NURSE CARE OF BUCKHEAD
For profit - Partnership
220 Beds
WELLINGTON HEALTH CARE SERVICES
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#301 of 353 in GA
Photo by Tessa Rogers
Photo by Tessa Rogers
Photo by Tessa Rogers
1 / 5 photos
Last Inspection: September 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Nurse Care of Buckhead has a Trust Grade of F, indicating a poor level of care with significant concerns. They rank #301 out of 353 facilities in Georgia, placing them in the bottom half, and #15 out of 18 in Fulton County, suggesting limited local options. The facility is worsening, with issues increasing from 23 in 2024 to 35 in 2025. Staffing is a weakness here, with a low rating of 1 out of 5 stars and a concerning turnover rate of 66%, which is higher than the state average of 47%. Additionally, there are serious compliance issues, including failures to ensure residents received necessary dialysis treatments, leading to missed appointments and avoidable hospitalizations, highlighting significant risks to resident safety.
- Trust Score
- F
- In Georgia
- #301/353
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 66% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $14,842 in fines. Lower than most Georgia facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Georgia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 77 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 15%
Review needed
23 → 35 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 35 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Georgia average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 66%
20pts above Georgia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $14,842
Below median ($33,413)
Minor penalties assessed
Chain: WELLINGTON HEALTH CARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (66%)
18 points above Georgia average of 48%
The Ugly 77 deficiencies on record
3 life-threatening 1 actual harm
Jun 2025
28 deficiencies
3 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Comprehensive Care Plan
(Tag F0656)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** null null null
Based on observations, interviews, record review, and review of facility policy titled Care Plan, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** null null null
Based on observations, interviews, record review, and review of facility policy titled Care Plan, the facility failed to develop or implement a comprehensive care plan for six of 106 sampled residents (R) (R49, R87, R96, R109, R80, and R180) related to dialysis for R49 and 87; related to Post Traumatic Stress Disorder (PTSD) for R96; related to activities of Daily Living (ADL) care for R109; related to pain management for R80; and related to positioning for R180.
On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025.
An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025.
Findings included:
A review of the facility's policy titled Care Plan dated August 2022 documented:
Intent: It is the policy of the facility to create Care Plans in accordance with State and Federal regulations. Procedure: Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of: a. Physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential.
Resident care plan means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident, the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being, a list of services provided within or outside the facility to meet those needs, and an explanation of service goals. The facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.
At the resident's option, every effort must be made to include the resident and family or responsible party, including a private duty nurse or nursing assistant, in the development, implementation, maintenance, and evaluation of the resident's plan of care.
1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder.
A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment.
A review of R49's care plan was initiated on 11/1/2022 with a focus on diagnoses of end-stage renal disease, bilateral kidney cancer, nephrectomy, and receiving dialysis. The interventions included, but were not limited to, encouraging R49 to go for the scheduled dialysis appointments. It was noted on 5/19/2025 that R49 was admitted to the Intensive Care Unit (ICU) in an acute care hospital for monitoring.
A review of the care plan dated 3/5/2021 revealed that R49 was at risk of experiencing adverse reactions and altered psychosocial wellbeing related to transportation issues with dialysis transportation. The outcome was that R49 would be free from increased signs and symptoms of adverse reactions related to issues with dialysis transportation through the next review. Interventions included contacting the transportation [NAME] and the standing order supervisor for the inquiry or complaint number. Ensure an alternative dialysis time option is available for the residents.
A review of the EMR discharge note revealed that R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload.
During an interview conducted on 6/4/2025 at 9:17 am, Dialysis Facility Administrator ZZZZ confirmed and provided the dates missed for chair appointments for residents R49 missed seven out of twelve dialysis treatments on 6/7/2025, 6/9/2025, 6/19/2025, 6/21/2025, 6/23/2025, 6/26/2025, and 6/28/2025. R49 was sent to the hospital on 6/19/2025, after displaying symptoms of shortness of breath and elevated potassium levels.
2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia end end-stage renal disease, and dependence on renal dialysis.
A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating Intact cognitive function.
A review of the care plan created on 2/16/2023 indicated that R87 needed hemodialysis related to end-stage renal failure. Interventions included hemodialysis on Tuesdays, Thursdays, and Saturdays, and if R87 missed dialysis, an attempt would be made to secure alternative transportation.
During an interview on 5/28/25 at 12:57 pm, Dialysis Facility Administrator (FA) YYYY and the Social Worker disclosed that R87 was hospitalized due to missing two consecutive treatments. It was shared that the facility confirmed the missed appointments were due to transportation issues and to be seen three times a week. The FA YYYY explained that the dialysis doctor contacted the facility and ordered R87 to be sent to the hospital for treatment. The previous transportation company was canceled, and the facility began using its own. The current transportation company operates only with one truck.
3. A review of the EMR revealed that R96 was admitted to the facility on [DATE] with a diagnosis that included, but was not limited to, PTSD.
A review of the admission MDS dated [DATE] documented that R96 presented with a BIMS score of one, which indicated R96 had severe cognitive impairment and had an active diagnosis of PTSD.
A review of the care plan in the EMR revealed there was no active, comprehensive care plan for PTSD.
During an interview on 6/2/2025 at 12:09 pm, MDS Coordinator KKK confirmed there was no care plan for R96's diagnosis of PTSD. She stated that the nursing staff, as well as herself and the other MDS Coordinators, were responsible for developing the comprehensive care plan related to the PTSD care area, and that it was not done. She further stated that if there was no care plan for PTSD, R96 was at risk for not receiving the appropriate care.
During an interview on 6/2/2025 at 1:08 pm, the DON revealed she confirmed there was no comprehensive care plan for PTSD for R96. She stated that the responsibility for ensuring there was a care plan developed for R96's PTSD was a collaborative effort between the MDS coordinators and the nursing department. She further stated it was important for a comprehensive care plan to include a plan of care for the diagnosis of PTSD to ensure that R96 received appropriate services to manage his condition.
During an interview on 6/5/2025 at 12:14 pm, the Assistant Director of Nursing (ADON) revealed that R96 could be missing out on care that he should be receiving for his condition since there was no comprehensive care plan. She stated that R96 would need various interventions related to that diagnosis.
4. A review of the facility's admission records revealed that R109 was admitted to the facility on [DATE] with diagnoses that included restlessness and agitation, major depressive disorder, fall on same level, dysphagia, aphasia, atherosclerotic heart disease of native coronary artery without angina pectoris, cerebral ischemia, muscle weakness (generalized), and history of falling.
A review of the Quarterly MDS dated [DATE] revealed that R109 presented with a BIMS score of nine, indicating moderate cognitive decline; had impairment on one side; that R109 required a wheelchair for mobility; required partial/ moderate assistance with toileting and upper body dressing; required substantial/ maximal assistance with lower body; and that R109 was ordered antipsychotic, antidepressant, and antiplatelet medications.
A review of R109 care plan revised on 4/15/2025, revealed a focus area stating that R109 has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, history of Cerebral Vascular Accident (CVA).” Outcome revealed that R109 will improve the current level of function in bed mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date. Interventions include to promote dignity by ensuring privacy, toilet use: require one person staff participation to use toilet, transfer: require two person staff participation with transfers, bed mobility: require two person staff participation to reposition and turn in bed, bathing: check nail length and clean on bath day and as necessary, report any changes or necessity for trimming to the nurse, bathing: is totally dependent on staff to provide a bath and as necessary, bathing: provide with a sponge bath when a full bath or shower cannot be tolerated, personal hygiene/oral care: require one person staff participation with personal hygiene and oral care, dressing: require one person staff participation to dress and eating: require supervision and setup help with meals.
A review of the Physician's orders revealed the use of Seroquel oral tablet 100 milligrams (mg) (quetiapine fumarate) give one tablet by mouth at bedtime, Seroquel oral tablet 50 mg (quetiapine fumarate) give 50 mg by mouth one time a day, sertraline hcl oral tablet 100 mg (sertraline hcl) give one tablet by mouth one time a day.
During an observation/ interview on 5/27/25 at 11:53 am, R109 was observed sitting on his bed. Left-sided weakness was observed with contracture of the left hand. All fingernails on both hands were long, with black substances underneath each nail. R109 stated that he had asked for help sometime this year and still has not gotten it. He stated that he has asked the staff to cut his nails on more than one occasion, but no one has done it. R109 stated that his nails keep breaking. He said, “I don't want them to break because it hurts when it breaks.” He stated that he has difficulty opening his closet and drawers due to the long fingernails.
During a second observation on 5/29/2025 at 10:36 am with R109 revealed his fingernails had not been cut, cleaned, or filed. He revealed that his Certified Nursing Assistant (CNA) had been in to bring him supplies earlier. He stated that sometimes they take a long time to come to him, so he does the best he can to provide his own self-care.
During an observation on 5/30/2025 at 12:42 pm, R109 revealed his fingernails still had not been cut, cleaned, or filed. R109 stated he is still waiting for someone to cut them for him. He further stated that if he were able, he would have cut them himself by now.
During an interview on 5/30/2025 at 1:30 pm with CNA FF revealed that she has been working in the facility for about three years and is familiar with the resident, but stated that she is normally not his aide. She added that she is his aide just for today. CNA FF stated that CNAs do not cut fingernails, activities usually do nails, we don't do nails. We can clean them but not clip them, and I have never seen a nail file in this facility.
During a fourth observation on 6/2/2025 at 9:01 am with R109 revealed himself lying in bed holding his fingers. He stated that still no one has come to cut them and doesn't want them to break while he is sleeping.
5. A review of the facility's admission record for R80 revealed that she was admitted to the facility on [DATE] with diagnoses that include insomnia, pyoderma gangrenosum, personal history of other venous thrombosis and embolism, paresthesia of skin, non-pressure chronic ulcer of other parts of right lower leg limited to breakdown of skin and lymphedema.
A review of the Quarterly MDS assessment dated [DATE] revealed that R80 presented with a BIMS score of 15, indicating that R80 is cognitively intact; presented with lower extremities impairment on both sides that require the use of a wheelchair for mobility; required substantial/ maximal assistance with toileting, partial/ moderate assistance with showers, upper body dressing and personal hygiene; that R80 was dependent with lower body activities of care; received scheduled pain medication for occasional pain that does not interfere with activities; and was ordered anticoagulant, opioid and diuretic medication.
A review of R80 care plan revised on 4/4/2025 revealed a focus area of Pain medication Therapy (opioid), both PRN and routine, also to be given prior to wound care. Outcome revealed, will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions include, Administer medication as ordered, review (FREQ) for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required.
A review of the physician's orders revealed oxycodone HCL tablet 5 milligram (mg), give 5 mg by mouth before wound care, and oxycodone HCL tablet 5 mg, give 5 mg by mouth every six hours for pain. Pain: Assess pain level. Initial and score every shift and as needed. 0=No Pain/1-4=Mild Pain/ 5-7=Moderate Pain/ 8-10=Excruciating pain, every shift for pain monitoring. Treatment: cleanse the right posterior calf with wound cleanser/ normal saline (WC/NS). Apply alginate and wrap with kerlix, cleanse the left posterior calf with WC/NS. Apply alginate and wrap with kerlix.
During an interview on 5/27/2025 at 2:44 pm, R80 revealed that her wound is doing better now, and they are giving me my medication, but I have reported them because they sometimes refuse to give me my pain medication. I constantly ask them why they are refusing to give me my medication, and they told me that they don't think I need it. The last time I had to tell them I'm gonna snitch on them to the state if they don't give it to me, and so they have been giving it to me lately. R80 stated that she sometimes refuses her treatment because she is in so much pain, because the nurse refuses to administer her pain medication.
A review of R80 medication administration records for several days during the months of August 2024, September 2024, March 2025, and May 2025 revealed missing signatures on the Medication Administration Record (MAR).
A review of the nurse's notes dated 8/6/2024 revealed medication out of stock.
A review of the nurse's notes dated 11/10/2024 revealed medication not administered, waiting for pharmacy delivery, phone call to pharmacy and MD.
A review of the nurse's notes dated 11/11/2024 revealed oxycodone HCL tablet 5 mg give 5 mg before wound care every Monday, Wednesday, and Friday for wound care to be given before wound care Med on order.
A review of the nurse's notes dated 5/5/2025 revealed Medication is on order.
A review of the nurse's notes dated 5/28/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every six hours for pain. Awaiting pharmacy.
A review of the nurse's notes dated 5/31/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every six hours for pain, unavailable.
During an interview on 6/5/2025 at 11:54 am, Licensed Practical Nurse (LPN) EE stated, “I do part-time, and I do a cart audit before I leave each day I'm here and reorder medication as needed. If I hear a resident say they did not get their medication, I do a grievance, and it goes to the DON. I have not heard anything about residents' missing medications.”
During an interview on 6/5/2025 at 12:07 pm with Certified Medication Aide (CMA) NNN revealed that she has been working in the facility for about a year and a half and has always worked on the third floor in the hall in question. CMA NNN admitted to having had instances where residents run out of medications, and it is not in the cart. She stated that if the patient does not have medication, I call the pharmacy and reorder it. Once the pharmacy is notified, then you let the nurse know and document in progress notes what was said.”
During an interview on 6/2/2025 at 1:08 pm, the DON stated, Medications for the residents are reordered by faxing the order to the pharmacy or by calling the pharmacy.” She stated that the main fax machine was at the front desk, and the nurse is required to fax the paper script to the pharmacy for reordering the medications. The DON also stated that for pain medications, it's a different process. A script is needed, and it has to be signed by the doctor and sent to the pharmacy.” The DON stated that the nurse is to follow up with the pharmacy, which will give a code or a number to remove the medication from the pyxis if available, and if the medication is not in the pyxis, the resident is offered an alternative until the medication is received. DON stated that the nurses on the units are responsible for ordering and reordering the medications in a timely manner before the stock is completely out. She stated that the medications are to be ordered within a week of them finishing, so the pharmacist has enough time to send the medication. She confirmed that there were gaps in the MAR for some residents who did not receive their pain medication and stated that, if it's not documented, it was not done. My expectation from the nurses if there is a problem where the fax and the pyxis system are down, they should notify me, and I will get in contact with the pharmacy regarding the medication.”
