mats as ordered was added to the care plan.
On 2/2/23 at 5:30 p.m., a fall investigation form noted Staff observed Resident #1 sitting on the floor on her buttocks, legs out. Resident #1 was not able to explain. Under Why they think the fall happened, staff noted, Unable.
The fall investigation form did not list any contributing factors to the fall but noted the resident rolled out of bed and had a recent room change. The form documented the root cause as re-acclimate to environment and reevaluate for memory unit placement.
There was no documentation if the larger mattress listed as an intervention after the fall of 12/26/22 was implemented, or the perimeter mattress, and fall mats listed on the care plan were in place at the time of the fall.
The care plan was updated on 2/3/23 for a bariatric bed (wider than standard hospital beds).
On 2/7/23 at 7:48 p.m., a fall investigation form noted Resident #1 was on the floor against the bedroom door. The form did not include an interdisciplinary team review, including contributing factors. The form documented the resident was going to the bathroom as the root cause.
On 2/16/2023 at 12:00 p.m., Resident #1 was observed in her room. Resident #1's bed was a regular bed with a regular mattress. Resident #1 was not able to answer any questions about the multiple falls.
The resident's son who was in the room visiting and said Resident #1 fell, Mostly at night. He said he did not know why she fell but she gets confused.
On 2/17/2023 at 1:15 p.m., a joint interview was conducted with the Administrator, Director of Nursing, and the Regional Nurse Consultant. They acknowledged Resident #1 had multiple falls and said they discussed her case many times. They decided she would be better monitored in the facility's memory care unit, but they had not moved her there since they had no bed available in the unit.
There was no documentation of increased supervision to prevent recurrence of falls for Resident #1.
2. Resident #2 was admitted to the facility on [DATE]. The admission MDS with an assessment reference date of 1/20/23 noted the resident's cognition was severely impaired. Resident #2 was not steady moving from seated to standing position, walking, turning around and facing the opposite direction while walking but able to stabilize without human assistance.
The Certified Nursing Assistant [NAME] (Contains information necessary to safely care for the resident) noted Resident #2 required extensive assistance by one staff for toileting.
Review of the facility's incident log and fall investigation revealed a fall investigation form dated 1/16/23 which noted Resident #2 was found sitting on the floor, leaning against the wall besides the bathroom. Under Why they think the fall happened, staff documented Confused. Overestimates ability.
The fall investigation form did not list a root cause for the fall.
The care plan initiated on 1/17/23 noted the resident had an actual fall with poor communication/comprehension, impaired balance. The interventions included bed in low position, room move closer to the nursing station.
On 1/19/23 at 12:00 p.m., a fall investigation form noted a witnessed fall. The form noted the resident had increased confusion, decreased balance. The fall investigation form listed cognition as a contributing factor. The updated interventions noted a room transfer and psych meds review. No witness statements were found for the investigation. The fall investigation form did not list a root cause for the fall in order to determine appropriate interventions to prevent further falls.
Review of the psychiatry progress note dated 1/20/23 noted. Received a call from nursing staff that the patient had a resident to resident altercation and became aggressive with his roommate. The psychiatric Advanced Practice Registered Nurse documented both residents were separated, and rooms changed. She informed the unit manager that is the patient will be administered Ativan (antianxiety) gel or quetiapine (antipsychotic) to place an order to not administer oral Ativan at the same time as the gel.
On 2/8/23 at 11:00 a.m., a fall investigation form noted the resident was observed lying on the bathroom floor. Resident #2 was not able to answer. The Personal Care Assistant (PCA) noted the resident got up from the wheelchair using the bar in the bathroom with assistance. Resident #2 began to turn, started to lose balance and swayed backwards. The PCA noted she went behind him and laid him down gently to the floor and went to get the nurse.
The fall investigation did not list a root cause.
The care plan was not updated with new interventions to prevent further falls.
On 2/14/23 at 7:30 a.m., a fall investigation form noted the resident was seen on the floor on the right side of the bed between the bathroom door and the floor. The form noted the resident was ambulating without assistance.
A radiology result report of the left elbow dated 2/14/23 noted, possible subtle fracture of the radial head (radius bone near the elbow).
There was no investigation of the fall, including witness statements, contributing factors to determine the root cause of the incident.
The care plan was not updated with new interventions to prevent further falls.
3. Review of the facility's incident log revealed five falls in October 2022, 13 falls in November 2022, 17 falls in December 2022, 19 falls in January 2023 and as of February 17, 13 falls were listed.
4. On 2/17/23 at 1:15 p.m., a joint interview was conducted with the Administrator, the Director of Nursing (DON), and the Regional Nurse Consultant.
The DON said the facility had identified falls as a problem and implemented a Performance Improvement Initiative to decrease falls starting on 12/20/22. Initiative included staff education to reduce falls, and fall reporting. Care plans are discussed, and updated each day in morning meetings. The facility provided a performance improvement plan dated 12/20/2022 with action steps for an objective and goal of initiation and follow up of resident centered fall interventions. The goal was to 100% compliant within 30 days.
The Administrator, DON and Regional Nurse Consultant said fall prevention remained a focus that needed to be resolved. The DON said they had not developed a system for monitoring and tracking improvements for interventions identified in the process improvement plan.
Dec 2021
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, the facility failed to ensure the MDS (Minimum data set) assessment accurately reflected falls and fractures for 1 (Resident #37) of 4 sampled resi...
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Based on clinical record review and staff interview, the facility failed to ensure the MDS (Minimum data set) assessment accurately reflected falls and fractures for 1 (Resident #37) of 4 sampled residents with falls. Inaccurate MDS assessments can result in a resident not receiving appropriate health care.
The findings included:
Clinical Record review showed Resident #37 sustained a fall on 6/30/21 and was sent to the hospital for evaluation. The resident was diagnosed with a nasal fracture and subdural hematoma.
Resident #37 returned to facility on 7/1/21, sustained a second fall on 7/2/21 and a new diagnosis of right knee fracture.
The five-day Minimum Data Set (MDS) assessment with a reference date of 7/5/21, and the significant change in status MDS assessment, with a reference date of 7/15/21, failed to identify the fall with major injury. Under section J1800 of the MDS asking if the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent, the facility coded No. Under number of falls since admission or prior assessment - Major injury was also coded as No.
On 12/2/21 at 9:03 a.m., in an interview the facility's MDS Coordinator, and the Regional MDS Coordinator acknowledged Resident #37's falls with injury were not coded as per the Resident Assessment Instrument (RAI) manual and the assessments were inaccurate.
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 record review and staff interview, the facility failed to develop and implement an individualized, person-centered care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement an individualized, person-centered care plan for 1 (#24) of 4 residents reviewed for care planning. Failure to develop and implement a comprehensive care plan can lead to the resident's medical, physical, mental, and psychosocial needs not being met.
The findings included:
Review of Resident #24's clinical record revealed the resident was admitted to the facility on [DATE]. An admission comprehensive Minimum Data Set (MDS) with an assessment reference date (ARD) of 9/20/21 was completed and transmitted. Based on the assessment, care plan decisions were completed on 9/24/21 to proceed to care plan for areas of communication, risk for pressure ulcers, behaviors and psychotropic (drugs that affect a person's mental state) medication.
The Registered Nurse (RN) MDS Coordinator certified and signed the care plans for Resident #24 were completed but the facility failed to develop a comprehensive and individualized care plan for Resident #24.
Review of the MDS assessment dated [DATE] showed Resident #24 was coded for the following: Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others); behaviors put the resident at significant risk for physical illness or injury and Significantly interfere with the resident's care and interfere with the resident's participation in activities or social interactions; rejection of care. Those behaviors listed above were noted daily during the look back period, but a behavior care plan was not in place with interventions for staff to use when the resident exhibited these behaviors.
Resident #24 was prescribed an antidepressant daily for a diagnosis of depression. A Psychotropic medication care plan was not completed.
Resident #24 had expressive and receptive communication impairment. The MDS noted Resident #24 was rarely or never understood for ability to express ideas and wants, considering both verbal and non-verbal expression. The MDS documented Resident #24 rarely or never understood verbal content, however able (with hearing aid or device if used). A Comprehensive care plan to ensure the resident's communication needs were met was not completed.
On 12/2/21 at 9:45 a.m., in an interview with the Regional MDS Coordinator and the facility MDS Coordinator, the facility MDS Coordinator acknowledged the facility failed to develop a comprehensive care plan for Resident #24 as required by regulation.
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 observation and staff interview the facility failed to ensure proper storage of medications in 1 (Nurses station #2) of 2 medication storage rooms. This has the potential for expired medicati...