5. A review of the EMR revealed that R180 was admitted on [DATE] with diagnoses including but not limited to dysphagia following nontraumatic intracerebral hemorrhage, tracheostomy, respiratory failure, and morbid obesity. BIMS score of 99 due to dysphagia.
A review of the care plan revealed no focus, outcome, or interventions for R180 in regards to positioning/repositioning to preserve skin integrity and promote movement of extremities.
An interview was completed on 5/29/2025 at 9:05 am with a family member of R180, who revealed he visits on weekends due to his work schedule. He is concerned with her sitting in urine and feces for long periods of time. She is not getting physical therapy anymore due to her insurance, per the therapy team. She is not getting up out of bed due to staffing. She only lies in bed, which makes him concerned about her skin breaking down. He makes her medical decisions when they contact him. He has not been invited to any of her care conferences since she was admitted . He was not aware of, nor had he reviewed, a document called a care plan.
An interview was completed on 6/5/2025 at 4:08 pm with DON, who confirmed R180 did not have a task in the medical record to prompt staff to position R180 frequently and document in this area. During the interview, the DON added the task that stated, turn and re-position frequently, as tolerated for comfort and pressure relief when in bed. DON confirmed that the current care plan for R180 did not include a focus and interventions for frequent repositioning.
The facility implemented the following actions to remove the IJ:
1. Education for Licensed Nurses: The licensed nurses, to include the administrative nurses of the DON, ADON, the MDS Nurses, and the Unit Manager (UM), were educated on 6/3/2025 by the RDCO on completing comprehensive care plans related to dialysis and dialysis transportation.
New hire orientation for licensed nurses will encompass training to ensure care plans are implemented for patients, including dialysis and dialysis transportation.
Staff Education: 37 of 40 licensed nurses have been educated so far. No licensed nurses will work until the education on this care plan implementation has been completed.
2. Root Cause Analysis: On 6/3/2025, the [NAME] President of Operations (VPO), the Administrator, the Assistant Administrator, the DON, the RDCO, and the Medical Director (MD) discussed the root cause of F656. The center's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, nor consistent follow-up if transportation failed to arrive to transport the resident.
3. Audit of Current Dialysis Care Plans: A 100% audit of all current dialysis care plans has been reviewed to ensure accuracy of the information and care plan implementation.
4. Systemic Change in Practice Plan: Weekly, the MDS nurses, the DON, the ADON, and the UM will hold a meeting to review all care plans for which MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly.
An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, MD, DON, RDCO, and VPO. Citation F656 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency.
5. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025.
The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:
1. Verified on 6/6/2025 by interview with the Administrator and the RDCO. The sign-in sheet was reviewed, and the contents of the education provided were confirmed. Education was provided on 6/3/2025.
Interviews were conducted on 6/6/2025 through 6/8/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 1:57 pm with Certified Medication Administration Technician (CMAT) ZZZ; 6/6/2025 at 2:02 pm with Licensed Practical Nurse (LPN) LLLL; 6/6/2025 at 2:07 pm with LPN MMMM; 6/6/2025 at 2:12 pm with LPN ZZ; 6/6/2025 at 2:17 pm with LPN NNNN; 6/6/2025 at 2:22 pm with LPN OOOO; 6/6/2025 at 2:27 pm with LPN DD; 6/6/2025 at 2:32 pm with LPN PPPP; 6/6/2025 at 2:37 pm with LPN QQQQ; 6/6/2025 at 2:42 pm with LPN RRRR; 6/6/2025 at 2:47 pm with LPN EE; 6/6/2025 at 2:52 pm with LPN SSSS; 6/6/2025 at 2:57 pm with LPN YYY; 6/6/2025 at 3:02 pm with LPN WW, 6/6/2025 at 3:07 pm with LPN OOO; 6/6/2025 at 3:12 pm with LPN TTTT; 6/6/2025 at 3:27 pm with the ADON; 6/6/2025 at 3:32 pm with the DON; 6/7/2025 at 12:03 pm with LPN KK; 6/7/2025 at 12:10 pm with LPN UUUU; 6/7/2025 at 12:12 pm with CMAT RRR; and 6/7/2025 at 12:30 pm with CMAT BBB.
2. Verified by interview on 6/6/2025 with the Administrator and the RDCO that a meeting was held on 6/3/2025 to discuss the root cause analysis. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified.
3. Verified on 6/6/2025 by interview with the Administrator and the RDCO that the residents’ care plans were updated to reflect transport arrangements for dialysis.
4. Verified by interview on 6/6/2025 with the Administrator and the RDCA that there will be a weekly meeting with the MDS, DON, ADON, and the UM to review all care plans that MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly.
Verified by interview on 6/6/2025 with the Administrator and the RDCO that an Ad Hoc meeting was held on 6/4/2025 at 4:30 pm to discuss the root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified.
5. Based on the information in the AOC, it was determined that the immediacy was removed on 6/5/2025.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0698
(Tag F0698)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services were provided in accordance with profe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure services were provided in accordance with professional standards of practice for two of seven residents (R) (R49 and R87) who are dependent on dialysis three times weekly for end-stage renal disease (ESRD) received reliable transportation to attend life-sustaining dialysis treatments. This failure resulted in missed dialysis sessions and avoidable hospitalizations due to volume overload and severe hyperkalemia.
On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.
The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025.
An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025.
Findings included:
1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease, end-stage renal disease, major depressive disorder, and anxiety disorder.
A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment.
A review of R49 Physician's Orders revealed an order dated 10/24/2023 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday.
A review of R49 care plan date initiated on 3/5/2021 revealed a focus category of resident is at risk to experience adverse reactions and altered psychosocial wellbeing r/t transportation issues w/ dialysis transportation. The outcome was for R49 will be free from increased s/s of adverse reactions r/t issues w/ dialysis transportation thru the next review. Interventions Contact Transportation [NAME] QA and Standing Order Supervisor for inquiry/complaint number. Ensure an alternate dialysis time option for resident.
A review of R49 medical record discharge note R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload
2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia end end-stage renal disease, and dependence on renal dialysis.
A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating Intact cognitive function.
A review of R87's physician's orders revealed an order dated 5/28/2025 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday.
A review of R87 care plan date initiated on 2/16/2023 revealed a focus category of resident needs hemodialysis related to end-stage renal failure. Risk for missing dialysis due to refusals/transportation issues. The outcome for R87 will have no s/sx of complications from dialysis through the review date. Interventions If R87 misses dialysis: 3. Attempt to secure other means for transportation.
A review of R87 hospital discharge diagnoses dated 5/17/2025 at 10:57 am revealed hyperkalemia due to diminished renal excretion due to missed hemodialysis.
On 5/28/2025 at 12:17 pm, R87 confirmed that he had missed a dialysis appointment again on 5/27/2025 and stated that over the past weeks, he believed he had missed dialysis at least three times or more.
A review of the nursing progress notes dated 5/19/ 2025 at 8:30 pm revealed R87 complained of mild pain and cramps in the left arm. Recorded vital signs were as follows: Blood Pressure was 135/82; Heart Rate was 90 BPM (beats per minute); Respiratory Rate was 18 breaths per minute; Temperature was 98.2 degrees Fahrenheit (F); and Oxygen Saturation was 98% (percent). R87's sister requested a hospital evaluation. A physician's order was received. At 11:00 pm, R87 was transported to an acute care hospital via stretcher, accompanied by two paramedics.
Interview on 5/28/25 at 12:57 pm, the Dialysis Facility Administrator (FA) YYYY confirmed that R87 completed appointments scheduled in May on the 3rd, 13th, 22nd, and 24th. The social worker disclosed that R87 was hospitalized due to missing two consecutive treatments. It was shared that the facility confirmed the missed appointments were due to transportation issues and to be seen three times a week. The FA YYYY explained that the dialysis doctor contacted the facility and ordered R87 to be sent to the hospital for treatment. Additionally, FA YYYY confirmed that the facility discounted R87's transportation on May 6th. The previous transportation company was canceled, and the facility began using its own. The current transportation company operates only with one truck. FA YYYY further explained that she has called the facility at least two to three times regarding R87 appointments, yet it seems that no one is concerned about ensuring he attends them.
During an interview on 5/29/2025, at 1:35 pm with the Social Worker (SW) LLL, it was confirmed that the social work department is not responsible for dialysis transportation, but rather it is the responsibility of the nursing department and/or the Director of Nursing.
During an interview on 5/29/2025 at 1:47 pm with the Director of Nursing (DON), it was confirmed that she acknowledged her awareness of residents missing their appointments and she did not conduct any scheduling of transportation.
During an interview on 5/29/2025 at 2:02 pm with the Assistant Director of Nursing (ADON), she revealed she had no role in coordinating dialysis transportation. She occasionally verified that the previous central supply clerk scheduled appointments. She expressed that the current system is inadequate, leading to missed appointments for residents.
During an interview with the Administrator on 5/30/2025 at 10:12 am, he acknowledged that the central supply clerk was responsible for coordinating dialysis transportation. The Administrator also admitted that he was unaware multiple residents had been hospitalized in May due to missed dialysis treatments and stated that the nursing team had not informed him. Furthermore, the Administrator was unable to confirm that the transportation barrier was discussed in QAPI.
On 6/2/2025, at 1:05 PM, an interview with the Administrator and the Administrator's Assistant confirmed that residents R49 and R87 were both utilizing state state-funded (Medicaid) transportation company. Per Administrator Assistance, the state-funded transportation company has a history of being difficult, the appointment process is antiquated, and appointments must be arranged through phone calls, faxes, and/or emails. The Administrator's Assistant disclosed that the facility is required to carry out these tasks, and the Central Supply clerk (CSC) was initially responsible for this. However, the Central Supply clerk transitioned from the role of Certified Nurse Assistant (CNA) on 4/28/2025 but left the facility as the CSC on May 21, 2025. The Administrator Assistant confirmed she assumed these responsibilities after his termination, but just returned from her vacation, having departed on May 24, 2025, and returned on May 31, 2025. Both individuals indicated that there is no proactive plan in place to prevent missed appointments; they simply wait to see if state state-funded transportation company arrives on the date of the appointment. If not, they contact their brokerage transportation company, but confirmed that sometimes they are not able to accommodate the residents due to the short notice, so they call the physician.
Interview on 6/2/2025 at 3:56 pm with the Medical Director confirmed her awareness of the hospitalization of both residents. She emphasized the importance of arranging transportation, ensuring access is ready, and providing necessary medications. She expressed concern that even one missed appointment per month is a significant issue and should be viewed as a red flag for the facility's operations.
Interview conducted on 6/4/2025 at 9:17 am, with Dialysis Facility Administrator ZZZZ, who confirmed and provided the dates missed for chair appointments for residents R49 and R87. Resident R87 failed to attend seven out of twelve scheduled dialysis treatments on 6/6/2025, 6/8/2025, 6/10/2025, 6/15/2025, 6/17/2025, 6/20/2025, and 6/27/2025. Consequently, after missing two consecutive treatments, the dialysis physician directed the facility to transfer the resident to the hospital on 6/15/2025 for emergency dialysis. Similarly, Resident R49 missed seven out of twelve dialysis treatments on 6/7/2025, 6/9/2025, 6/19/2025, 6/21/2025, 6/23/2025, 6/26/2025, and 6/28/2025. R49 was sent to the hospital on 6/19/2025, after displaying symptoms of shortness of breath and elevated potassium levels. FA ZZZZ indicated that the dialysis physician had to recommend sending residents to the hospital, and although the dialysis service has initiated and coordinated transportation for R87, as per our agreement, the facility remains responsible for these actions.
The facility implemented the following actions to remove the IJ:
1. Administration Education: The RDCO educated the Administrator, Assistant Administrator, and DON on 6/3/2025, ensuring reliable transportation services for dialysis residents. Transportation aides and licensed nursing staff were educated on the importance of scheduling appointments, follow-up of appointments, and preparing residents for their required dialysis treatments. No licensed nurses will work until the education on this care plan implementation has been completed.
2. Root Cause Analysis: On 6/3/2025, the [NAME] President of Operations (VPO), the Administrator, Assistant Administrator, the DON, the RDCO, and the Medical Director (MD) discussed the root cause of F698. The center's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, nor consistent follow-up if transportation failed to arrive to transport the resident.
3. Audit of Current Dialysis Residents: A 100% audit of all current dialysis resident records has been initiated to determine if reliable transportation to and from dialysis appointments is available.
4. Systemic Change in Practice Plan: DON, the ADON, the Administrator, the Assistant Administrator, and the Transportation Aide will hold a weekly meeting to review all dialysis transportation schedules. Any scheduling conflicts or changes in scheduling companies will be addressed to ensure timely dialysis appointments.
5. Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting: An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, the MD, the DON, the RDCO, and the VPO. Citation F698 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency.
6. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025.
The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:
1. Verified on 6/6/2025 by interview with the Administrator and the RDCO. The sign-in sheet was reviewed, and the contents of the education provided were confirmed. Education was provided on 6/3/2025.