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Based on observation and staff interview the facility failed to ensure proper storage of medications in 1 (Nurses station #2) of 2 medication storage rooms. This has the potential for expired medications to be administered to residents.
The findings included:
On 11/30/21 at 11:30 a.m., observation of Medication room at Nurses station #2 with Licensed Practical Nurse (LPN) Staff M revealed:
Three bottles of Pro Stat expired 9/3/2021.
Photographic evidence obtained
Four bottles of Magnesium Chloride best by 8/21.
Photographic evidence obtained
One bottle of Calcium + D3 expired 8/21.
At the time of the observation, LPN Staff M confirmed the medications were expired.
On 11/30/21 at approximately 11:40 a.m., in an interview, the Regional Director of Nursing confirmed the medications were expired and removed them from the medication room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review, review of the facility's policy and procedure, staff and resident interview, the facility failed to administer the influenza vaccine as requested to 1 (Resident #56) of 6 sampl...
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Based on record review, review of the facility's policy and procedure, staff and resident interview, the facility failed to administer the influenza vaccine as requested to 1 (Resident #56) of 6 sampled residents reviewed for immunization.
The findings included:
Review of facility policy titled Influenza Vaccine - Resident with a revision date of 8/17/2020 stated, Residents will be offered the influenza vaccine annually (between October 1st and March 31 st unless otherwise directed by the CDC) to encourage and promote the benefits associated with vaccinations against influenza, in accordance with the local health department and Centers for Disease Control Guidelines . Have the resident / resident representative sign the informed consent, indicating acceptance or declination. Obtain a physician's order. Administer the vaccine, and document on the Medication Administration Record (MAR) .
On 11/29/21 at 11:18 a.m., in an interview Resident #56 said she has been asking for an influenza vaccine since her admission to the facility on 9/29/21. The resident said she's asked multiple nurses over the past several weeks since October, but they just keep brushing her concerns to the side and not telling her why she cannot have the flu vaccine.
On 12/1/21 review of the clinical record revealed on 10/26/21 Resident #56 signed an informed consent for the influenza vaccine. The options I accept and give the facility permission to administer the influenza vaccine and I was offered the influenza vaccine but have already received the vaccine during the current season outside of the facility were checked off. The nurse wrote N/A (not applicable) followed by her initials next to the option indicating the resident already received the vaccine during the current season.
Review of Resident #56's immunization record in Florida Shots (centralized online immunization information system) showed Resident #56 had not received the influenza immunization for the 2021/2022 flu season.
Review of Resident #56 electronic clinical record showed an update immunization entry for the influenza, seasonal, injectable noting a Consent confirmed date of 11/5/2021. The note indicated Resident #56 refused the vaccine. The reason refused was, Resident refused.
On 12/1/21 at 11:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said she was not sure why the consent to give and the refusal were both checked off on Resident #56's informed consent for the influenza vaccine. LPN Staff B pointed to the 11/5/2021 entry and said, Here it says that she refused the vaccine. LPN Staff B said she would speak with Resident #56 regarding the influenza vaccine.
On 12/1/21 at 12:10 p.m., in an interview LPN Staff B said she spoke with Resident #56 and verified the resident wanted the influenza vaccine. She said she did not know how the decline got placed in the electronic clinical record.
On 12/1/2021 at 1:20 p.m., LPN Staff B wrote in a progress note, Miscommunication about flu and pneumonia vaccine consent. Upon further research and discussion with resident she states that she does want both vaccines .
On 12/2/21 at 11:25 a.m., in an interview the Director of Nursing (DON) confirmed Resident #56 requested the influenza vaccine several times but did not receive it. The DON confirmed this was a breakdown in the immunization process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews the facility failed to maintain/store resident personal care items in a sanitary manner to prevent potential cross contamination for 9 (Residents #11, #39, #...
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Based on observations and staff interviews the facility failed to maintain/store resident personal care items in a sanitary manner to prevent potential cross contamination for 9 (Residents #11, #39, #48, #77, #86, #91, #24, #37, and #52) of 20 sampled residents. In addition, the resident chairs in the Memory care unit were in disrepair.
The findings included:
1. On 11/29/21 at 9:45 a.m., the shared bathroom of Resident #77 and #86 was observed to have unmarked, unidentified personal care items being stored in an unsanitary manner. An opened bottle of total bath wash and a bottle of mouthwash were stored on the sink. A tube of toothpaste and a toothbrush with the bristles facing down and against the wall were stored on the soap dish.
Photographic evidence obtained
The same observation was made on 11/30/21 at 10:10 a.m., and 12/1/21 at 9:51 a.m. The unmarked, unlabeled personal care items remained stored on the sink and the soap dish.
On 12/01/21 at 10:15 a.m., Certified Nursing Assistant (CNA) Staff K verified the personal care items in the shared bathroom of Residents #77 and #86 were not labeled and stored in a sanitary manner. CNA Staff K said he did not know which items belonged to which resident and said, I don't know. I use the items for both residents if needed. They are low on supplies here. I have been to other places where they have the items bagged with the resident's name on the bag but not here. This is how I have seen it in every room here. I haven't seen any of the rooms with the items separated here.
2. On 11/29/21 at 11:15 a.m., the shared bathroom of Resident #48 and #39 was observed to have unlabeled, unidentified personal care hygiene items stored in an unsanitary manner.
An opened bottle of total bath wash, a bottle of shaving cream, and two toothbrushes with the bristles against the sink were stored on the bathroom sink.
Photographic evidence obtained
The same observation was made on 11/30/21 at 10:07 a.m.
On 12/01/21 at 9:40 a.m., the bottle of total bath wash, a bottle of shaving cream, and two toothbrushes remained stored on the sink. An unlabeled bottle of mouthwash was stored on the toilet tank.
On 12/1/21 at 145 p.m., in an interview CNA, Staff L, caring for Residents #48 and #39 confirmed the residents' personal items were unlabeled and stored on the sink and on the toilet tank in the shared bathroom. When asked how she knew who the items belonged to, she said, I think they are [Resident #48's]. [Resident #39] keeps most of his stuff in his drawer. CNA, Staff L said, We don't have space to keep them separate in the bathroom.
3. On 12/1/21 at 12:05 p.m., observed Registered Nurse (RN) Staff N washing her hands in the sink of the shared bathroom of Resident #11 and #91. A partially filled bottle of total bath was observed stored on the sink.
In an interview at the time of the observation RN Staff N said she did not know who the bottle of total wash belonged to. She said, I think they use it for both of them. They are both bed baths since they do not go to the showers.
On 12/02/21 at 8:45 a.m., in an interview regarding policy for storage of residents' personal hygiene items Regional Registered Nurse (RN) said, We do not have a specific policy. It is expected that they maintain their hygiene items separately to maintain cleanliness.
On 12/02/21 at 11:15 a.m., in an interview about storage of residents' personal hygiene items, Licensed Practical Nurse (LPN) unit manager Staff B said, They should be separate and bagged or in a bin labeled.
After looking at the photographic evidence obtained from the shared bathrooms of residents #39, #48, #77, and #86, LPN Unit Manager Staff B said, We have been using a lot of agency staff, but they should know better. I am going to go room by room and throw away all of the items now and educate the staff.
On 12/2/21 at 11:25 a.m., in an interview the Director of Nursing (DON) said Residents' personal care items should be labeled and stored separately. After looking at the photographic evidence obtained from the shared bathroom of residents #39, #48, #77, and #86 the DON verified the personal care items were not stored in a sanitary manner and could be an infection control issue.
7. On 11/30/21 at 10:31 a.m., the shared bathroom for Resident #37 and Resident #52 was observed to have unmarked, unidentified personal care items being stored in an unsanitary manner. A resident's wash basin was being stored on the floor next to the toilet, a tube of skin protectant, bottle of periwash, and bottle of mouth rinse were on the sink. On 12/1/21 at 4:19 p.m., the unlabeled personal care items were observed being stored on top of the paper towel dispenser.
8. On 11/30/21 at 10:31 a.m., Resident #24's shared bathroom was observed to have unmarked unidentified personal care items being stored in an unsanitary manner. A toothbrush was lying on the top of the toilet tank with the bristles up against the wall along with a tube of toothpaste; an unmarked denture cup was on the sink; a bottle of periwash, mouthwash, skin protectant, were present and a can of hairspray was on the towel bar. On 12/1/21 at 4:19 p.m., the unidentified personal care items were still present including a comb being stored on the toilet tank along with the toothbrush.