Interviews were conducted on 6/6/2025 through 6/8/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 1:57 pm with Certified Medication Administration Technician (CMAT) ZZZ; 6/6/2025 at 2:02 pm with Licensed Practical Nurse (LPN) LLLL; 6/6/2025 at 2:07 pm with LPN MMMM; 6/6/2025 at 2:12 pm with LPN ZZ; 6/6/2025 at 2:17 pm with LPN NNNN; 6/6/2025 at 2:22 pm with LPN OOOO; 6/6/2025 at 2:27 pm with LPN DD; 6/6/2025 at 2:32 pm with LPN PPPP; 6/6/2025 at 2:37 pm with LPN QQQQ; 6/6/2025 at 2:42 pm with LPN RRRR; 6/6/2025 at 2:47 pm with LPN EE; 6/6/2025 at 2:52 pm with LPN SSSS; 6/6/2025 at 2:57 pm with LPN YYY; 6/6/2025 at 3:02 pm with LPN WW, 6/6/2025 at 3:07 pm with LPN OOO; 6/6/2025 at 3:12 pm with LPN TTTT; 6/6/2025 at 3:27 pm with the ADON; 6/6/2025 at 3:32 pm with the DON; 6/7/2025 at 12:03 pm with LPN KK; 6/7/2025 at 12:10 pm with LPN UUUU; 6/7/2025 at 12:12 pm with CMAT RRR; and 6/7/2025 at 12:30 pm with CMAT BBB.
2. Verified by interview on 6/6/2025 with the Administrator and the Director of Clinical Operations that a meeting was held on 6/3/2025 to discuss the root cause analysis. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified.
3. Verified on 6/6/2025 by interview with the Administrator and the RDCO that the residents’ records were updated to reflect transport arrangements for dialysis.
4. Verified by interview on 6/6/2025 with the Administrator and the RDCO that there will be a weekly meeting with the MDS Coordinator, DON, ADON, and the Unit Managers (UMs) to review all care plans that MDS assessments have been recently completed to ensure dialysis and dialysis transportation have been addressed and to ensure care plans are implemented promptly.
5. Verified by interview on 6/6/2025 with the Administrator and the RDCO that an Ad Hoc meeting was held on 6/4/2025 at 4:30 pm to discuss the root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. The sign-in sheet and confirmation email from the attendees were reviewed and confirmed. The contents of the root cause analysis, which were provided to the participants, were reviewed and verified.
6. Based on the information in the AOC, it was determined that the immediacy was removed on 6/5/2025.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the Job Description for the Administrator and the Director of Nursing (D...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the Job Description for the Administrator and the Director of Nursing (DON), it was determined that the facility's Administration did not adequately address issues related to Dialysis and Transportation procedures. Furthermore, they failed to provide sufficient oversight and supervision related to dialysis transportation for two of seven residents (R) (R49 and R87). The facility administration failed to establish systems or offer administrative support to guarantee that residents receive the physician-ordered life-sustaining dialysis treatments. This oversight led to numerous missed dialysis appointments and subsequent hospitalizations. On 6/3/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, the DON, and Regional Director of Clinical Operations (RDCO) were informed of the Immediate Jeopardy (IJ) for F656, F698, and F835 on 6/3/2025 at 11:14 am. The noncompliance related to the IJ was identified to have existed on 5/6/2025. An Acceptable IJ Removal Plan was received on 6/5/2025 related to Comprehensive Care Plans, C.F.R. 483.21; Dialysis, C.F.R. 483.25(l); and Administration, C.F.R. 483.70. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/5/2025. Findings included: A review of the undated Administrator Job Description revealed it is the Administrator's job to lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with a focus on maintaining excellent care for the residents while achieving the facility's business objectives. A review of the undated Director of Nursing Job Description revealed it is the job of the DON to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices, and governmental regulations so as to maintain excellent care of all residents' needs. 1. A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease, major depressive disorder, and anxiety disorder. A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R49 had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. A review of R49 Physician's Orders revealed an order dated 10/24/2023 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R49 care plan date initiated on 3/5/2021 revealed a focus category of the resident is at risk of experiencing adverse reactions and altered psychosocial wellbeing related to transportation issues with dialysis transportation. The outcome for R49 will be free from increased signs and symptoms of adverse reactions related to issues with dialysis transportation through the next review. Interventions included contacting transportation and the standing order supervisor for inquiry complaint number. Ensure an alternate dialysis time option for the resident. A review of R49's medical record discharge note, R49 was sent to the hospital on 5/19/2025, after exhibiting symptoms of shortness of breath and elevated potassium levels. It was noted on 5/19/2025 that R49 was admitted to the ICU for monitoring. R49 was admitted from 5/20/25 through 5/22/2025, and again from 5/25/2025 through 5/27/2025, for complications related to missed dialysis, including severe hyperkalemia and volume overload 2. A review of the EMR revealed that R87 was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus without complications, chronic pulmonary edema, essential (primary) hypertension, anemia in chronic kidney disease, other hyperlipidemia, hyperkalemia, end-stage renal disease, and dependence on renal dialysis. A review of a Quarterly MDS assessment dated [DATE] revealed R87 had a BIMS score of 15, indicating intact cognitive function. A review of R87's physician's orders revealed an order dated 5/28/2025 for the resident to receive dialysis services at 11:15 am on Tuesday, Thursday, and Saturday. A review of R87 care plan date initiated on 2/16/2023 revealed a focus category of resident needs hemodialysis related to end-stage renal failure. Risk for missing dialysis due to refusals/transportation issues. The outcome for R87 will have no signs and symptoms of complications from dialysis through the review date. Interventions included that if R87 misses dialysis, the facility staff were to attempt to secure other means for transportation. A review of R87 hospital discharge diagnoses dated 5/17/2025 at 10:57 am revealed hyperkalemia due to diminished renal excretion due to missed hemodialysis. The facility implemented the following actions to remove the IJ: 1. Administration Education: On 6/3/2025, the RDCO educated the Administrator, Assistant Administrator, and DON on administering the facility in a manner that ensured dialysis residents received the necessary transportation services to attend hemodialysis appointments. On 6/3/2025, the Administrator, Assistant Administrator, and the DON reviewed their job descriptions to clarify expectations and aspects of leadership in the administration of the facility's operations. 2. Root Cause Analysis: On 6/3/2025, the root cause of F835 was discussed with the [NAME] President of Operations (VPO), the Administrator, Assistant Administrator, the DON, the RDCO, and the Medical Director (MD). The facility's administration identified the root cause of this issue as the facility did not have a dedicated dialysis transport provider, and did not have a consistent follow-up provider if transportation failed to arrive to transport the resident. This barrier prevented the center from being administered effectively to meet the residents' dialysis transportation needs. 3. Systemic Change in Practice Plan: Weekly, the Administrator, Assistant Administrator, and the DON will hold a meeting to discuss the center's policies and progress in implementing procedures, ensuring the appropriate administration is in place to run the facility effectively. 4. Ad Hoc Quality Assurance Performance Improvement (QAPI) Meeting: An Ad Hoc QAPI Meeting was held at 4:30 pm on 6/4/2025, which included the Administrator, Assistant Administrator, the MD, the DON, the RDCO, and the VPO. Citation F835 was discussed, along with its root cause, a corrective action plan, education, and systemic changes in practice necessary to remove the immediacy and correct the deficiency. 5. Steps Taken with Medicaid Contractors: Other Medicaid Dialysis Contractors have been researched. Permanent Medicaid Dialysis Contractors have been assigned to residents.A new transportation [NAME] will provide back-up transportation services for dialysis residents. 6. Based on the steps above, the facility alleged that the immediacy was removed on 6/5/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the sign-in sheets revealed that education was completed on 6/3/2025 by the RDCO. Education was provided to the Administrator, Assistant Administrator, DON, and ADON. The job descriptions for Administrator, Assistant Administrator, DON, and ADON were provided and were signed as having been reviewed. Interviews were conducted on 6/6/2025 with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: 6/6/2025 at 3:27 pm with the ADON, the DON, the Administrator, and the Assistant Administrator. 2. Discussion conducted on 6/3/2025, members in attendance consisted of VPO, Administrator, Assistant Administrator, DON, RDCO, and MD. Members not in person were informed via telephone, with confirmation receipt via. Email presented. 3. A review of the removal plan documentation revealed that the facility will conduct weekly meetings on Mondays at 9:30 am to ensure compliance with the first meeting scheduled for 6/9/2025. 4. A review of the sign-in sheets dated 6/4/2025 revealed that the Ad Hoc QAPI meeting was conducted with Administrator, Assistant Administrator, MD, DON, RDCO, and VPO in attendance. 5. Email communication between the facility and the transportation contractor was reviewed. The dialysis transportation contractor revealed residents were on a running schedule for pickup. The contract was observed with a new transportation [NAME] as backup transportation. During an observation on 6/3/2025 at 10:58 am and on 6/4/2025 at 9:00 am, residents requiring dialysis were observed being transported out of the facility timely manner for appointments. 6. Based on the information in the AOC, interviews and observations, it was determined that the immediacy was removed on 6/5/2025.
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 observations, staff and resident interviews, and review of the facility's policies titled Falls and Fall Risk, Managin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, staff and resident interviews, and review of the facility's policies titled Falls and Fall Risk, Managing and Self-Administration of Medication”, the facility failed to provide an environment free of accident hazards for three of 106 sampled residents (R) (R371, R14, and R159) related to failing to conduct a fall risk assessment and implement fall interventions after a fall that resulted in a major injury for R371 and failed to secure medications at the bedside for R14 and R159. Harm was identified as having occurred on 7/3/2024, when R371 had not been assessed after a fall, resulting in a delay in diagnosis and treatment for a left displaced femoral neck fracture and a closed left hip fracture.
Findings included:
1. A review of the facility's policy titled, Falls and Fall Risk, Managing, with a revised date of March 2018, revealed that Based on previous evaluations and current date, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
A review of the electronic medical record (EMR) revealed that R371 was admitted to the facility on [DATE] and discharged from the facility on 10/31/2024. Pertinent diagnoses during his residence at the facility included, but were not limited to, history of falling, unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, fracture of unspecified part of neck of left femur, and fall on same level from slipping, tripping, and stumbling without subsequent striking against object.
A review of R371's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R371 was cognitively intact; that R371 displayed no rejection of care; that R371 required supervision during a sit-to-stand transfer; required supervision (touching assistance) to walk ten feet; and that R371 had an indwelling catheter.
A review of R371's care plan dated 9/14/2023 documented that R371 was at high risk for falls related to deconditioning and being unaware of safety needs. Goals included that R371 would be free of falls. Interventions included, but were not limited to, encouraging the resident to call for assistance before transferring self-unassisted and maintaining a clear pathway free of obstacles.
A review of a nurse's note dated 6/30/2024 documented, PAR [Patients at risk] Review for Falls: IDT [interdisciplinary team] met to discuss falls. PAR review for fall. The resident experienced falls on 6/22/24. The resident was assisted to the bathroom by two staff members. The resident stated he was trying to get his wallet when he fell into the tub. The resident continued to be impulsive. Staff assisted the resident off the floor. It was documented that there were “No injuries noted.” The family and physician were notified of the incident. The new intervention included the completion of a fall screening. Staff were reeducated on not leaving residents unattended while in the bathroom. R371 remained on Weekly PAR Review. Last fall: 5/4/2024, 5/17/2024, and 6/20/2024.
A review of the nurse's notes in R371's EMR revealed no documentation on 7/3/2024, the day of the fall that resulted in injury.
A review of a nurse's note dated 7/5/2024 in R371's Unrevealed that at approximately 12:00 pm on 7/5/2024, R371 complained of pain in the left thigh and knee. The resident was asked what had happened, and he stated he had fallen a few days prior. It was documented that the resident had a history of falls. The resident voiced no other concerns, and upon assessment, there were no bruising or open areas noted at the time of the reported incident. The Nurse Practitioner (NP) was notified and ordered an x-ray and as-needed (prn) pain medication.
A review of a nurse's note dated 7/5/2024 in R371's EMR documented an acute visit note by the NP that she was called by nursing staff with a report that R371 was complaining of left leg and knee pain due to a recent fall. On her arrival at the facility, R371 was assessed for pain and injury and stated that he had sustained a fall three days ago while he was trying to go into the restroom. It was documented that R371 stated that he tripped over his Foley catheter because it was too long. The NP assessed R371’s leg and knee; the resident flinched when his leg was touched or raised. It was documented that R371 stated that his pain level was seven out of ten with movement. Verbal orders were given to staff for a view x-ray of R371's left leg and knee, and instructions to staff to continue to assist R371 with ADL care as needed and continue pain management.
A review of a radiology report dated 7/7/2024 in R371's EMR documented an acute left femoral neck fracture.
A review of a nurse's note dated 7/8/2024 in R371's EMR documented a phone encounter signed by the NP that the X-Ray results showed left femur fracture. Verbal order given to send patient out to hospital for further evaluation and treatment. Under Assessment, the NP documented ICD codes of Abnormal x-ray of femur, Femur fracture, left, and Fall with injury.
A review of a nurse’s note dated 7/8/2024 in R371's EMR documented, Writer received X-ray results, NP notified of results and writer was given an order to send to (emergency room) for evaluation/treatment (related to) X-ray results; 911 was notified and resident to be sent to hospital, report was given to hospital that this resident is impulsive and has a (history) of falls - he was (complaining of) pain and on call (physician) was notified and x-ray order was obtained; daughter made aware of transfer; and (R371) aware that he is going to the hospital, all safety measures are in place, will continue with (plan of care).
A review of a hospital Discharge summary dated [DATE] documented that R371 was admitted to the hospital on [DATE] and discharged on 7/12/2024. Under section titled Discharge Diagnoses, a left displaced femoral neck fracture and a closed left hip fracture were documented. Section titled Care Timeline revealed an arthroplasty, hip, bipolar was performed on 7/9/2024.
A review of an undated Witness Statement Form, Certified Nursing Assistant (CNA) CCC stated that he observed [R371] on the floor from tripping over his cat. bag. I helped him into the wheelchair and back into bed, and he replied that he was okay. This occurred on 7/3/2024. I let the nurse on duty know at the time it was [Licensed Practical Nurse (LPN) DDD], this occurred around 11:45 am.”