9. On 11/29/21 during a tour of the facility, three of the side chairs in the living room of the Memory Care unit were observed to be in disrepair with the protective surface rubbed off creating uncleanable surfaces. The chairs were observed to be low to the ground with high arms, light weight, and easily moved. On 11/30/21 at 3:00 p.m., an incontinent pad was noted on one of the chairs.
Certified Nursing Assistant (CNA) Staff A was present during the observation and said because the chairs are so worn, if a resident is incontinent, urine will soak down into the cushion of the chair due to no barrier. The CNA said the chairs are difficult for residents to get up out of and easily move creating a fall hazard. On 12/2/21 at 5:15 p.m., the facility's Administrator acknowledged the concern with the chairs being in disrepair.
Photographic evidence obtained
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review, policy review, and staff interview, the facility failed to provide pharmacy services to ensure 3 (Resident #52, #24, and #37) of 7 residents medication administration records r...
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Based on record review, policy review, and staff interview, the facility failed to provide pharmacy services to ensure 3 (Resident #52, #24, and #37) of 7 residents medication administration records reviewed received medication in accordance with physician orders.
The findings included:
The facility's policy 7.0 Medication Shortages/Unavailable Medications with a revision date of 1/1/13 read, .Upon discovery that Facility has an inadequate supply of a medication to administer to a Resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . Action may include . Use of an emergency (back-up) Third Party Pharmacy. If emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions .
1. Record review revealed Resident #52 had a physician's order, dated 11/17/21, for the antibiotic medication Cefazolin 1 gram to be given IV (intravenously) every morning for 10 days to treat an upper respiratory infection. The medication was scheduled to start on 11/18/21.
Resident #52's Medication Administration Record (MAR) for November 2021 was reviewed and showed the antibiotic was not started until 11/19 noting the delivery was pending from the pharmacy.
The stop date for the antibiotic was changed to 11/29/21. On 11/27/21 and 11/28/21 the nurse entered 9 (other/see nurse notes) on the MAR. The nurse documented in a medication administration note for 11/27/21 and 11/28/21, Awaiting pharmacy. No more in fridge. The clinical record documentation showed the IV antibiotic was only administered for eight days and not for 10 days as ordered.
On 12/1/21 at 12:39 p.m., in an interview the facility's Pharmacy Consultant said the pharmacy log indicated the medication was sent on 11/17 probably later in the day. More doses were sent on 11/22. She said she was still checking to see if the medication actually arrived at the facility on 11/17 but confirmed the resident did not receive the full 10 doses as ordered.
2. Record review revealed Resident #24 had a physician's order for Omeprazole one tablet daily for Gastroesophageal reflux disease, and Gabapentin 100 milligrams three times a day for nerve pain. Resident #24's MAR for September, October and November 2021 were reviewed. The Omeprazole was not documented as given on 9/28, 10/1, 10/2, 10/4, 10/8, 11/12, 11/16, 11/17, and 11/24. The Gabapentin was not documented as given for one dose on 11/6, and two doses on 11/7. Each time the nurse entered 9 (Other/See Nurse notes) on the MAR and documented n/a on the nurses note indicating the medication was not available.
3. Record review revealed Resident #37 had a physician's order for Rivastigmine patch for treatment of Dementia daily and Ropinirole one daily for tremors. Resident #37's MARs for September, October and November 2021 were reviewed. The Rivastigmine patch was not documented as given on 9/6. The nurse documented the medication was not available. The Ropinirole was not given on 10/10. The nurse documented awaiting pharmacy delivery.
On 12/1/21 at 12:34 p.m., reviewed the concern of medications not being available from the pharmacy with the Director of Nursing. She said she was not aware of issues of medications not being available. She said she gets reports of medications not given but it would not notify her if there was a nursing note with a reason.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
4. On 12/2/21 clinical record reviewed for Resident #86 including Medication Administration Records (MAR) for October 2021 and November 2021.
The MARs lacked documentation Cyanocobalamin 1000 microgr...
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4. On 12/2/21 clinical record reviewed for Resident #86 including Medication Administration Records (MAR) for October 2021 and November 2021.
The MARs lacked documentation Cyanocobalamin 1000 micrograms intramuscular was administered as ordered on 10/28/21, 11/18/21 and 11/25/21.
There was no documentation the Senna tablet 8.6 micrograms (mg) was administered as ordered for constipation on 10/28, 11/14, 11/23, 11/25 and 11/27/21.
5. On 12/2/21 clinical record reviewed for Resident #48 including MARs.
The MARs lacked documentation risperidone tablet 2 milligrams (mg) was administered at bedtime as ordered for schizophrenia on 10/28/21, 11/14/21, 11/23/21 and 11/27/21.
6. On 12/2/21 clinical record reviewed for Resident #53 including MARs. The MARs lacked documentation of administration of atorvastatin calcium tablet 40 mg at bedtime for cholesterol, trazodone HCL tablet 50 mg at bedtime, levetiracetam solution 7.5 milliliters for seizures on 10/28/21, 11/14/21, 11/23/21, and 11/27/21.
There was no documentation the blood glucose was monitored, and Regular insulin administered based on the blood glucose result as ordered at 6:00 a.m., on 10/14/21 and 9:00 p.m., on 10/28/21, 11/14/21, 11/23/21 and 11/27/21.
On 12/02/21 at 11:25 a.m., in an interview with the Director of Nursing (DON) about documentation of medication administration expectation, the DON said, Staff are expected to administer medications as ordered and to document when they administer them.
Based on record review and staff interview, the facility failed to ensure medical records contained accurately documented information for the administration of medications for 6 (24, #37, #52, #48, #53, #86) of 7 residents medication administration records reviewed.
The findings included:
The facility's Policy N-853 Medication-Oral Administration Of (revised 9/22/17) indicated to, . Chart on Medication Administration Record (MAR) according immediately following when medication is given and before proceeding to the next resident .
The facility's policy 7.0 Medication Shortages/Unavailable Medications with a revision date of 1/1/13 read, .Upon discovery that Facility has an inadequate supply of a medication to administer to a Resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy . If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . Action may include . Use of an emergency (back-up) Third Party Pharmacy. If emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions .
1. Review of Resident #37's clinical record revealed the physician's orders included to administer Trileptal twice a day for seizures.
On 11/30/21 Resident #37's MARs for September, October, and November 2021 were reviewed.
There was no documentation the Trileptal was administered on 11/10 and 11/19 and 11/30.
On 12/1/21 at 10:26 a.m., Licensed Practical Nurse Staff B reviewed the MARs for Resident #37 and confirmed if there was no check mark in the box and a code number was entered in the MAR, it meant the medication was not given and the reason should be documented in the nurses' notes. Staff B confirmed there was no documentation as to why the medication was not given in the nursing notes.
2. Resident #52's clinical record revealed the physician's orders included Diltiazem daily for rapid heart rate; Colace twice a day for constipation; Eliquis twice a day for heart disease/blood thinner; Levetiracetam three times a day for seizures; and Azithromycin daily for 5 days treatment for Upper Respiratory infection.
On 11/30/21 Resident #52's MARs for September, October and November 2021 were reviewed.
There was no documentation the morning dose of Diltiazem, docusate sodium and Eliquis were administered on 9/1/21. The clinical record lacked documentation the 1:00 p.m. dose of Levetiracetam was administered on 9/1 and 10/17. The Azithromycin 500 was not documented as administered on 11/20/21.
3. Review of Resident #24's clinical record revealed the physician's orders included Gabapentin three times a day for nerve pain and Eliquis daily for heart disease/blood thinner. On 11/30/21 Resident #24's MARs for October, and September 2021 were reviewed.
There was no documentation of the Gabapentin being given on 10/17, or the Eliquis being given on 9/16 and 9/17.
On 12/1/21 at 12:34 a.m., during an interview with the Director of Nursing (DON), reviewed the concern with medications not being documented as given or if not given, the reason noted in the medical record. The DON said she was not aware of any issues with medications not being given. She said she gets a report if there are omissions (left blank) with the medications but had not identified any concerns.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, and staff interview, the facility failed to maintain the kitchen in a clean and sanitary manner and in good repair by having openings into the ceiling with potential contaminatio...
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Based on observation, and staff interview, the facility failed to maintain the kitchen in a clean and sanitary manner and in good repair by having openings into the ceiling with potential contamination of the food areas; uncleanable surfaces in food storage and preparation areas, and outdated food items.
The findings included:
1. On 11/29/21 at 9:28 a.m., during the initial tour of the kitchen, the following was observed:
The ceiling upon entry to the kitchen had a partially detached broken rusted vent with a three-inch-by-three-inch hole.