A review of an Employee Counseling Form dated 7/11/2024 revealed LPN DDD was terminated with details that stated, Resident fell on 7/3/2024 and was reported to [LPN DDD] by a CNA on duty. The nurse did not report the fall or do a risk assessment pertaining to the fall. The fall resulted in injury. When the nurse was questioned, she stated she did not recall a fall.
A review of a final summary dated 7/14/2024 of the facility reported incident documented a conclusion that documented that it was determined by the Interdisciplinary Team (IDT) team that [R371's] fracture had occurred when he fell from his room on 7/3/2024. [CNA CCC] had reported to the charge nurse [LPN DDD] that [R371] had fallen. However, [LPN DDD] did not document or assess [R371] . On 7/5/2024, [R371] complained of left leg pain. Orders were obtained to get an X-ray of the left hip and leg area. An X-ray was obtained, and results revealed a fractured left femur. Family and (physician were notified of the results. Orders received to send [R371] to ER. [R371] was scheduled for surgery for left femur fracture. [R371] will be returning to the facility. Investigation also revealed that [LPN DDD] failed to follow facility policies regarding incidents/falls. [LPN DDD] failed to assess and document [R371's] incident after it was reported to her. Due to these reasons, [LPN DDD] was terminated from her position at the facility. [CNA CCC] received education on not getting a resident off the floor until the nurse assessed them after a fall.
During an interview on 6/3/2025 at 9:27 am, the Human Resources Director confirmed that LPN DDD was terminated on 7/8/2025 for violating company policy/procedure and is not eligible for rehire.
During a phone interview on 6/7/2025 at 11:30 am, CNA CCC revealed that R371 always tried to get up and go back and forth to the restroom without asking. He noticed the resident on the floor, picked the resident off the floor, and then went to the nurses' station to report it to the nurse. He told the nurse that the resident fell, and that the nurse said, “Okay.” He stated that the nurse did not make any sudden moves to assess the resident after he reported the fall.
During an interview on 6/6/2025 at 9:26 am, the Director of Nursing (DON) revealed R371 resided at the facility before she sated working at the facility. The DON stated that when a resident falls, there should be an immediate physical assessment, neuro assessment, pain assessment, vitals taken, notification to the physician and family, documentation, follow-up, X-ray, and other interventions as indicated, such as hospitalization. The DON confirmed that, according to the facts, the nurse did not assess the resident following the fall. The DON confirmed that she does not see any care plan interventions regarding tripping over his catheter bag. The DON further confirmed that the CNA should not have moved the resident before the resident was assessed, and the charge nurse should have assessed immediately following the fall. The DON stated that potential negative outcomes of not meeting these expectations following a resident's fall could result in injuries they are not aware of.
2. A review of the facility's policy titled Self-Administration of Medication, dated April 2022, under section titled General Guidelines, number one documented, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team.
A review of R14's EMR revealed R14 was admitted to the facility on [DATE] with pertinent diagnoses that included osteoarthritis, asthma, rheumatoid arthritis, and cognitive communication deficit.
A review of R14's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, indicating R14 was cognitively intact.
A review of R14's physician orders revealed no order for an inhaler or any topical medications. Additionally, there was no order for self-administration of medications.
A review of R14's EMR revealed no assessment for self-administration of medications.
During an observation on 5/27/2025 at 11:00 am of R14's bedside table revealed a pill bottle with an unknown opaque substance inside and a name on the bottle that is not R14's or any responsible party listed in R14's EMR. Further observation revealed an inhaler on the bedside table. An interview with R14 during this time revealed that she uses the inhaler often, sometimes two to three times a day. When asked about the pill bottle, she stated there is some eczema medication inside.
During an observation on 5/28/2025 at 5:49 pm of R14's bedside table revealed the same pill bottle with opaque substance and the inhaler.
During an observation on 5/29/2025 at 9:45 am of R14's bedside table revealed the same pill bottle with opaque substance and the inhaler.
During an interview on 5/29/2025 at 9:48 am with Certified Medication Aide Technician (CMAT) SS revealed that R14 does not use an inhaler or any topical medications according to R14's physician orders. She further confirmed these medications should not be at the bedside and that all of R14's medications should be administered through the facility staff. She further confirmed that they can only give what the physician prescribed.
During an interview on 6/6/2025 at 8:59 am with the DON confirmed that the pill bottle with opaque substance and the inhaler should not be kept at R14's bedside, and they need to do an assessment for self-administration. The DON confirmed she does not see any order for creams and confirmed the pill bottle was something the facility probably did not know anything about and possibly the family brought in. The DON further confirmed she does not see an order for an inhaler and stated that family possibly brought that in as well.
3. A review of the facility's policy titled Self-Administration of Medication dated April 2022 documented Policy: The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs.
General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team.
A review of the facility's Electronic Medical Records (EMR) documented R159 was re-admitted to the facility on [DATE] with a diagnosis of, but not limited to, major depressive disorder.
A review of the Medicare 5-Day MDS dated [DATE] documented that R159 presented with a BIMS score of 14, which indicated R159 had intact cognition, and presented with a diagnosis of major depressive disorder.
A review of the care plan documented no evidence of a care plan for self-administration of medication.
A review of Physician's Orders documented no evidence of physicians' orders for self-administration of medication.
A review of the facility's documents revealed no evidence of approval of medication self-administration by the interdisciplinary team.
An observation on 5/27/2025 at 2:40 pm revealed one bottle of vitamin C 500 milligram (mg) tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. During an interview at this time, R159 stated the tablets belonged to her and she took them whenever she wanted to take them.
An observation on 5/28/2025 at 9:46 am revealed one bottle of vitamin C 500 milligram (mg) tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. During an interview at this time, R159 stated she had had the tablets for weeks and had been taking them whenever she wanted to take them.
During an interview on 5/28/2025 at 9:48 am, Licensed Practical Nurse (LPN) DD revealed she confirmed there was one bottle of vitamin C 500 mg tablets, one bottle of vitamin D3 Softgels, and one bottle of vitamin E Softgels in a container on R159's bedside table. LPN DD stated she did not know the tablets were there at R159's bedside. She stated R159 should not have the medications at her bedside without the nurses' knowledge, and that she was the regular nurse on this unit, and she was not aware of the medications at R159's bedside. LPN DD stated the doctor should be aware of it and order the medications if R159 were to get them. She also stated R159 was not ordered for self-administration of medications, and there was no process in place for her to self-administer medication. She further stated the tablets may interact with other medications she was taking, interact with medications given by the nurses at the facility, and worst-case scenario, she may have a negative reaction to the medications.
During an interview on 5/31/2025 at 10:47 am, CNA QQQ revealed that she stated the residents should not have medications at the bedside. She stated she would let the nurse know because R159 may take more than what she should be taking if the nurse was giving her the same medications.
During an interview on 6/2/2025 at 1:08 pm, the DON revealed her expectations were for the residents not to have medications at the bedside. She stated that the nurses need to manage the residents' medications to know what medications are being given by the facility. She stated the nurses were to follow up with the medical doctor to see if the doctor wanted the resident to receive those medications and go through the process of allowing the resident to have the medication. The DON stated the process involved physicians' orders, the IDT allowing self-administration of medications, and it be care was planned, and that process was not in place.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and a review of the facility's policies titled Assistance with Meals, the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and a review of the facility's policies titled Assistance with Meals, the facility failed to provide a dignified existence for three of 106 sampled residents (R) (R187, R159, and R108) related to exposed catheter bags for R187 and R159, and during meals for R108. This deficient practice had the potential to negatively impact the residents' sense of self-worth and overall well-being. Findings included: 1. The policy regarding the Foley catheter bag was requested from the facility, and it was not provided by the exit date of this survey. A review of the facility's electronic medical records (EMR) revealed that R187 was re-admitted to the facility on [DATE] with a diagnosis including, but not limited to, urinary retention. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R187 presented with a Brief Interview of Mental Status (BIMS) score of 15, which indicated R187 was cognitively intact; had an active diagnosis of Neurogenic bladder and Obstructive Uropathy; and had an indwelling catheter. A review of the care plan dated 2/13/2025 documented that R187 had an Indwelling Catheter related (r/t) Neurogenic bladder with a goal that R187 would remain free from catheter-related trauma through the next review date. A review of the physician orders dated 2/22/2025 the following orders for R187:* Foley cath (on admission) 16fr/10cc. Change monthly, once a day every 30 days (s).* Catheter strap on at all times, on every shift.* Change Foley/Suprapubic catheter with occlusion or removal as needed for occlusion or removal.* Clean around Foley/suprapubic catheter with soap and water every shift. During an observation on 5/27/2025 at 11:15 am, R187's Foley catheter bag was attached to the bedrail, and it was not covered with a privacy bag. During an observation on 5/27/2025 at 4:15 pm, R187's Foley catheter bag was attached to the bedrail and was not covered with a privacy bag. During an observation on 5/28/2025 at 9:35 am, R187's Foley catheter bag was attached to the bedrail, and it was not covered with a privacy bag. During an interview on 5/28/2025 at 9:37 am, Licensed Practical Nurse (LPN) DD revealed that R187's Foley catheter bag was not covered with a privacy bag. She stated the catheter bag should be covered because it was a dignity issue. She further stated R187 could be uncomfortable when it was not covered, and the bag should be covered at all times for the resident's privacy. During an interview on 5/28/2025 at 9:39 am, Certified Medication Assistant Technician (CMAT) RRR confirmed that R187's foley catheter bag was not covered. She stated the catheter bag should be covered for the resident's privacy because it was a dignity issue. During an interview on 5/28/2025 at 10:07 am, Certified Nursing Assistant (CNA) BB confirmed the catheter bag was uncovered. She stated the bag should be covered for the resident to have dignity. She stated that if the bag was not covered, it would mess with the resident's confidence, and they would not enjoy being out and about because people would see it. She stated the resident would feel like their business is being exposed, and they would not feel good about it, even if they were in their room, because when the room door was opened, everyone who passed or went into the room would see it. During an interview on 6/2/2025 at 1:08 pm, the Director of Nursing (DON) stated that she expected that the Foley catheter bags would be covered to maintain the residents' privacy. The policy regarding the Foley catheter bag was requested by the facility, and it was not provided. 2. A review of the EMR revealed that R159 was re-admitted to the facility on [DATE] with a diagnosis including, but not limited to, neurogenic bladder. A review of the Medicare 5-Day MDS assessment dated [DATE] documented that R159 presented with a BIMS of 14, which indicated R159 had intact cognition; had an active diagnosis of neurogenic bladder, and had an indwelling catheter. A review of the care plan dated 11/26/2024 documented that R159 was at high risk for infection related to the complications associated with an indwelling catheter. A goal was for R159 to remain free from catheter-related trauma through the review date. Interventions included positioning the catheter bag and tubing below the level of the bladder; placing the drainage bag in a privacy bag. A review of the physician's orders dated 2/22/2025 documented included but not limited to: Change Foley Catheter every month and as needed (PRN) every night shift every 30 days. During an observation on 5/27/2025 at 11:18 am revealed that R159's Foley catheter bag was attached to the bedrail and not covered with a privacy bag. R159's bed was the first bed to be seen on entering the room, and the Foley catheter bag was hanging on the right side of the bed and visible from the entrance of the room door, and when the room door was opened. During an observation on 5/27/2025 at 4:20 pm, R159's Foley catheter bag was observed attached to the bedrail and not covered with a privacy bag. R159's bed was the first bed to be seen on entering the room, and the Foley catheter bag was hanging on the right side of the bed and visible from the entrance of the room door, and when the room door was opened. During an observation on 5/28/2025 at 9:35 am, R159's Foley catheter bag was observed attached to the bedrail and not covered with a privacy bag. R159's bed was the first bed to be seen on entering the room, and the Foley catheter bag was hanging on the right side of the bed and visible from the entrance of the room door, and when the room door was opened. During an interview on 5/28/2025 at 9:37 am, LPN DD confirmed that R159's Foley catheter bag was not covered with a privacy bag. She stated the catheter bag should be covered because it was a dignity issue. She further stated R159 could be uncomfortable when it was not covered, and the bag should be covered at all times for the resident's privacy. During an interview on 5/28/2025 at 9:39 am, CMAT RRR revealed she confirmed R187's Foley catheter bag was not covered with a privacy bag. She stated the catheter bag should be covered for the resident's privacy because it was a dignity issue. During an interview on 5/28/2025 at 10:07 am, CNA BB revealed she confirmed the catheter bag was uncovered. She stated the bag should be covered for the resident to have dignity. She stated that if the bag was not covered, it would mess with the resident's confidence, and they would not enjoy being out and about because people would see it. She stated the resident would feel like their business is being exposed, and they would not feel good about it, even if they were in their room, because when the room door was opened, everyone who passed or went into the room would see it. During an interview on 6/02/2025 at 1:08 pm, the DON revealed that she stated that her expectations are for the Foley catheter bags to be covered to maintain the residents' privacy. 3. A review of the facility's policy titled Assistance with Meals, revised March 2022, documented: Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation: Dining Room Residents; 2. Facility staff will serve residents and will help residents who require assistance with eating. A review of the facility's EMR documented R108 was re-admitted to the facility on [DATE] with a diagnosis including but not limited to dysphagia following cerebral infarction. A review of the Quarterly MDS assessment dated [DATE] documented that R108 presented with a BIMS score of three, which indicated R108 had severe cognitive impairment; requires partial/moderate assistance for eating; has upper extremity (shoulder, elbow, wrist, hand) impairment on one side; has lower extremity (hip, knee, ankle, foot) impairment on one side; and mechanically altered diet requiring a change in the texture of food or liquids (e.g., pureed food, thickened liquids). A review of the care plan dated 2/8/2022 documented that R108 had limited physical mobility related to (r/t) stroke, weakness, and that staff would provide the following level of assistance: one-to-one assistance at all meals and meal assistance. A review of the physician's orders dated 5/25/2023 documented included, but not limited to:* Regular diet, Pureed / Dysphagia Puree texture, Thin Liquids consistency, double portions, 4 ounce (oz) Mighty Shake with lunch and dinner.* Liquid Protein one time a day, 30 milliliter (ml) Supplement. During an observation on 5/27/25 at 12:44 pm, R108 was seated in the dining room at a table by herself. R108 was observed using her left bare hand to scrape mashed potatoes from her plate and feed herself. During an observation on 5/28/2025 at 12:36 pm, R108 was seated in the dining room at a table by herself. R108 used her left bare hand to dip into a bowl of green beans and placed a handful of beans into her mouth. During an interview on 5/27/2025 at 12:50 pm, LPN ZZ confirmed and verified R108 was seated in the dining room at a table by herself and she was using her left bare hand to scrape mashed potatoes from her plate and fed herself. She stated R108 was on a pureed diet and she needed assistance with eating her meals. She stated R108 needed to be redirected and assisted during her meals. LPN ZZ stated that if R108 were not redirected to use a spoon and not use her bare hands to eat, she would lose her fine motor skills, which would involve knowing how to use utensils to eat. During an interview on 5/28/2025 at 12:37 pm, CNA OO confirmed that R108 used her bare hands to eat. She stated R108 did not need assistance to eat. She further stated that R108 just had to be prompted to use a spoon instead of using her hands, and she had not been redirected yet. During an interview on 6/9/2025 at 9 am, the Assistant DON revealed she stated she expected the staff to redirect the residents and assist them with feeding during mealtimes to prevent them from eating with their bare hands.
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 F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administration of Medication and Administering Medications, the facility failed to assess one of 106 sampled residents (R) (R2) for self-administration of medications. Findings included: A review of the facility's policy titled Self-Administration of Medication, dated April 2022, under section titled General Guidelines, number one documented, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of the facility's policy titled, Administering Medications, revised April 2019, under section titled Policy Interpretation and Implementation, number 27 documented, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Alzheimer's Disease. A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R2 presented with a Brief Interview for Mental Status (BIMS) score of 15, indicating that R2 was cognitively intact, and that R2 was ordered an antidepressant, opioid, hypoglycemic, and anticonvulsant. A review of R2's care plan with a revision date of 5/8/2025 indicated a focus on using antidepressant medication related to the diagnosis of depression. Goals included that R2 would be free from adverse reactions related to antidepressant therapy. Intervention included, but was not limited to, giving R2 antidepressant medications as ordered by the physician. A review of R2's care plan with a revision date of 2/18/2025 revealed that R2 uses anti-anxiety medications related to anxiety disorder. Goals included that R2 would be free from adverse reactions related to anti-anxiety therapy. An intervention included, but was not limited to, giving R2 anti-anxiety medications as ordered by the physician. A review of R2's physician orders included but was not limited to an order dated 3/14/2025 for Cymbalta oral capsule delayed release particles 30 mg with directions to take one capsule by mouth one time a day for depression, an order dated 3/31/2025 for lamotrigine oral tablet 100mg with directions to take one tablet by mouth two times a day for anticonvulsant, an order dated 1/21/2025 for mirtazapine oral tablet 15 mg with directions to take one tablet by mouth at bedtime, and an order dated 11/26/2024 for pregabalin oral capsule 75 mg with directions to take one capsule by mouth two times a day for neuropathy. Further review of R2's physician orders revealed no order for self-administration of medication. A review of R2's EMR revealed no assessment for self-administration of medication. During an observation and interview on 5/27/2025 at 11:55 am with R2 revealed three pills in a medication cup on her bed that she was actively taking. When asked if she normally administers her own medication, she stated yes and that the nurse will give her the pills, and she will take the pills at her own pace due to problems swallowing. During an observation on 5/29/2025 at 9:12 am, R2 was observed with three pills at her bedside that she was actively taking. Certified Medication Aide Technician (CMAT) SS was observed to walk into R2's room and quickly exit the room. During an interview with R2 at this time, she stated that the staff had taken her pills away. During an interview on 5/29/2025 at 9:20 am, CMAT SS stated that she has worked at the facility for two years and knows the residents on this floor well. CMAT SS confirmed she took the pills from R2's room and discarded them. She stated she checked on the roommate and saw the pills at R2's bedside and removed them because they should not be there. When asked why she removed them from the room, CMAT SS stated that medications should not be left at the bedside. When asked what kind of pills those were, she stated that they may have been part of the evening medications. During an interview on 6/6/2025 8:43 am, the Director of Nursing (DON) confirmed that R2 does not have an assessment for self-administering medications and will need to get one completed. She stated that her expectation for self-administering medications is to first determine if the resident is cognitively intact, then conduct an assessment for self-administration, have a physician order, education with the resident, and establish parameters for regular check-ins and documentation. The DON further stated that potential negative outcomes would depend on the medications.
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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and a review of the facility's policy titled Residents' Ri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and a review of the facility's policy titled Residents' Rights, the facility failed to honor the resident rights for one of 25 sampled residents (R) (R12) related to the choice to be transferred out of bed daily. This failure had the potential to cause a decrease in the residents' mental and emotional progress. Findings included: A review of the facility's policy titled Resident Rights dated 10/8/2022 revealed that all activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident, goals, preferences, and choices. A review of the electronic medical record (EMR) revealed that R12 was admitted on [DATE] with diagnoses that included bipolar disorder, schizoaffective disorder, morbid obesity, anxiety disorder, drug-induced subacute dyskinesia, and drug-induced secondary Parkinsonism. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that R12 presented with a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive deficits; R12 very rarely suffers from social isolation; that R12 exhibited no behavior; that R12 had lower extremity impairment on both sides, and uses a wheelchair; and that R12 was ordered antipsychotic, antiplatelet, and anticonvulsant medications. A review of the care plan dated 4/4/2025 revealed that R12 was at risk for altered mood or behavior related to the diagnosis of schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia. It was noted that R12 would have improved mood state, happier, no signs or symptoms of depression, anxiety, or sadness through the review date. The interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.), and educating the resident regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. During an observation on 5/27/2025 at 12:19 pm, R12 was lying in bed, staring at the ceiling. He stated that he would like to get out of bed every day, but they get him up once a week whenever they can due to the Hoyer and short staff and due to his weight. He stated that he mostly stays in bed and gets very few visits from staff, but they come whenever he rings for help. R12 stated that he is from Kentucky but likes being here in Georgia because this is where his wife is from, and she passed away, and being here makes him feel close to her when he feels sad. He stated that he would like to do activities or some kind of recreation with other people. During an observation on 5/28/2025 at 11:01 am, R12 was lying in bed watching TV. He stated that he informed the Certified Nursing Assistant (CNA) that he would like to get out of bed today, but was told that they were short-staffed and so she couldn't get him up. R12 stated that he understands and is just grateful to be able to stay here so he can feel close to his wife. During an interview on 5/29/2025 at 2:00 pm, CNA FF revealed that she was not the regular CNA for R12 but was assigned to his care that day. CNA FF stated that she is aware that R12 likes to get out of bed daily, but stated that sometimes it is difficult because of staffing, and he requires a Hoyer lift and requires two staff members for transfer. She stated, I'm not saying that it is right, but that is how it is here sometimes. During an interview on 5/30/2025 at 1:00 pm, the Activities Director (AD) revealed that she has been working in the facility for a little over a year now. She stated, We do an admission assessment on each resident when they get admitted and get their preference and try to put a plan together that best suits the individual. Initially, he was a little depressed and did not want to do anything. But then he was moved to another floor and is now more verbal. He's my one-on-one, and he does say he would like to get up, but when they are short-staffed, they don't get him up. When he is in the room, we talk about sports and family, and I offered him games, but he refuses. He consistently verbalizes he wants to get out of bed to socialize, but is unable to, due to not getting out of bed. I do know that he wants to be in the group, but can't when they don't get him out of bed. I bring him bingo bucks, but he can't come down to use them because he hasn't gotten out of bed. He wants to come out of his room. AD stated that for residents who do not leave the room to attend activities, she goes around and offers one-on-one activities they may like and gives them bingo bucks, so they are able to buy snacks. She also stated that this administration has further cut the activities budget, and so she is unable to buy things for the residents that she used to buy before. During an observation on 5/30/2025 at 1:00 pm, R12 was lying in bed watching TV. He again stated that he would like to get out of bed, but stated that he is aware that they were short-staffed, so he didn't ask today. R12 stated, It's okay because I know they're doing their best, but it would be nice to attend the activities downstairs. During an interview on 5/30/2025 at 2:18 pm, CNA MMM revealed that she has been working in the facility for almost two years, periodically. She stated that she is R12's regular CNA when she is working, and that is about four to five days per week. She stated, Sometimes when we are short-staffed, we are unable to get (the residents) up out of bed, and that R12 also did not have a cushion for his wheelchair, and his bottom hurts when he is up in the wheelchair. CNA MMM stated, Therapy has been aware and told me about two weeks ago that the cushion was on the way, and it still hasn't come. I give him the option if he wants to get up, and he has not told me he wanted to get up. CNA MMM stated that there is no set schedule when R12 gets out of bed and that he didn't get up all week because he didn't tell me he wanted to get up. He usually tells me when he wants to get up. During an interview on 5/30/2025 at 3:23 pm, the Director of Rehab Services revealed that central supplies orders equipment for residents, and it is communicated verbally with the central supply person. She denies there being any documentation of the request; therefore, there is no paper trail to look back on. To be honest, there are no checks and balances where ordering and follow-up are concerned when it comes to the mobility device for residents. We do not order wheelchairs or cushions for residents. That is a central supply thing. She denied having any knowledge of a wheelchair cushion being ordered for R12. During an interview on 6/2/2025 at 10:09 am, the Director of Nursing (DON) revealed that she is aware of the communication issues within the facility but stated that that is something she is constantly working on. The DON stated that there has to be a better system of checks and balances when it comes to ordering residents' supplies and that she will be looking into the matter. She further stated that she expects that the staff are following the resident's care plan and taking their choices and preferences into consideration. DON denied the issue ever being reported to her but stated that if the resident wants to get out of bed, then the CNA should take them out of bed.
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 F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDEDBased on record review, staff interviews, and review of the facility policy titled Advance Directives, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDEDBased on record review, staff interviews, and review of the facility policy titled Advance Directives, the facility failed to ensure one of 106 sampled residents (R) (R48) Advance Directives was completed and followed up on. Findings included: A review of the facility policy titled Advance Directives dated April 2022 documented that a resident's choice about Advance Directives will be respected. Prior to or upon admission, the Care Plan Team will ask residents/their family members about the existence of any Advance Directives. A review of the electronic medical records (EMR) revealed that R48 was admitted to the facility on [DATE] with diagnoses including, but not limited to, medically complex conditions, vascular dementia, moderate, with agitation, hypertension, non-Alzheimer's dementia, depression (other than bipolar), bipolar disorder, and schizophrenia. A review of the annual Minimal Data Set (MDS) assessment dated [DATE] revealed that R48 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. A review of R48's care plans dated 5/22/2025 indicated a focus on the Resident/family desire for full code status. Goals indicated that R48 desires will be met through the next review date. Interventions indicated to follow facility protocol for FULL CODE status. A review of R48's physician orders dated 5/22/2025 revealed a code status of full code. A review of the physician orders for life-sustaining treatment (POLST) in the electronic health record (EHR) reveals that it was blank and has no signatures on it. During a phone interview on 5/30/2025 at 2:13 pm, the family member of R48 revealed that no one from the facility has called her or spoken with her about Advanced Directives for her mother. She further stated she has not been able to speak to anyone regarding the admission paperwork from the facility. During an interview on 6/6/2025 at 8:15 am, the Social Services Director (SSD) revealed that the process for getting Advance Directives from residents and families begins when the resident first admits to the facility. They ask the family if the hospital explained to them the process of Advance Directives. If they do have Advance Directives on admissions, the facility Admissions Coordinator will ask for the documentation and will upload it in the system under Advance Directives. A POLST is completed with the resident if they are of sound mind. If the resident is not of sound mind, they will attempt to get the responsible party to come in to discuss. They will automatically be Full Code until then. The SSD confirmed the POLST was blank for R48 and that the family had not been reached to come in and sign it. She further revealed that it was not typical to only have one attempt, and they need to make more attempts to reach that family member. During an interview on 6/6/2025 at 12:06 pm, the Director of Nursing (DON) revealed she expects the Advance Directive to be completed timely which depends on being able to get confirmation from the families. The DON further revealed that the SSD typically completes the POLST. Turn-around time is usually within the same day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to notify the responsible party and attending physician about a change in residents' condition for two of 106 sampled residents (R) (R371 and R170). Specifically, the facility failed to notify R371's responsible party and attending physician following a fall and failed to notify R170's responsible party of a change in condition.
Findings included:
A review of the policy titled Change in a Resident's Condition or Status with a revised date of February 2021 revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status. The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury, including injuries of an unknown source, or it is necessary to transfer the resident to a hospital/treatment center.
1. A review of R371's electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and discharged from the facility on 10/31/2024. Pertinent diagnoses during his residence at the facility included, but were not limited to, history of falling, unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, fracture of unspecified part of neck of left femur, and fall on same level from slipping, tripping, and stumbling without subsequent striking against object.
A review of R371's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R371 was cognitively intact.