Photographic evidence obtained
The ceiling tiles in the main kitchen were stained with a brown substance in front of the stove and food prep areas.
Photographic evidence obtained
Several of the ceiling vents and support frames were heavily soiled with a black bio-growth.
Photographic evidence obtained
The pipe next to the plate warmer and steam table had a one-inch opening into the ceiling around the pipe.
The plastic coating was peeling on the surface of a utility cart holding beverages.
Photographic evidence obtained
The inside frame of the reach-in freezer was stained/soiled with a brown substance.
Several of the utility and storage carts had rusted/corroded wheels creating an uncleanable surface.
Photographic evidence obtained
The door frame of the walk-in refrigerator was heavily soiled/stained and in disrepair.
Photographic evidence obtained
The floor was in disrepair with large sections of loose concrete across entrance to the freezer area.
Photographic evidence obtained
The inside of freezer floor was heavily soiled with spillage and debris.
Photographic evidence obtained
Two egg salad sandwiches dated 11/24 being were stored in the reach-in refrigerator for potential use.
Photographic evidence obtained
On 11/29/21 at 10:04 a.m., in an interview [NAME] Staff G said the storage of leftover food was for three days and confirmed the egg salad sandwiches should have been disposed of on 11/27. [NAME] Staff G removed the sandwiches.
2. On 11/29/21 at 11:25 a.m., observation revealed [NAME] Staff G taking the temperature of the uncovered food on the steam table.
There were two uncovered bins of rolls next to the food. Maintenance Staff F was observed on a step ladder in front of the steam table with a spray bottle cleaning the biogrowth off the ceiling vents. [NAME] Staff G said maintenance was usually not in the kitchen when food was present on the steam table.
On 11/29/21 at approximately 11:30 a.m., in an interview, the Registered Dietitian (RD) came into the kitchen and said she was aware of Maintenance Staff F being in the kitchen but did not realize uncovered food was on the steam table. The RD confirmed the potential contamination of the food on the steam table and instructed Maintenance Staff F stop cleaning the vents.
On 11/29/21 at 1:30 p.m., in an interview, Maintenance Staff D said normally he does not do any maintenance work when food is being prepared or served and waits until after hours. He said he had no record of being told to clean the vents and relied on the kitchen staff to tell him. He said this morning around 10:30 a.m., Food Services Supervisor Staff H notified him to clean the vents as quickly as possible. He said Maintenance Staff F was using a bleach mixture to get rid of the biogrowth on the vents.
3. On 11/29/21 at 1:45 p.m., biogrowth on the wall in the storage area was observed along with the RD who said she was unaware of this. She acknowledged the floor of the food storage area was soiled and rust was present on the food storage racks.
On 12/2/21 at 11:51 a.m., in a follow up tour with the RD the broken grate was still present in the ceiling in front of the entry door of the kitchen. The inside of the reach in freezer was soiled and stained. The denuded cart was still in use, holding drinks. a dead insect was observed on the floor under the rack.
The RD acknowledged the rusted wheels were uncleanable and needed to be replaced.
Feb 2020
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review, observation, and staff interview the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment related to Behaviors and Discharge status for 2 (Residents #49 ...
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Based on record review, observation, and staff interview the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment related to Behaviors and Discharge status for 2 (Residents #49 and #111) of 3 residents reviewed for Behaviors and Discharge status. This has the potential to lead to delayed care planning and services for the residents effected.
The findings included:
1. A discharge MDS 3.0 assessment was completed for Resident #111 on 1/15/20. The MDS was coded to indicate the resident was discharged to an acute care hospital. A review of Resident #111 clinical record indicated she was discharged to an Assisted Living Facility on 1/15/20 with medications and home health services.
On 2/13/20 at 1:46 p.m., MDS Staff Q confirmed the discharge MDS was incorrectly coded for Resident #111.
2. Resident #49's clinical record revealed a diagnosis of Dementia with behavioral disturbance. On the admission Data Collection form completed by Licensed Practical Nurse Staff Z on 9/18/19, noted Resident #49 was angry, verbally abusive, and became very upset during an assessment of his skin. Staff Z noted the resident said, if he had a gun, he'd shoot us.
In a Social Service Progress Review on 9/25/19, Social Worker (SW) Staff E noted Resident #49 had exhibited the behaviors of Hitting and Rejects care.
An admission MDS assessment completed on 9/25/19, indicated the resident had exhibited no behaviors. The Care Area Assessment did not trigger for any review or assessment of the resident's behaviors and no behavior care plan was developed.
In an interview on 2/13/20 at 10:05 a.m., SW Staff F said Resident #49 had angry outbursts, but was not aware of any hitting. Staff F reviewed the note by Staff E along with the MDS completed on 9/25/20 and confirmed the coding of behaviors by Staff E on the MDS was incorrect. Staff F said she was not aware the resident had been exhibiting behaviors on admission and should have developed a care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and record review the facility failed to develop individualized activity programs for 1 (Resident #25) of 4 residents reviewed for activities. Residents who atte...
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Based on observation, staff interview, and record review the facility failed to develop individualized activity programs for 1 (Resident #25) of 4 residents reviewed for activities. Residents who attend activities of their choice maintain and/or improve their psychosocial well-being and independence.
The findings included:
On 2/10/20 from 1:40 p.m., to 2:15 p.m., observed Resident #25 in the day room next to nursing station #2 with 3 other residents. The television (TV) was on but Resident #25 was unable to see the TV because she was facing the window. During the observation none of the facility staff came into the day room to interact with Resident #25 or the other residents.
On 2/10/20 at 3:39 p.m., observed Resident #25 in the day room next to nursing station #2. The TV was on but Resident #25 was unable to see the TV because she was facing the window. During the observation none of the facility staff came into the day room to interact with Resident #25.
On 2/11/20 from 10:00 a.m., to 10:36 a.m., observed Resident #25 in the day room next to nursing station #2 with 6 other residents. The TV was on, but Resident #25 and 3 other residents were unable to see the TV because they were not facing the TV. During the observation none of the facility staff came into the dayroom to interact with Resident #25 or the other residents to involve them in an activity.
On 2/12/20 at 11:24 a.m., Resident #25's daughter said her mother was a social person and liked to interact with the staff and other residents. Her mother also liked to watch TV, listen to music, read, write and played games. She said she visited her mother almost every day and she would find her in the day room facing away from the TV without staff in the room interacting with her and/or the other residents. She thought they needed more help in the activity department so there would always be someone in the nursing station day room to run the activity program and engage with the residents.
On 2/13/20 review of Resident #25's plan of care initiated on 7/26/19 stated Resident #25 was dependent on staff for meeting her emotional, intellectual and social needs. Resident #25 enjoyed writing, watching TV, reading, music and games. She interacts with staff and her peers daily.
On 2/13/20 from 10:00 a.m., to 10:31 a.m., observed Resident #25 in the day room next to nursing station #2 with 7 other residents. Resident #25 was sitting at a table with paper and pencil in front of her. During the observation none of the facility staff came into the dayroom to interact with Resident #25 and the other residents.
On 2/13/20 at 10:39 a.m., the Activity Director said he was the only person in the activity department since November 2019. He said there were scheduled activities in both nursing station day rooms and in the activity room throughout the day. Since he was the only person in the activity department, he was unable to conduct all the activities in the facility at the same time so he would ask one of the floor Certified Nursing Assistant to run the activity in their nursing station's day room. He said he didn't remember who he asked to run the activity program today in the day room next to nursing station #2. He confirmed there was no staff in the day room next to nursing station #2 conducting the activity program or interacting with Resident #25 and the other residents in the day room as required. The Activity Director acknowledged that even though documentation on Resident #25's activity record noted she attended the activity, there was no staff present to conduct the activity, to ensure Resident #25 could see the TV from her wheelchair or to interact with any of the residents in the day room next to nursing station #2.
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 observation, interview and record review the facility failed to ensure medication administration was free from errors having a medication error rate of 7.69% for 1 (Resident #65) of 7 residen...
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Based on observation, interview and record review the facility failed to ensure medication administration was free from errors having a medication error rate of 7.69% for 1 (Resident #65) of 7 residents observed receiving medications, by having 2 errors out of 26 opportunities.