A review of a final summary facility investigation dated 7/14/2024 revealed, It has been determined by the IDT (Interdisciplinary Team) that [R371's] fracture had occurred when he fell from his room on 7/3/2024. [Certified Nursing Assistant (CNA) CCC] had reported to the charge nurse [Licensed Practical Nurse (LPN) DDD] that [R371] had fallen. However, [LPN DDD] did not document or assess [R371] in a timely manner. On 7/5/2024, [R371] complained of left leg pain. Orders were obtained to get an X-ray of the left hip and leg area. An X-ray was obtained, and the results revealed a fractured left femur. Family and MD notified of results. Orders received to send [R371] to ER. [R371] was scheduled for surgery on the left femur. [R371] will be returning to the facility. Investigation also revealed that [LPN DDD] failed to follow facility policies regarding incidents/falls. [LPN DDD] failed to assess and document [R371's] incident after it was reported to her. Due to these reasons, [LPN DDD] was terminated from her position at Nurse Care of Buckhead. [CNA CCC] received education on not getting a resident off the floor until the nurse assessed them after a fall. Care plan reviewed and updated. No further incidents noted at this time.
A review of R371's EMR revealed no documentation on the day of the fall or any evidence of notifications to R371's responsible party or physician regarding the fall that occurred on 7/3/2024.
During an interview on 6/3/2025 at 9:27 am, the Human Resources Director confirmed that LPN DDD was terminated on 7/8/2025 for violating company policy/procedure and is not eligible for rehire.
During a phone interview on 6/7/2025 at 11:30 am, CNA CCC revealed that R371 always tried to get up and go back and forth to the restroom without asking. He noticed the resident on the floor, picked the resident off the floor, and then went to the nurses' station to report it to the nurse. He told the nurse that the resident fell, and she said ‘Alright.’ He stated that the nurse did not make any sudden moves to assess the resident after he reported the fall.
During an interview on 6/6/2025 at 9:26 am, the Director of Nursing (DON) revealed that R371 resided at the facility prior to her working at the facility. The DON stated that when a resident falls, there should be an immediate physical assessment, neuro assessment, pain assessment, vitals taken, notification to the physician and family, documentation, follow-up, X-ray, and other interventions as indicated, such as hospitalization. The DON confirmed that, according to the facts, the nurse did not assess the resident following the fall. The DON further confirmed that the charge nurse should have assessed immediately following the fall, and a notification to the physician and responsible party should have been made. The DON stated that potential negative outcomes of not meeting these expectations following a resident's fall could result in injuries they are not aware of.
2. A review of the EMR revealed that R170 was admitted to the facility on [DATE] with diagnoses of, but not limited to, unspecified dementia, unspecified severity, with agitation, acquired absence of left leg above knee, other acute osteomyelitis, left ankle and foot and acquired absence of right leg above knee. A guardian was listed on the face sheet as the Emergency Contact and the responsible party contact.
A review of the most recent quarterly MDS assessment dated [DATE], revealed that R170 presented with a BIMS score of three, indicating that R170 has severe cognitive impairment; that R170 was dependent on staff for transfers, toileting, and personal hygiene; and that R170 was assessed as having one fall with injury. Falls were triggered as an area of concern on the Care Area Assessment Summary (CAAS).
A review of the care plan last updated 2/7/2025, revealed that R170 is at risk for falls. Interventions to be implemented included frequent rounding for observation, anticipating and meeting the resident's needs.
A review of the nursing note dated 8/6/2024 revealed that R170 was sitting on her Geri chair within sight of the nursing station when she tumbled over and hit her forehead on the floor. Staff rushed to her side and assisted her off the floor to a sitting position. There was a hematoma on the side where her head landed on the floor, and blood was coming from her forehead. Emergency 911 was called immediately to transfer the resident to an acute care hospital for further evaluation. There was no documentation that the primary contact listed on the face sheet was notified.
A review of a nursing note dated 3/5/2025 revealed that R170 fell out of the Geri chair. The nurse assessed the resident for pain and injury. R170 stated that her head hurt on her forehead. The CNA reported to the nurse that the resident jumped out of the Geri chair and hit her head on the bed rail. The nurse practitioner was notified and ordered for R170 to be sent to an acute care hospital. There was no documentation that the primary contact listed on the face sheet was notified.
A review of the EMR revealed no documentation that R170's guardian was notified about the change in condition.
During an interview on 5/30/2025 at 4:12 pm, the DON discussed regarding notification of change to R170's guardian regarding the falls that occurred on 3/25/2025 and 8/6/2025. DON confirmed that R170's guardian was not notified when the falls occurred. She revealed that she expects staff to make every effort to contact family and document each attempt if not successful in reaching the family. She revealed that she expects staff to assess and evaluate every fall.
During an interview on 6/2/2025 at 11:00 am, CNA AA revealed that she is familiar with R170 and worked on the third floor on 3/5/2025 when R170 jumped out of the Geri chair and fell. She revealed that R170 was sitting on her Geri chair when she reached out to grab R170’s brief to change her in a split second, R170 fell out of the chair. She stated that she had notified the nurse, and R170 was evaluated. She stated that she could not tell if the resident was taken to the hospital because it was at the end of her shift.
During an interview on 6/3/2025 at 9:15 am, the Administrator revealed that he expects staff to complete an incident report, notify the DON and investigate every incident as well as abuse, and notify the family. He stated that in the case of an injury of unknown origin, the staff are expected to notify him, and he will make a report to the state. He stated that they have a clinical meeting every morning to discuss incidents and take appropriate action.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations and investigations of abuse, including injuries of unknown source, were reported timely to the State Survey Agency (SSA) for one of five sampled residents (R) (R128) reviewed for abuse. Findings included:A review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, was conducted, and under section titled Policy Interpretation and Implementation, subsection titled Follow-Up Report, number one documented, Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.A review of R128's electronic medical record (EMR) revealed he was admitted to the facility on [DATE], and his pertinent diagnoses included but were not limited to aphasia following nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side, and generalized muscle weakness.A review of R128's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four, indicating R128 had severe cognitive impairment.A review of the facility report dated 2/11/2025 regarding an allegation of abuse from Certified Nursing Assistant (CNA) TTTT to R128. A review of the follow-up report revealed a submission date of 4/24/2025.During an interview with R128 on 6/3/2025 at 10:54 am, the resident stated that there was a staff member who punched him in the head a few months ago. When asked if the staff member was still working at the facility, he stated no.During an interview on 6/3/2025 at 9:27 am, the Human Resources Director revealed that the alleged perpetrator, CNA TTTT, was terminated on 2/17/2025 for resident abuse and is not eligible for rehire.During an interview on 6/6/2025 at 9:49 am, the Director of Nursing (DON) confirmed that the follow-up report was submitted after the five-day window. The DON stated it is possible that this delay in reporting was due to the recent turnover of administrators. She further stated that she was not the DON during this time.During an interview on 6/6/2025 at 11:11 am, the Administrator revealed he started working at the facility on 4/22/2025 and was not working at the facility during the time of the alleged abuse. He confirmed the date of the initial report being submitted on 2/11/2025 and the follow-up report being submitted on 4/24/2025. He further stated that this incident was identified when he was hired as not having a five-day report and needed one completed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations of abuse, including injuries of unknown source, were thoroughly investigated for two of five sampled residents (R) (R128 and R379) reviewed for abuse. Findings included: 1. A review of the policy titled Reporting and Investigating, revised September 2022, revealed that the individual conducting the investigation, as a minimum, documents the investigation completely and thoroughly. A review of the electronic medical record (EMR) revealed R128 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to aphasia following nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side, and generalized muscle weakness. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R128 presented with a Brief Interview for Mental Status (BIMS) score of four, indicating R128 had severe cognitive impairment. A review of the facility report dated 2/11/2025 revealed an allegation of abuse from Certified Nursing Assistant (CNA) TTTT to R128. A review of the follow-up report dated 4/24/2025 documented no specific interviews but concluded the allegation of abuse as unsubstantiated. A review of the facility investigation provided by the facility on 5/28/2025 revealed no written statements regarding the investigation. During an interview on 6/3/2025 at 9:27 am, the Human Resources Director revealed that the alleged perpetrator, CNA TTTT, was terminated on 2/17/2025 for resident abuse and is not eligible for rehire. During an interview on 6/3/2025 at 10:54 am, R128 stated that there was a staff member who punched him in the head a few months ago. When asked if the staff member was still working at the facility, he stated no. During an interview on 6/05/2025 at 10:02 am, Certified Medication Aide Technician (CMAT) GGG revealed she has worked at the facility for six months. She recalled a few months ago when she heard that R128 alleged that the CNA that night punched him in the face. She further stated that she has not seen the CNA since then. During an interview on 6/6/2025 at 11:11 am, the Administrator revealed he had started working at the facility on 4/22/2025 and was not working at the facility during the time of the alleged abuse. He stated that if the evidence of the statements is not in there, they should be. He further stated that there should be statements in the folder, including police notes. He expects all the evidence of investigations, including statements, to be put into one folder. 2. A review of the facility's policy titled Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property with no review date, revealed that all suspected cases of abuse or misappropriation of a resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee.The findings will be reported to the appropriate governing agencies.Interview the person reporting the allegation.Ensure resident safety is not jeopardized and physically assess the resident.Secure the area, if indicated.Notify the physician, resident representative, Administrator, and DON immediately.Interview all associates, residents, and family members involved.Ensure confidentiality.File a report with government agencies.Suspend the associate pending investigation.Continue the investigation to determine if other residents may be at risk for similar occurrences. If similar residents are at risk, appropriate measures /changes will be implemented.Track resolutions to ensure future safety for the residents.If a family member, a center visitor, a consultant, volunteer staff, a family friend, or other individual is implicated, request that they leave the center with instructions that they will be contacted by the Center Administrator.Involuntary seclusions - this is to be used as the last restrictive approach for the minimum amount of time for resident protection and is to be done according to the resident's needs and not for staff convenience. A review of EMR revealed that R379 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses, which included, but were not limited to, encounters for other orthopedic aftercare, orthopedic surgery (except major joint replacement or spinal surgery). fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, muscle weakness (generalized), other abnormalities of gait and mobility. unspecified lack of coordination. A review of R379's quarterly MDS assessment dated [DATE] revealed that a BIMS indicated the resident has memory problems for short and long term and was unable to complete the cognitive interview. A review of the Care Plan dated 2/17/2025 revealed that R379 had a focus area of risk for falls related to Actual fall and ER evaluation. A review of Nursing Notes dated 9/20/2024, revealed that the CNA reported the resident had something on her forehead, the nurse observed a hematoma in the forehead area. the resident was unable to say what happened, the nurse placed a phone call to the Nurse Practitioner (NP) to make her aware. Transferred resident was transferred to an acute care hospital, and the responsible party was made aware of the transfer. There was no documentation that the injury was investigated or reported to the State Agency. During an interview on 5/30/2025 at 4:25 pm, the Director of Nursing (DON) confirmed that the injury was not reported to the state and not investigated. She revealed that she expects staff to notify the Administrator when it comes to injury of unknown origin to the facility administrator and the facility to start an investigation. During an interview on 6/3/2025 at 9:15 am, the facility administrator revealed that he expects staff to fill incident report, notify the DON, and investigate if it's an abuse. He stated that for injury of unknown origin, staff are expected to notify the Administrator, and he will make a report to the state. He stated that they have a clinical meeting every morning to discuss incidents and take appropriate actions.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and review of the facility policy titled Coordination- Pre-admission Scree...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and review of the facility policy titled Coordination- Pre-admission Screening and Resident Review (PASARR) Program and MDS Error Correction, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for four of 106 sampled residents (R) (R12, R104, R117 and R33, and 133). Findings included: A review of the undated facility policy titled Coordination Pre-admission Screening and Resident Review (PASARR) Program revealed that the facility will coordinate assessments with the PASARR program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and efforts. Coordination includes incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a residence assessment, care planning, and transitions of care. A review of the facility policy titled MDS Error Correction dated June 2025 revealed that if an error is discovered after the encoding and editing, then correct the error. For minor errors, correct the record. A major error is one that inaccurately reflects the resident's clinical status and/or may result in an inappropriate plan of care. For major errors: correct the original assessment to reflect the resident's status as of the original assessment reference date and submit the record; and perform a new significant change in status (if this has occurred) or a new significant correction to a prior assessment with a new observation period and assessment reference date. 1. A review of the electronic medical record for R12 revealed that he was admitted on [DATE] with diagnoses that include bipolar disorder, schizoaffective disorder, morbid obesity, anxiety disorder drug drug-induced subacute dyskinesia, and drug-induced secondary parkinsonism. PASARR II observed in R12 miscellaneous records revealed an accepted PASARR II document dated 8/20/2024. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed A Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive deficits. Section A of the MDS revealed that the R12 PASARR II assessment indicated No. Section D revealed that R12 very rarely suffers from social isolation. Section E reveals no behavior exhibited. Section GG revealed lower extremities impairment on both sides, wheelchair, dependent with lower body dressing, showers, and toilet hygiene. Section N reveals antipsychotic, antiplatelet, and anticonvulsant medication use. A review of the residence care plan dated 4/4/2025, revealed a focus area stating, at risk for altered mood or behavior related to diagnosis of schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia. Outcome documented, will have improved mood state, happier, no signs or symptoms of depression, anxiety, or sadness through the review date. The interventions included administer medications as ordered, monitor/ document for side effects and effectiveness. Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) and educate the resident regarding expectations of treatment, concerns with side effects, potential adverse effects, evaluation, and maintenance. Focus area revealed, has an Activities of Daily Living (ADL) self-care performance deficit, personal assistance myself except for. The outcome states, Residents' needs will be met. The interventions include Assist with ADLs as needed, Physical Therapy/ Occupational Therapy (PT/ OT) evaluation and treatment as per Physician (MD) orders. A review of the Physician's orders revealed Abilify oral tablet 10 milligrams (mg), HCL 100 mg, Depakote delayed release 500 mg one tablet daily, and Depakote 500 mg given four tablets by mouth at bedtime for schizoaffective disorder. 2. A review of the EMR revealed that R104 was admitted to the facility on [DATE] with diagnoses that include dementia with agitation, paranoid schizophrenia, major depressive disorder, hallucinations, and cognitive communication deficit. A review of R104 admission MDS assessment dated [DATE] revealed a BIMS score of 11, indicating minimal cognitive deficits revealed that the R104 PASARR II assessment indicated No. A review of R104 care plan, revised on 6/6/2025, revealed a focused area stating, has diagnosis of paranoid schizophrenia, brief psychotic disorder, hallucinations, and problem related to social environment. Level II. Outcome revealed, will have fewer episodes of behaviors through the review date. Interventions included administering medications as ordered. Monitor/document for side effects and effectiveness, anticipate and meet needs, approach in a calm manner, document behaviors and resident response to interventions. Focus area states, diagnosis of paranoid schizophrenia, hallucinations, and brief psychotic disorder. Outcome reveals, will remain free of drug-related complications, including movement disorder, discomfort, hypertension, Constipation, or cognitive impairment to review date. Interventions include administer medications as ordered. Monitor/ document for side effects and effectiveness, observe for hypotension, tardive dyskinesia, excessive sedation, or AMS; promptly report such to the MD, observe for signs of hallucinations or other psychotic episodes; Promptly report such to the MD. Focus area also includes uses antidepressant medications for poor appetite. Outcome states will show decreased episodes of signs and symptoms of depression through the review date. Interventions include: educate the resident/family/caregiver about risks, benefits, and the side effects and/ or toxic symptoms of (Specific: antidepressant drugs being given), give antidepressant medications ordered by the physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, Constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing signs and symptoms of depression on altered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/ comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, change in condition, change in weight/ appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A review of the Physician's orders revealed mirtazapine 15 mg, one tablet at bedtime, for poor appetite, melatonin tablet 3 mg by mouth at bedtime for sleep. 3. A review of EMR revealed R117 was admitted to the facility on [DATE] with a diagnosis that includes bipolar disorder, intellectual disabilities, Ogilvie syndrome, and chronic pain. A review of R117 admission MDS, dated [DATE], revealed a BIMS score of 15, indicating no cognitive deficits, and that R117 PASARR II assessment indicated No. A review of R117 care plan dated 5/27/2025 revealed a focus area stating has impaired cognitive function/ dementia or impaired thought process related to bipolar disorder, intellectual disabilities, disease process, acute respiratory failure with hypoxia. Resident has a PASSAR [sic] level 2 related to severe mental illness. The outcome states, will maintain current level of cognitive function through the review date. Interventions include, refer resident to cycle therapy for PASARR support services, administer meds as ordered, ask yes/ no questions in order to determine the residents needs, break tasks into one step at a time, cue, reorient and provides as needed, keep the routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time. A review of the Physician's orders revealed the use of mirtazapine 15 mg, 0.5 tablet daily for depression, Seroquel 100 mg, one and a half tablets two times daily for bipolar disorder, and Buspirone HCL 5 mg, one tablet three times a day, related to bipolar disorder. 4. A review of the admission records for R33 revealed an admission date of 4/11/2025 with diagnoses that include schizophrenia, major depressive disorder, mild cognitive impairment, and hemiplegia and hemiparesis following cerebral infarction. A review of R33 admission MDS assessment dated [DATE] revealed BIMS score of 12, indicating minimal cognitive deficit, and revealed that R33 PASARR II assessment indicated No. A review of R33's care plan, last revised on 6/6/2025, revealed a focus area stating, has diagnosis schizophrenia/ schizoaffective disorder; Resident exhibiting signs and symptoms of vulgar and verbally aggressive behaviors. PASARR level II. Outcome states, the resident will be free from increased silent symptoms of impulsivity, poor coping skills, and verbal aggression toward others through the next review. The interventions include calling staff out of their names, knocking items off the medication cart and the desk area--(emergency room) evaluation. Do not encroach nor argue w/ the resident to allow for calming, make notifications to residents RP of residents exhibited behaviors, as appropriate and provide reality orientation to resident, as tolerated and refer resident for geri psych support provider services as appropriate. Focus area reveals, has impaired cognitive function/ dementia or impaired thought process related to impaired decision making, neurological symptoms. Outcome states, will be able to communicate basic needs on a daily basis through the review date. Interventions include, administer meds as ordered, ask yes/ no questions in order to determine needs, break tasks into one step at a time, cue, reorient and supervise as needed, discuss concerns about confusion, disease process, NIH placement with R33/ family/ caregivers. Focus area reveals, has mood problem related to schizophrenia, depression. Outcome states, will have improved mood state (happier, calmer appearance, no signs or symptoms of depression, anxiety or sadness) through the review date. Interventions include, administer medications as ordered. Monitor/ document for side effects and effectiveness, educate R33/ family/ caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. Monitor/ record mood to determine if problems seem to be related to external causes, i.e., medications, treatments, concerns over diagnosis. Monitor/ record/ report to MD PRN acute episode feelings of sadness; Loss of pleasure and interest in activity; Feelings of worthlessness or guilt; Changing appetite/reading habits; Change in sleeping habits; diminished ability to concentrate; Change in psychomotor skills, monitor/ record/ report to MD PRN mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. A review of the physician's orders revealed use of Seroquel 150 mg two times per day for aggressive behaviors. During an interview on 6/2/2025 12:19 pm, the SSD DDDD, she stated that all four residents R12, R33, R117 and R104 currently had a PASARR II with recommendations on the care plan completed by the social work department and that all recommendations were accepted and is being followed. SSD DDDD stated that they have psychological services through ***** Healthcare services at least monthly and has recommendation for inhouse psychological services overseen by a psychiatrist as needed. SSD DDDD admitted that the recommendations documented in the EMR differ from those listed on the care plans, but stated that a PASARR II is usually picked up on admission and captured by the MDS department; therefore, she was not sure why it wasn't. SSD DDDD also stated that social work completes the parts on the MDS they are responsible for and the MDS team should do the rest, but she was unsure who completes what areas. During an interview on 6/2/2025 at 1:08 pm, MDS Coordinator KKK revealed that she was new to MDS and had only been working in the facility since October 2024. MDS KKK confirms that R12, R104, R33, and R117 were all coded as No on their admission MDS assessment. She stated that all assessments were completed before she worked in the facility, but denies ever looking at his admission records since then. MDS KKK stated that she is still learning the MDS process and usually follows whatever was done on the previous assessment. 5. A review of the facility's policy titled, MDS Error Correction, dated 6/2025, section titled Policy Interpretation and Implementation, number five, letter a, documented, A minor error is one related to the coding of the MDS. For minor errors, correct the record and submit to the QIES ASAP system. A review of R133's EMR revealed R133 was admitted to the facility on [DATE] and pertinent diagnoses included, but were not limited to, vascular dementia, cognitive communication deficit, cerebral infarction, and type 2 diabetes mellitus. A review of R133's annual MDS assessment dated [DATE] revealed a BIMS of 00, which indicates R133 had severe cognitive impairment.Section E, Behaviors, coded R133 as having no rejections of care. A review of R133's care plan with a revision date of 5/13/2025 revealed a focus stating R133 occasionally refuses medication. A review of R133's physician orders included, but was not limited to, an order dated 5/24/2024 for aspirin 81mg oral tablet once daily, an order dated 8/22/2024 for Humalog injection subcutaneously before meals, and an order dated 4/17/2024 for losartan potassium oral tablet 25 mg once a day. A review of R133's Medication Administration Record (MAR) from March 2025 to May 2025 documented multiple medications, including but not limited to insulin, as not given due to refusal. During an interview on 6/5/2025 at 10:13 am with Licensed Practical Nurse (LPN) ZZ, revealed that she has been working at the facility for six months and works with R133 often. LPN ZZ stated that R133 refuses care frequently. She further stated that R133 is alert and aware but aphasic and does not speak, but shakes his head and hands at the staff, indicating no. During an interview on 6/5/2025 at 10:15 am, Certified Nursing Assistant (CNA) AAA revealed he has been working at the facility for one year. He stated that he has witnessed the resident often refuse medication, take blood pressure medication, and take anything medication related. During an interview on 6/5/2025 at 1:56 pm with R133, this surveyor wrote on paper, Do you ever refuse your medications? R133 shook his hands and mouthed that he didn't want them. This surveyor then wrote, Did you get your medications today? R133 shook his head no. During an interview on 6/5/2025 at 2:22 pm, the Certified Medication Aide Technician (CMAT) BBB revealed she has been working at the facility for one month. CMAT BBB stated that R133 does not like to take medications. She further stated that R133 does not talk, and he shakes his head and hands no to refuse. CMAT BBB stated that if residents refuse, she reports to the nurse and attempts to reapproach at a different time. During an interview on 6/5/2025 at 2:28 pm, LPN ZZ confirmed he did not get his insulin this morning or afternoon. LPN ZZ stated R133 shook his head, indicating no when offered the blood sugar check and insulin. LPN ZZ further stated that the nurse practitioner (NP) is aware of his refusals. During a phone interview on 6/5/2025 at 6:04 pm with Nurse Practitioner (NP) CCCC revealed she started working for the facility about three months ago. NP CCC confirmed R133 has been refusing medications since she started. She stated she has talked to R133 about the importance of his medications. She further stated R133 is mostly nonverbal, but can understand. During an interview on 6/6/2025 at 9:53 am, the Director of Nursing (DON) revealed she is aware that R133 refuses medications consistently and refuses care at times. The DON confirmed R133 is not coded for rejections of care on the recent MDS assessment, but should be.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility's policy titled Care Plan, the facility failed to revise car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility's policy titled Care Plan, the facility failed to revise care plans for three of 106 sampled residents (R) (R96, R214, and R159) regarding denture care for R96, regarding diabetes mellitus for R214, and related to for midline dressing for R159. Findings included:A review of the facility's policy titled Care Plan dated August 2022 documented that it is the policy of the facility to create Care Plans in accordance with State and Federal regulations. Each resident admitted to the nursing home facility shall have a plan of care. The plan of care must consist of physician's orders, diagnosis, medical history, physical exam, and rehabilitative or restorative potential. A review of the facility's Electronic Medical Records (EMR) revealed that R214 was admitted to the facility on [DATE] with diagnosis included but not limited to type 2 diabetes mellitus, R159 was re-admitted to the facility on [DATE] with diagnosis included but not limited to sepsis and R96 was admitted to the facility on [DATE] with diagnosis included but not limited to Alzheimer's disease.Review of the admission Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview of Mental Status (BIMS) of 01 which indicated R96 had severe cognitive impairment. Review of the Medicare - 5 Day Minimum Data Set (MDS) dated [DATE] documented Section C (Cognition) Brief Interview of Mental Status (BIMS) of 13 which suggested R214 had intact cognition, Section I (Diagnoses) diabetes mellitus.Review of the Medicare 5- Day Minimum Data Set (MDS) dated [DATE] documented Section C(Cognition) Brief Interview of Mental Status (BIMS) of 14 which indicated R159 had intact cognition.Review of the facility's care plans revealed no evidence of revised care plans for R96 related to denture care, R214 related to diabetes mellitus and R159 related to midline care.Interview on 6/2/2025 at 11:01 am with Licensed Practical Nurse (LPN) YYY revealed she stated she started working at the facility one week ago. She stated the MDS does care plans. She stated she had not done nor updated care plans since working at the facility. She further stated that she would speak with the supervisor to find out how to proceed if something new comes up that needs to go in the care plan.Interview on 6/2/2025 at 11:09 am with LPN DD revealed she started working at the facility since February 2025. She stated the nurses did the baseline care plan when the residents were admitted but the nurses do not update care plans.Interview on 6/2/2025 at 12:09 pm with MDS Coordinator KKK revealed she confirmed there was no care plan for R96 related to denture care, R214 related to diabetes mellitus and R159 related to midline care. She stated the nursing staff as well as herself and the other MDS coordinators were responsible to ensure the care plans were updated and it was not done. She further stated if the care plans were not revised the residents would not get the appropriate care they should receive.Interview on 6/2/2025 at 1:08 pm with the Director of Nursing (DON) revealed she confirmed there was no care plan for R96 related to denture care, R214 related to diabetes mellitus and R159 related to midline care. She stated there should be care plans for the care areas and there were not. She stated the responsibility for ensuring care plans were revised was a collaborative effort between the MDS and nursing. She further stated it was important for the care plans to be revised to ensure the residents received services to manage their medical conditions.Interview on 6/5/2025 at 12:14 pm with the Assistant Director of Nursing (ADON) revealed she stated the care plans should be revised and updated for the residents. She stated that the residents could be missing out on care that they should be receiving if the care areas were not documented in the care plans. She stated that the residents would need various interventions and if it was not documented in the care plans, they would miss out on care they should receive.