The findings included:
On 2/12/20 at 9:07 a.m., Registered Nurse (RN) Staff O was observed preparing medications for Resident #65. The Medication Administration Record (MAR) indicated Resident #65 was to receive Albuterol Sulfate inhaler (a bronchodilator) inhale 1 puff every 4 hours for COPD (Chronic Obstructive Pulmonary Disease). RN Staff O instead prepared to administer the medication Ipratropium Bromide/Albuterol 0.5 mg - 3 mg/3 ml solution (DuoNeb). The MAR indicated this medication was to be inhale 1-unit dose via nebulizer every 4 hours as needed for URI (upper respiratory infection). When questioned as to why she was administering the DuoNeb, RN Staff O said this was the right medication she was to administer and wrote her initials next to the 8:00 a.m. dose of the Albuterol Inhaler.
RN Staff O took the DuoNeb solution into Resident #65 room and was observed filling a nebulizer (device used for inhaling mist into the lungs). RN Staff O told Resident #65 she was going to give him a nebulizer treatment. Resident #65 said Okay and Staff O handed Resident #65 the nebulizer mouthpiece and started the breathing treatment. Staff O did not assess the resident for the necessity of the breathing treatment.
In an interview at the time of the observation, Resident #65 said he did not recall requesting the nebulizer treatment, but I must have.
Review of Resident #65's MAR revealed the Albuterol inhaler was documented as not given since 2/11/20 at 12:00 a.m. It was noted on 2/11/20 4:00 a.m. the reason the inhaler was not given do not have. The DuoNeb solution for the month of February was blank, indicating Resident #65 had not received any nebulizer treatments.
On 2/12/20 at 9:51 a.m., RN Staff O confirmed there was no Albuterol Inhaler available for Resident #65 and had given a different medication than what was scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and staff interview the facility failed to maintain the kitchen and nourishment room equipment for 2 of 2 nourishment rooms in a clean, safe and sanitizing manner to prevent poten...
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Based on observation and staff interview the facility failed to maintain the kitchen and nourishment room equipment for 2 of 2 nourishment rooms in a clean, safe and sanitizing manner to prevent potential contamination.
The findings included:
On 2/10/20 at 9:29 a.m., during the initial tour of the kitchen, the following was observed:
The heavy-duty coffee machine was heavily soiled and stained with grime and debris
A container used to store serving utensils underneath the chef's table was wet inside and soiled with debris and grime.
The tray stacking shelves on 2 of the food service carts were soiled with grime, debris and particles of food.
The Dietary Manager Staff C was present and confirmed the findings and stated, the staff could use this as a learning lesson, and the equipment should always be kept clean for use.
On 2/11/20 at 10:51 a.m., in an observation of the nourishment room in front of nurses' station 1. The coffee pot was soiled and stained with grime and debris inside of the pot and on the exterior of the pot. The microwave was corroded and rusted on the inside of the appliance and the interior of the door.
On 2/11/20 at 11:11 a.m., in an observation of the nourishment room in front of nurses' station 2. The coffee pot was soiled and stained with grime and debris. The coffee machine was corroded and soiled with debris, and grime. The refrigerator freezer had a broken shelf and was in disrepair.
On 2/12/20 at 9:22 a.m., in an observation of the nourishment room in front of nurses' station 1. The coffee pot and machine was stained and soiled with grime and debris. The microwave was still corroded and rusted on the inside of the appliance and the interior of the door.
On 2/12/20 at 9:25 a.m., Registered Nurse Unit Manager Staff A observed the nourishment room on station 1 and confirmed the microwave was corroded, peeling and the interior of the door was rusted, and the coffee pot and machine was soiled and stained with debris and grime. She said staff used the coffee pot to make, store and serve coffee to residents during the night shift, and the microwave was used to heat residents' food from outside that was stored in the refrigerator. She acknowledged it needed to be kept clean. She said nursing was responsible for the cleaning of the microwave and the coffee pot and machine, and the microwave needed to be thrown out.
On 2/12/20 at 10:24 a.m., during observation of the nourishment room in front of nurses' station 2, the coffee pot was stilled soiled and stained with grime and debris. The coffee machine was still corroded and soiled with debris and grime.
During interview on 2/12/20 at 10:28 a.m., Registered Nurse Unit Manager Staff B observed the nourishment room on station 2 and confirmed the soiled and stained coffee pot and corroded coffee machine. She said the coffee pot was used by staff to serve coffee to the residents at night, and the nursing staff was responsible for cleaning the appliances in the nourishment room.
On 2/13/20 at 9:23 a.m., during interview with Assistant Maintenance Staff D, he said the microwaves and coffee machines in the nourishment rooms were only inspected prior to installment to verify the electrical cords and the machine was adequate and in good working condition at that time.
On 2/13/20 at 10:35 a.m. during interview with the Director of Nursing, she confirmed the coffee machine and pots were soiled, stained and corroded and the microwave was peeling and rusted. She said the nursing staff was responsible for keeping the coffee pots, machines, and microwaves clean. She acknowledged the appliances were used for coffee for the residents during the night and the microwave was used to heat residents' food when needed. She said the nursing staff was to clean the appliances using soap and water and confirmed there was no soap in the nourishment rooms. She said the facility had no policy for the cleaning of the appliances in the nourishment rooms.
***Photographic evidence obtained***
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to maintain a clean and sanitary environment for 1 of 2 shower rooms. The facility failed to maintain resident care equipment in a functional and...
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Based on observation and interview the facility failed to maintain a clean and sanitary environment for 1 of 2 shower rooms. The facility failed to maintain resident care equipment in a functional and sanitary manner. This failure had the potential for the spread of infection to residents, and for potential injury.
The findings included:
During observation of Station #1 shower room on 6/2/20 at 9:15 a.m., the following was found:
A. The walls of the storage area in the shower room had holes with missing tiles.
B. There was an uncovered wall outlet box with exposed wires.
C. The sharps container on the wall was filled past the recommended fill line and had 12
D. The baseboards were pulled away and falling off one wall in the storage area of the shower room.
E. A trash can filled with soiled briefs had trash that had overflowed on to the floor.
F. Wet wash clothes were crumpled on the floor in the shower stalls and storage area.
G. The laundry barrel lid was on the floor, and soiled laundry was hanging over the uncovered barrel. The laundry barrel lid was used to cover an open drain hole on the floor.
H. The floor had missing and cracked tiles and was covered with dirt and grime.
I. The shower chair had a brown substance and grime under the seat frame.
J. Three mechanical lifts were stored in the room. Each lift had dirt, grime and dust on the footrests and lift frames. The two sit-to-stand lifts that were used to transfer residents, had torn, frayed and ripped slings with exposed foam padding.
K. Hair dryers stored in a cabinet, were covered with dirt and grime.
L. The shower room fronted a water heater room. The water heater room had three missing ceiling tiles, with one opening large enough for an adult to fit through. The walls were covered with dead insects. The floor was covered with dirt and debris. There were three dead frogs and scattered skeletal remains of other frogs on the floor. There was evidence of large, fresh, black rodent droppings on the floors. The room had a screened wall vent with a twelve-inch hole that directly exposed the water heater room to the outdoors.
On 6/2/20 at 9:30 a.m., in an interview Certified Nursing Assistant (CNA), Staff G said the shower room was in use daily for the CNA's to shower the residents. Staff G said housekeeping was responsible for cleaning the room. Staff G acknowledged the lift slings were torn and should not be in use.
On 6/2/20 at 9:40 a.m., in interview the Director of Nursing (DON) observed the condition of the shower and water heater rooms and said housekeeping was to clean the shower room daily. The DON verified the sharps container was filled past the recommended fill level and said the nurse was responsible to check the sharps container daily and change it when needed.
On 6/2/20 at 10:00 a.m., in an interview the Director of Maintenance (DM) said he was not aware of the condition of the Station #1 shower room. He said he had not received any maintenance repair requests to fix the holes in the shower room walls, or the open floor drain. The DM said he checked the shower rooms daily but did not see the holes in the wall and said, it must have just happened. He said he was not aware of the exposed wires in the wall outlet box. The DM said the wires were not live and were from an old call light. The DM said the uncovered drainage hole in the shower room floor appeared to be from a sink that was removed. The DM said the water heater room was checked weekly, but he was not aware of missing ceiling tiles or holes in the wall. The DM said he was unaware of bugs covering the walls in the water heater room, The DM verified the room had skeletal remains of frogs and fresh rodent droppings. The DM confirmed he had no documentation of the monthly or weekly checks of the shower room and water heater room.
On 6/2/20 at 10:30 a.m., in an interview Housekeeper Staff H said she mopped the shower room daily and emptied the garbage. The Housekeeper said she was not aware of the uncovered plumbing drain or the holes in the walls.
On 6/2/20 at 11:30 a.m., in an interview the District Manager said the CNA's were responsible for cleaning the mechanical lifts. The District Manager said there was no policy or documentation for the process to clean the lifts, or who was responsible to clean them. The District Manager viewed the photographs of the torn lift slings and said the Laundry Aides check the lift slings and if damaged, they were not to be used for resident transfers.
***Photographic evidence obtained***
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on staff interview and record review the facility failed to ensure 5 (Staff R, S, T, U and V) of 5 employee records had a performance review completed at least once every 12 months. The facility...
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Based on staff interview and record review the facility failed to ensure 5 (Staff R, S, T, U and V) of 5 employee records had a performance review completed at least once every 12 months. The facility failed to ensure staff has in-service education based on the outcome of their performance reviews by not having annual competency evaluations.
The findings included:
On 2/13/20, a review of the Facility Assessment Tool updated on 12/19/19 stated every staff member will have knowledge competency in abuse, neglect, exploitation, resident rights, dementia management, infection transmission and prevention with additional knowledge competencies which are determined according to the amount of resident interaction required by their job role. Competencies are based on current standards of practice and may include knowledge base test and return demonstration. Competencies are verified upon orientation, annually and as needed.
On 2/13/20, a review of Certified Nursing Assistant (CNA) Staff R's employee file revealed they were hired 12/24/18. There was no documentation Staff R had an employee performance review in 2019.
On 2/13/20, a review of CNA Staff S's employee file revealed they were hired 10/22/02 and their last employee performance review was completed on 11/27/16. There was no documentation Staff S had a performance review for 2017, 2018 and 2019.
On 2/13/20, a review of CNA Staff T's employee file revealed they were hired 16/18/13 and their last employee performance review was completed on 6/2/16. There was no documentation Staff T had a performance review for 2017, 2018 and 2019.
On 2/13/20, a review of CNA Staff U's employee file revealed they were hired 2/26/08 and their last employee performance review was completed on 5/9/17. There was no documentation Staff U had a performance review for 2018 and 2019.
On 2/13/20, a review of CNA Staff V's employee file revealed they were hired 8/6/07 and their last employee performance review was completed on 8/7/16. There was no documentation Staff V had a performance review for 2017, 2018 and 2019.
On 2/13/20 at 1:43 p.m., the Human Resources Director (HRD) said she has been working as the HRD since September 2018. She said since December 2018 she had noted some of the employees did not have their required annual employee performance review as required. She further said the nursing department was required to do each employee performance review yearly by their hire date. She confirmed Staff R was hire 12/24/18 and had not had his annual performance review as of this time. She confirmed Staff S, T and V did not have their annual performance review in 2017, 2018 and 2019. She also confirmed Staff U did not have their annual performance review in 2018 and 2019.
On 2/13/20 at 4:10 p.m., the Administrator said their Facility Assessment Tool which was last updated 12/19/19 stated under the section Staff Training/Education and Competencies of all staff are based upon their job role, job specific knowledge and skills which were tested to ensure they were at the current standard of practice, which may include a test of their knowledge during their annual performance evaluation. Staff competencies were verified upon orientation, annually and as needed. She confirmed Staff R, S, T, U and V did not receive annual competencies/performance evaluations as required as per their policy and Facility Assessment Tool last update 12/19/19. The Administrator stated the corporate consultant identified in October 2019; the 2019 staff competency evaluations had not been completed as required. She stated some evaluations were completed in December 2019, however not all employees hired prior to 2019 had their annual competency evaluation for the calendar year 2019 as of this date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assess the behaviors, identify triggers, plan ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assess the behaviors, identify triggers, plan care, and provide individualized interventions to prevent/minimize distress prior to the initiation of an antipsychotic medication for 1 (Resident #49) of 4 residents reviewed for dementia care of 24 residents with dementia. In addition, the facility failed to administer the antipsychotic medication as ordered so the effectiveness of the medication could be evaluated by the prescribing physician.
The findings included:
The facility's policy and procedure for Medication Management-Psychotropic Medications (N-1255, revised 3/23/18) included: Monitor behavior and side effects every shift using the Behavior Monitoring Flow Record Resident centered non-pharmacological interventions should be initiated as indicated .Care plan to include person centered goals and non-pharmaceutical interventions . and monitoring should also include evaluation of the effectiveness of non-pharmacological approaches.
On 2/10/20 at 9:42 a.m., Resident #49 was observed lying in bed, wearing a gown. The resident said he had no concerns but things are slow around here and they always leave me until last. On 2/10/20 at 2:28 p.m., the resident was up in the wheelchair and self-propelling down the hallway. He was not smiling and responded No at attempt to interview. Licensed Practical Nurse (LPN) Staff G was present in the hallway and said Resident #49 can get agitated and his cognition varies during the day.
Resident #49's clinical record revealed a diagnosis of Dementia with behavioral disturbance. An admission Data Collection form completed by LPN Staff Z on 9/18/19, noted Resident #49 was angry, verbally abusive, and became very upset during an assessment of his skin. Staff Z noted the resident said, if he had a gun, he'd shoot us. In a Social Service Progress Review on 9/25/19, Social Worker (SW) Staff E noted Resident #49 had exhibited the behaviors of Hitting and Rejects care. An admission Minimum Data Set 3.0 (MDS) assessment completed on 9/25/19, indicated the resident had exhibited no behaviors. The Care Area Assessment did not trigger for any review or assessment of the resident's behaviors and no behavior care plan was developed.
On 10/3/19, Resident #49's care plan was updated to include the problem of behaviors related to increased confusion, with a goal to have no behaviors of yelling by next review. The approaches included to intervene as necessary, divert attention, and remove from situation. There was no further documentation of the resident having any behaviors until an Interdisciplinary (IDT) progress note on 12/16/19, where Resident #49 was noted to be non-compliant, refusing care, and agitated. On 12/19/19, a physician's order was obtained to re-consult with psych to evaluate and treat physical agitation, verbal aggression, and combative behavior.
On 1/3/20, the consulting psych physician ordered the antipsychotic medication Risperdal 0.5 milligrams (mg) daily at bedtime and Risperdal 0.25 mg twice a day for Dementia with behaviors (total of 1.0 mg per day). There was no Behavior Monitoring Flow Record to document the number of occurrences of these behaviors before or after the initiation of the antipsychotic medication to evaluate the effectiveness of any non-pharmacological interventions.
The resident's care plan was updated on 1/6/20 to include the use of an antipsychotic medication for behavior management. The approaches included to monitor/record occurrence of target behavior symptoms of violence/aggression towards staff/others, yelling out, and angry. The care plan did not identify what the behavior triggers were or interventions for staff to use to prevent or minimize these behaviors.
In an IDT note on 1/10/20 at 5:00 p.m., Resident #49 was noted to be aggressive, kicking and swinging at staff in the hallway when staff was trying to redirect him.
On 1/15/20, the psychiatric physician wrote an order to change the Risperdal 0.25 mg to 0.125 mg three times a day. Review of Resident #49's Medication Administration Record for January 2020 revealed the Risperdal 0.25 mg twice a day was discontinued on 1/16/20. On 1/17/20, the resident received his bedtime dose of Risperdal 0.5 mg but did not receive any daytime doses of the Risperdal. On 1/18 the resident received only 2 of the 3 scheduled daytime doses of the Risperdal 0.125 mg in addition to the bedtime dose of Risperdal 0.5 mg. From 1/19 through 1/23, the resident received Risperdal 0.125 mg three times a day and Risperdal 0.5 mg at bedtime (total of 0.875 mg/day). On 1/24/20 the bedtime dose of Risperdal 0.5 mg was marked as being discontinued. There was no evidence of a physician's order to discontinue the bedtime dose of Risperdal 0.5 mg or physician notification of the missed doses on 1/17 and 1/18. From 1/24 through 2/5 the resident only received the Risperdal 0.125 mg three times a day (total of 0.357 mg per day).
In a skilled nursing note on 2/1/20, Registered Nurse (RN) Staff J noted Resident #49 was physically aggressive and hitting other residents. A Behavior Monitoring Flow Record was started on 2/1/20 for Striking out. On 2/5/20, the physician ordered to increase the resident's bedtime Risperdal to 1.0 mg and change the daytime Risperdal to 0.25 mg twice a day (total of 1.5 mg per day).
In an interview on 2/12/20 at 3:07 p.m., Certified Nursing Assistant (CNA) Staff H said she works both day and evening shifts and was familiar with Resident #49. The resident did not like people near his wife, (Resident #21), and would get confused and agitated. She would walk away and notify the nurse when he did this. The resident ate his meals and did activities with his wife. Staff H said the resident only gets upset when staff were trying to take his wife away from him to give her care and threatens staff with his fist. Staff H said in the evening he would not go to bed until his wife did. She got her information about resident care by asking the nurse or referred to the [NAME]. On 2/12/20, the CNA [NAME] for Resident #49 was reviewed and did not identify the resident had any behaviors for staff to be aware of when caring for him.
In an interview on 2/12/20 at 3:57 p.m., the Consulting Psych Physician said he was asked to see Resident #49 in November 2019 for Dementia with behaviors. The resident was declining cognitively and very agitated, especially in the evening. The goal was for him to sleep. He did adjust the antidepressant medication with some success, but more assaultive behaviors occurred late December into January, so he started Risperdal on 1/3/20. He lowered the dose of Risperdal during the day (on 1/15/20) but saw an increase in behaviors, so on 2/5/20 went to a full dose hoping he would be covered through morning.
In an interview on 2/12/20 at 4:50 p.m., LPN Staff K said Resident #49 had anger behaviors and displays them by yelling at staff. When staff tried to calm him down, he was combative. Staff K said the resident had exhibited these behaviors since admission.
In an interview on 2/13/20 at 9:29 a.m., LPN Staff I said Resident #49 could be uncooperative with care and became agitated if trying to provide care to him or his wife when they were together. When he was agitated, she would take the resident outside, offer food, take him to his wife, or give him a coloring activity.
In an interview on 2/13/20 at 10:05 a.m., Social Worker (SW) Staff F said Resident #49 had anger outbursts. but was not aware of any hitting. Staff F reviewed the note by SW Staff E along with the MDS completed on 9/25/20 and confirmed the coding of behaviors on the MDS was incorrect. SW Staff F said she was not aware the resident had been exhibiting behaviors on admission and should have developed a care plan.
In an interview on 2/13/20 at 11:45 a.m., the Administrator acknowledged the concern regarding the lack of documentation, monitoring, and care planning for Resident #49's behaviors being treated with an antipsychotic medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to properly store, label, and discard insulin according to standard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to properly store, label, and discard insulin according to standards of practice for 7 (Residents #5, #75, #90, #1, #42, #47, and #63) of 7 residents reviewed receiving insulin. This resulted in 3 residents (#5, #75, #90) of the 7 residents receiving insulin past the discard dates. Additionally, 2 of 3 carts observed were found with loose pills/debris in the bottoms of the carts, and an expired oral medication was found in 1 of 3 carts.
The findings included:
The facility provided Insulin Storage Recommendations ([DATE]) as their policy for insulin storage. Their recommended storage for Novolog and Humalog opened at room temperature is 28 days, Humulin R 31 days, Novolin R and Levemir 42 days.
1. On [DATE] at 01:15 p.m., observation of medication cart 2 station 2 revealed an opened vial of Novolog insulin for Resident #90 in a plastic medicine bottle. The labels on the vial said received on [DATE] and discard 28 days after opening. The insulin vial was opened but not dated. The plastic medicine bottle was dated opened [DATE]. If the vial was in the correct plastic medicine bottle, the discard date should have been [DATE].
Review of the resident's medication administration record, (MAR) noted Novolog was administered to Resident #90 on [DATE] (35 days after the vial was opened).
The findings were confirmed with Licensed Practical Nurse (LPN) Staff G.
2. On [DATE] at 2:05 p.m., observation of the Memory Care Unit medication cart revealed an opened vial of Novolog insulin for Resident #5 in a plastic medicine bottle. The labels on the vial said received on [DATE]. The plastic medicine bottle was dated opened [DATE]. The insulin vial was dated opened [DATE]. The vial was labeled, discarded 28 days after opening. The discard date should have been [DATE].
Review of the resident's MAR noted Novolog was administered to the resident on [DATE], (32 days after vial opened).
The findings were confirmed with LPN Staff P.
3. On [DATE] at 2:14 p.m., observation of the Memory Care Unit medication cart revealed an opened vial of Humalog insulin for Resident #75 in a plastic medication bottle. The label on the vial received on [DATE]. The plastic medicine bottle was dated opened [DATE]. The insulin vial was dated opened [DATE]. The vial was labeled, discarded 28 days after opening. The discard date should have been [DATE].
Review of the resident's MAR noted Humalog was administered to the resident on [DATE], (37 days after vial opened).
The findings were confirmed with LPN Staff P.
4. On [DATE] at 12:10 p.m., observation of cart 2 station 1 revealed an opened vial of Humalog insulin for Resident #63 was opened on [DATE]. The plastic medicine bottle was dated opened [DATE].
LPN Staff N acknowledged the Humalog plastic medicine bottle and vial date discrepancies and discarded the vial of insulin.
5. On [DATE] at 12:15 p.m., observation of cart 2 station 1 revealed an opened vial of Novolin R insulin for Resident #1 was received on [DATE]. The plastic medicine bottle was dated [DATE]. The vial was dated opened [DATE].
LPN Staff N acknowledged the Novolin R plastic medicine bottle and vial date discrepancies and discarded the vial of insulin.
6. On [DATE] at 12:25 p.m., observation of cart 2 station 1 revealed an opened vial of Levemir insulin for Resident #42 was received on [DATE]. The plastic medicine bottle was dated [DATE]. The vial was dated opened [DATE].
LPN Staff N acknowledged the Levemir plastic medicine bottle and vial date discrepancies and discarded the vial of insulin.
7. On [DATE] at 1:20 p.m., observation of cart 2 station 2 revealed an opened vial of Humulin R insulin for Resident #47 was received on [DATE]. The plastic medicine bottle was dated [DATE]. The vial was dated opened [DATE].
LPN Staff G acknowledged the Humulin R plastic medicine bottle and vial date discrepancies.
8. On [DATE] at 1:23 p.m. observation of cart 2 station 2 revealed 2 ½ loose unidentifiable pills in the bottom of the cart.
LPN Staff G acknowledged the finding.
9. On [DATE] at 2:30 p.m. observation of the Memory Care Unit Cart revealed 4 ½ loose unidentifiable pills in the bottom of the cart.
LPN Staff P acknowledged the finding.
10. On [DATE] at 2:35 p.m. observation of the Memory Care Unit Cart revealed an open bottle of over the counter stool softener, (Docusate Calcium) expired 2/2020. An opened date was not written on the bottle.
LPN Staff P acknowledged the finding and discarded the bottle.
***Photographic evidence obtained***
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Per record review of facility Clinical Guideline - Elopement/Wandering Risk, Document N-1031, Dated 9/2/16, Revision Date 8/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Per record review of facility Clinical Guideline - Elopement/Wandering Risk, Document N-1031, Dated 9/2/16, Revision Date 8/23/17, If utilizing a wander monitoring system device, check placement of the device every shift and functionality every day.
Per record review of the Care Plan initiated on 1/14/20, Resident #52 is an elopement risk/wanderer with history of attempts to leave facility unattended. Resident #52 attempts to remove wander guard, asks staff for scissors. Care Plan interventions include, remind resident not to remove wander guard and wander guard check placement every shift and functionality daily on 11-7.
Per record review, Elopement Risk Alert, Resident #52 was an exit seeking. Resident #52's picture and name were in the Elopement Risk book in the nurse's station.
Per record review of psychiatry notes on 1/29/20, Resident #52 was an exit seeking.
On 2/11/20 at 9:30 a.m., Resident #52 was observed walking in the hallway of the Memory Care Unit (locked unit). Resident #52 was holding a pen and small piece of paper. Resident #52 asked for the code to the locked door so she could write it down and leave the unit. Resident #52 was wearing a wander guard around her right wrist.
On 2/11/20 at 10:20 a.m., Resident #52 was observed asking the nurse for the code to the locked unit so she could get out. Resident #52 was holding a pen and small piece of paper.
On 2/12/20 at 9:15 a.m., Resident #52 was observed sitting at a Memory Care Unit dining room table. Resident #52 stood up from the table and said I'm gonna see if I can get out that door. Resident #52 proceeded to walk out of the dining room, into the hall. Registered Nurse (RN) / Unit Manager Staff B retrieved Resident #52 and brought her back into the dining room where Resident #52 sat in a chair in front of the television. Approximately one minute later, Resident #52 stood up from the chair and walked out of the dining room again.
On 2/13/20 at 10:50 a.m., in an interview with Certified Nursing Assistant (CNA) Staff Y said Resident #52 needs a wander guard because she always tries to get out.
On 2/13/20 8:49 a.m., in an interview with Licensed Practical Nurse (LPN) Staff W said Resident #52 was a flight risk and is not allowed out of the locked unit. She said she keeps colored pencils on the unit to re-direct her when she wants to leave. Staff W said Resident #52 got out of the locked unit before. She said Resident #52 got through the locked double doors when kitchen staff let her out by mistake. Staff W said she thought the wander guard was checked daily, but she did not know for certain. Staff W said the wander guard checks were written on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Staff W looked through the resident's MAR and TAR and could not find the documentation for wander guard checks. Staff W said the wander guard checks were not being done.
On 2/13/20 at 09:22 a.m., in an interview with Staff B said the resident was an elopement risk and should be getting wander guard checks. Staff B said the checks were documented in the MAR or TAR.
On 2/13/20 at 10:50 a.m., observed Memory Care Unit right-side double door propped wide-open for approximately 5-10 seconds. The door alarm was ringing, and Staff W came running out of the nurse's station to close the door and turn off the alarm.
On 2/13/20 at 4:00 p.m., in an interview with LPN Staff X, in the Memory Care Unit, she said the wander guard checks were documented on the MAR or TAR. Staff X looked through Resident #52's MARs and TARs and could not find the wander guard checks. Staff X looked through Resident #52's medical record and could not find the wander guard checks.
On 2/13/20 at 04:10 p.m., in an interview with the DON, she said wander guard checks were documented on the MAR or TAR. The DON said she thought the checks were done daily, but she was not sure.
Per record review of Resident #52s MAR and TAR for February 2020, there was no documentation for wander guard placement checks.
4. Per record review of the Policies and Procedures for Medication Management of Psychotropic Medications, Document N-1255, Effective 11/30/14, Page 1, Procedure #9, Resident(s) receiving anti-psychotic medications to have an AIMS [Abnormal Involuntary Movement Scale] completed quarterly, with initiation of new antipsychotic medications or increase in dosage.
Per record review of the psychiatry evaluation for Resident #68 dated 06/12/19, the psychiatrist prescribed Risperidone 0.25mg, give half tablet twice a day at 12:00 p.m. and half tablet at bedtime.
Per record review of Resident #68's Care Plans initiated on 6/14/19, Resident #68 is on antipsychotic therapy. The interventions included Complete AIMS quarterly.
Per record review of the Omnicare of [NAME] Consultation Report dated 11/20/19, an AIMS was not documented in the medical record within the previous 6 months. Please monitor for involuntary movements now and at least every 6 months thereafter or per facility protocol.
Per record review of physician's orders dated 1/30/20, Resident #68's current order is Risperidone 0.25 mg, half tablet by mouth at bedtime.
Per review of Resident #68's medical record, AIMS were completed on 7/23/20 (a future date that has not occurred), 10/24/20 (a future date that has not occurred), and 1/23/20. The signature of Staff B was written next to all three dates.
In a telephone interview on 2/13/20 at 09:49 a.m., the Omnicare Consultant Pharmacist confirmed an AIMS for Resident #68 was requested on 11/20/19, but there was no record of one being completed.
On 02/13/20 at 11:04 a.m., in an interview with Staff B she confirmed it was her signature at the bottom of the AIMS next the dates of 7/23/20, 10/24/20, and 1/23/20. Staff B confirmed she created the AIMS a few days ago to have it appear it was completed on 7/23/19, 10/24/19, and 1/23/20, and it was not. Staff B said she made the record up a few days ago and was not going to lie about doing that.
Based on record review and staff interview the facility failed to ensure medical records contained accurately documented information for the administration of medications, falls, behaviors, safety device, and medication side effect monitoring for 4 (Residents #49, #65, #52, and #68) of 19 sampled residents.
The findings included:
The facility's Policy N-853 Medication-Oral Administration Of (revised 9/22/17) indicated to Chart on Medication Administration Record (MAR) according immediately following when medication was given before proceeding to the next resident.
The facility's Policy 7.0 Medication Shortages/Unavailable Medications (revised 1/1/13) indicated upon discovery of an inadequate supply of medication to administer to the resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the ordered medication was not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery. If an emergency delivery was unavailable, facility nurse should contact the attending physician to obtain orders or directions. When a missed dose was unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the MAR and in the nurses notes per facility policy. Such documentation should include; a description of the circumstances of the medication shortage: a description of pharmacy's response upon notification; and action(s) taken.
1. Review of Resident #49's clinical record revealed physician's orders for the medications: Duloxetine 30 mg (an antidepressant) twice a day; Risperdal 0.25 mg (an antipsychotic) twice a day and Risperdal 0.5 mg at bedtime (ordered on 1/3/20); Risperdal 0.125 mg three times a day (ordered on 1/15/20), and Atorvastatin 10 mg (for high cholesterol) daily.
On 2/12/20, the MAR for January 2020 was reviewed.
On 1/1/20 at 9:00 a.m., and 5:00 p.m., there was no documentation of the reason Duloxetine was circled as not given; and on 1/14/20 at 9:00 p.m., there was no documentation of the medication being administered.
On 1/18/20 and 1/30/20 there was no documentation of the 9:00 a.m., dose of Atorvastatin being administered.
On 1/8/20 and 1/10/20 there was no documentation of the reason the 2:00 p.m., doses of Risperdal 0.25 mg were not administered.
On 1/17/20 there was no documentation of the Risperdal 0.125 mg being administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m., or the 10:00 p.m. dose on 1/18/20.
On 1/24/20 the 9:00 p.m. Risperdal 0.5 mg was marked as being discontinued. There was no physician's order to stop this medication.
In a review of the nursing notes for Resident #49, there was no description of the resident's falls that occurred on 11/3/19, 11/21/19, and 1/14/20. Resident #49 was also exhibiting behaviors starting from his admission on [DATE]. The behaviors became progressively worse requiring the initiation of an antipsychotic medication on 1/3/20. There was no documentation of any monitoring of the resident's behaviors from 9/18/19 until 2/1/20.
2. Review of Resident #65's clinical record revealed physician's orders for the medications: Albuterol Sulfate inhaler (a bronchodilator) inhale 1 puff every 4 hours.; and Bumetanide 1 mg (diuretic) daily.
On 2/12/20, the MAR for February 2020 was reviewed.
On 2/11/20 the Albuterol was circled as not given at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., and on 1/12/20 at 12:00 a.m., and 4:00 a.m. The back of the MAR indicated Do not have. On 2/11/20 the 9:00 a.m., dose of Bumetanide was circled as not given. There was no documentation of the actions taken to obtain the medications or physician notification of the medications not being given as ordered.
In an interview on 2/12/20 at 10:26 a.m., Registered Nurse Staff A said the Bumetanide was re-ordered from the pharmacy a few days ago but was available in the Emergency Medication Supply and should have been given.
In an interview on 2/13/20 at 2:25 p.m., the Director of Nursing (DON) said the facility's policy was to call the physician if a medication could not be given as ordered. In regard to the lack of documentation of falls and behaviors for Resident #49, the DON acknowledged this concern and said she would work with staff on improving their documentation.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 37 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $28,009 in fines. Higher than 94% of Florida facilities, suggesting repeated compliance issues.
- • Grade F (30/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Aviata At Venice's CMS Rating?
CMS assigns AVIATA AT VENICE 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 Aviata At Venice Staffed?
CMS rates AVIATA AT VENICE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Florida average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 64%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Aviata At Venice?
State health inspectors documented 37 deficiencies at AVIATA AT VENICE during 2020 to 2025. These included: 2 that caused actual resident harm and 35 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Aviata At Venice?
AVIATA AT VENICE 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 AVIATA HEALTH GROUP, a chain that manages multiple nursing homes. With 120 certified beds and approximately 92 residents (about 77% occupancy), it is a mid-sized facility located in VENICE, Florida.
How Does Aviata At Venice Compare to Other Florida Nursing Homes?
Compared to the 100 nursing homes in Florida, AVIATA AT VENICE's overall rating (2 stars) is below the state average of 3.2, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Aviata At Venice?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Aviata At Venice Safe?
Based on CMS inspection data, AVIATA AT VENICE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Florida. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Aviata At Venice Stick Around?
Staff turnover at AVIATA AT VENICE is high. At 59%, the facility is 13 percentage points above the Florida average of 46%. Registered Nurse turnover is particularly concerning at 64%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Aviata At Venice Ever Fined?
AVIATA AT VENICE has been fined $28,009 across 1 penalty action. This is below the Florida average of $33,359. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Aviata At Venice on Any Federal Watch List?
AVIATA AT VENICE 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.