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Food and Nutritio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Food and Nutrition Services, the facility failed to serve the correct diet for one of 11 residents (R) (R2) ordered to receive a puree diet. Findings included: A review of the facility's policy titled Food and Nutrition Services with a revised date of October 2017 revealed that food and nutrition services will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE], and pertinent diagnoses included, but were not limited to, Alzheimer's Disease. A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R2 was cognitively intact; R2 displayed no rejection of care; R2 was independent with eating; and R2 was on a therapeutic diet. A review of R2's care plan revealed a focus initiated on 5/30/2025 that R2 has a swallowing problem related to dysphagia, as evidenced by a puree diet. Goals documented that R2 will have no choking episodes when eating through the review date. Interventions included but were not limited to R2's diet to be followed as prescribed, puree diet, and to refer to a speech therapist for swallowing evaluation. A review of the physician orders dated 5/27/2025 revealed that R2 was ordered a puree/dysphagia puree diet, mechanical soft with pureed meats texture, and thin liquid consistency. During an observation on 5/27/2025 at 11:55 am, R2 was observed to be edentulous (to have no teeth). R2 stated she was in the process of trying to get dental work done. R2 stated she has a swallowing difficulty in her esophagus, but that the kitchen sends her food she cannot consume, including corned beef and chicken salad. She revealed she has been at the facility for four years. During an observation on 5/27/2025 at 1:18 pm, R2 was eating her lunch, which consisted of chicken on a bone and a roll. R2 stated that her lunch was difficult for her to chew. A review of her lunch meal ticket documented Only magic cup, mighty shake, milk, mashed potatoes, and pureed cream of chicken soup for every meal. R2 further stated she was not given the magic cup or mighty shake indicated on her meal ticket. She stated that sometimes those items are given on her tray and sometimes not. During an interview on 5/28/2025 at 5:31 pm, R2 stated that she had some grits and a waffle for breakfast. During an interview on 5/29/25 at 9:12 am, R2 stated that she did not want her breakfast. An observation during this time revealed that the breakfast tray and meal ticket for R2 were in the food warmer. A review of her meal ticket documented, No sausage. Only magic cup, mighty shake, milk, mashed potatoes, and pureed cream of chicken soup for every meal. Observation of the meal on the plate consisted of two whole waffles, a few pieces of whole bacon, and grits. During an interview on 5/29/2025 at 9:20 am, Certified Medication Aide Technician (CMAT) SS revealed that R2 receives a regular diet. When asked to confirm her diet on the EMR, she confirmed the resident is indicated to receive a puree and mechanical soft diet. She further confirmed that the regular breakfast tray she was served was not the puree diet she should have received. During an interview on 6/6/2025 at 8:50 am, the Director of Nursing (DON) confirmed R2's puree dysphagia diet that started 5/27/2025. When told of the observations of R2's meals, the DON stated that those diets should not have been served to her unless she requested them. The DON further confirmed R2 is edentulous (has no teeth). The DON stated that she expects the diets served to the residents to be correct, and potential negative outcomes of not meeting those expectations can lead to some consumption challenges.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled Pain and Admini...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews, and review of the facility's policy titled Pain and Administering Medications, the facility failed to ensure that one of 106 sampled residents (R) (R80) received her pain medication in a timely manner. Findings included: A review of the facilities policy titled Pain with a revised date of October 2022, revealed that the nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment, for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. A review of the facilities policy titled Administering Medications with a revised date of April 2019 revealed that medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: Enhancing optimal therapeutic effort of the medication; Preventing potential medication or food interactions; and Honoring resident choices and preferences, consistent with his or her care plan. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facilities medical director to discuss the concerns. A review of the facility's admission record for R80 revealed that she was admitted to the facility on [DATE] with diagnoses that include insomnia, pyoderma gangrenosum, personal history of other venous thrombosis and embolism, paresthesia of skin, non-pressure chronic ulcer of the other part of right lower leg, limited to breakdown of skin, and lymphedema. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive decline. Section GG indicated lower extremities impairment on both sides, the need for use of a wheelchair, substantial/ maximal assistance required with toileting, partial/ moderate assistance with showers, upper body dressing, and personal hygiene. It also indicated that R80 is dependent on lower-body activities of care; anticoagulants R80 receive scheduled pain medication for occasional pain that does not interfere with activities, indicated no swallowing issues, section L indicated no dental issues, section N indicated the use of anticoagulant, opioid and diuretic and indicated that physical therapy was started on 8/24/2024 and ended on 9/7/2024, it also indicated that R80 was offered immunizations but declined. A review of R80 care plan revised on 4/4/2025 revealed a focus area of Pain medication Therapy (opioid), both PRN and routine, also to be given prior to wound care. Outcome revealed, will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions include: Administer medication as ordered, observe any black box warnings and follow as indicated, review (FREQ) for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. Focus area stated, has an Activities of Daily Living (ADL) self-care performance deficit r/t Limited Mobility, pain. Outcome stated, The resident will have her basic ADL and functional mobility needs met via staff AEB her being clean and dressed appropriately. Interventions include, Observe for any changes in the resident's abilities to do her ADL's and mobility, provide assistance as needed (PRN), provide assistance with bathing, provide assistance with personal hygiene, provide physical assistance with dressing, PT/OT evaluation and treatment as per MD orders, encourage the resident to use bell to call for assistance as needed, skin inspection: The resident requires skin inspection every week and PRN. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. A review of the physician orders revealed oxycodone HCL tablet 5 milligram (mg) given 5 mg by mouth before wound care; oxycodone HCL tablet 5 mg given 5 mg by mouth every six hours for pain. Pain: Assess pain level. Initial and score every shift, and as needed. 0=No Pain/1-4=Mild Pain/ 5-7=Moderate Pain/ 8-10=Excruciating pain, every shift for pain monitoring. Treatment: cleanse the right posterior calf with wound cleanser/ normal saline (WC/NS). Apply alginate and wrap with kerlix, cleanse the left posterior calf with WC/NS. Apply alginate and wrap with kerlix. During an interview on 5/27/2025 at 2:44 pm with R80 revealed that her wound is doing better now, and they are giving me my medication, but I have reported them because they sometimes refuse to give me my pain medication. I constantly ask why you are refusing to give me my medication, and they told me that they don't think I need it. The last time I had to tell them I'm gonna snitch on them to the state if they don't give it to me, and so they have been giving it to me lately. R80 stated that she sometimes refuses her treatment because she is in so much pain, and the nurse refuses to administer her pain medication. A review of the R80 medication administration record for several days during the months of August and September of 2024, March and May 2025, revealed missing signatures on the Medication Administration Record (MAR). A review of the Nurses Notes (NN) dated 8/6/2024 revealed medication out of stock. A review of the NN dated 11/10/2024 revealed medication not administered, waiting for pharmacy delivery, phone call to pharmacy, and MD. A review of the NN dated 11/11/2024 revealed oxycodone HCL tablet 5mg Give 5mg by mouth before wound care every Mon, Wed, Fri for wound care to be given before wound care Med on order. A review of the NN dated 5/5/2025 revealed Medication is on order. A review of the NN dated 5/28/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every 6hours for pain. Awaiting pharmacy. A review of the NN dated 5/31/2025 revealed oxycodone HCL tablet 5 mg give 5 mg by mouth every 6hours for pain. During an interview on 6/5/2025 at 11:54 am with License Practical Nurse (LPN) EE revealed that she has been working in the facility since November of 2024 and stated that she had not been working permanently on the third floor in the beginning and has only been there since February of 2025. LPN EE stated that I do part-time, and I do a cart audit before I leave each day I'm here, and reorder medication as needed. If I hear a resident say they did not get their medication, I do a grievance, and it goes to the Director of Nursing (DON). I have not heard anything about residents' missing medications. During an interview on 6/5/2025 at 12:07 pm, Certified Medication Aide (CMA) NNN stated that there had been instances where residents ran out of medications, and it was not in the cart. During an interview on 6/2/2025 at 1:08 pm, the DON stated that there is a fax machine in the medication rooms on each unit, but they are not operational as yet, so the nurses have to use the main fax machine at the front desk to fax the paper script to the pharmacy for reordering the medications. The DON stated that there was no set schedule for the medications to get to the facility, and it depends on different variables, but within 24 hours, the medications usually get to the facility if ordered early. DON stated there is a Pyxis on the second floor and is available 24 hours with additional medications for the facility, and is accessed by supervisors. She stated that the supervisors are at the facility from 7:00 pm to 7:00 am. The DON also stated that she had instances where the residents ran out of medications. She stated, For pain medications, it's a different process. A script is needed, and it has to be signed by the doctor and sent to the pharmacy. DON stated that the nurse is to follow up with the pharmacy, which will give a code or a number to remove the medication from the Pyxis if available. She stated that the Pyxis is replenished by the pharmacist monthly, and if the medication is not in the Pyxis, the resident is offered an alternative until the medication is received. DON stated that the nurses on the units are responsible for ordering and reordering the medications on time before the stock is completely out. She stated that the medications are to be ordered within a week of them finishing, so the pharmacist has enough time to send the medication. She confirmed that there were gaps in the MAR for some residents who did not receive their pain medication and stated that if it's not documented, it was not done. The missing signature indicates that, and sometimes after we follow up with the resident, it is where the medication was given, but the nurse failed to sign. Sometimes the nurse can come back, but we give verbal counseling, and now we have a new system where the supervisor looks at the documentation before the end of the shift to identify and catch before the nurse leaves. Most of the time, it is the CMA, and we pull them off the cart if there is a pattern until we can get one-on-one education with them and go through their competency in those specific areas. We're moving closer to where we have more nurses because there is a different level of training. DON stated that the process on grievance related to missing medication is that she first look to see if the medication is in house, what's the root cause and how to handle it depending on if it's a pharmacy issue of otherwise. My expectation from the nurses is that if there is a problem where the fax and the Pyxis system are down, they should notify me, and I will get in contact with the pharmacy regarding the medication.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, record review, staff interviews, and review of the facility's policies titled Storage of Medications and Control of Drugs, the facility failed to remove expired items from the s...
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Based on observations, record review, staff interviews, and review of the facility's policies titled Storage of Medications and Control of Drugs, the facility failed to remove expired items from the second and third floor medication rooms and the 200 and 300 hall medication carts. The facility also failed to have an open date on glucometer strips and failed to have all signatures on the 400 hall narcotic count sheets. This deficient practice had the potential to cause worsening of medical conditions for the residents. The facility's census was 212. Findings included: A review of the facility's policy titled Storage of Medications dated April 2022 documented Policy: Drugs and biologicals should be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this Center. All such drugs are destroyed. A review of the facility's policy titled Control of Drugs dated April 2022 documented Policy Interpretation and Implementation: 7. Controlled drugs must be counted at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count. During an observation on 5/29/2025 at 1:29 pm revealed during review of the facility's medication room on the second floor with Licensed Practical Nurse (LPN) WW the following expired items were found: Nine boxes of Pilot COVID At Home Test which were expired 4/14/2025, one bag of 0.9% Sodium Chloride injection 250 milliliter (mls) which was expired 1/2025 and one bottle of aspirin 325 milligram (mg) tablets which was expired in 4/2025. During an observation on 5/29/2025 at 2:14 pm, during review of the facility's 200 hall back cart with LPN VVV revealed one bottle of aspirin 81 mg tablets with no expiration date was found. During an observation on 5/29/2025 at 2:30 pm, during review of the facility's 200 front hall cart with Certified Medication Assistant Technician (CMAT) WWW revealed one container of blood sugar strips with no open date, one bottle of acetaminophen 500 mg tablets with no expiration date and one bottle of Allergy 25 mg relief tablets with no expiration date. During an observation on 5/30/2025 at 5:13 pm, during review of the facility's 300 south side cart with CMAT XXX revealed one bottle of multi-vitamin dietary supplement tablets (bottle half full) with expiration date 4/2025, one bottle Cetirizine HCL 10 mg tabs with no expiration date and one bottle of Allergy relief 25 mg tabs with no expiration date. During an observation on 5/30/2025 at 5:40 pm, during review of the facility's third floor medication room with CMAT XXX revealed 36 boxes of COVID-19 Antigen test expired 10/31/2024, nine boxes of Pilot COVID-19 At-Home- Test expired 4/14/2025, and one box of COVID-19 Antigen Rapid Test expired 4/22/2025. During an observation on 5/30/2025 at 5:45 pm, during review of the 400 front hall cart narcotic count sheets revealed that there were missing signatures. The narcotic counts were correct. The missing signatures were noted for the following dates and shifts:4/1/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/1/2025 at 7:00 am - 7:00 pm (outgoing nurse)4/2/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/2/2025 at 7:00 am - 7:00 pm (outgoing nurse)4/3/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/4/2025 at 7:00 am - 7:00 pm (outgoing nurse)4/4/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/5/2025 at 7:00 pm - 7:00 am (outgoing nurse)4/5/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/16/2025 at 7:00 am - 7:00 pm (outgoing nurse)4/16/2025 at 7:00 pm - 7:00 am (oncoming nurse)4/20/2025 at 7:00 pm - 7:00 am (outgoing nurse) 4/21/2025 at 7:00 am -7:00 pm (outgoing nurse)4/21/2025 at 7:00 pm -7:00 am (oncoming nurse)4/22/2025 at 7:00 pm - 7:00 am (outgoing nurse)4/22/2025 at 7:00 am -7:00 pm (oncoming nurse)4/23/2025 at 7:00 pm - 7:00 am (outgoing nurse)4/23/2025 at 7:00 am - 7:00 pm (oncoming nurse)5/1/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/1/2025 at 7:00 pm - 7:00 am (oncoming nurse)5/2/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/2/2025 at 7:00 pm - 7:00 am (outgoing nurse)5/3/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/3/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/16/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/16/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/22/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/22/2025 at 7:00 pm - 7:00 am (outgoing nurse)5/27/2025 at 7:00 pm - 7:00 am (outgoing nurse)5/28/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/28/2025 at 7:00 pm - 7:00 am (oncoming nurse)5/29/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/29/2025 at 7:00 am - 7:00 pm (oncoming nurse)5/30/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/30/2025 at 7:00 pm - 7:00 am (oncoming nurse)5/31/2025 at 7:00 am - 7:00 pm (outgoing nurse)5/31/2025 at 7:00 pm - 7:00 am (oncoming nurse) During an interview on 5/29/2025 at 1:29 pm, LPN WW revealed that the expired items should not be in the medication room. She stated the nurses could make the mistake of administering them to the residents, and the residents could have adverse reactions to the medications, which would be something bad for the residents. During an interview on 5/29/2025 at 2:14 pm, LPN VVV revealed that the nurses and CMATs should not use medications without expiration dates because the residents could take the medications, and the medications could cause harm to the residents. During an interview on 5/30/2025 at 5:13 pm, CMAT XXX revealed that the expired medications should not be on the cart because they would not be good for the residents. During an interview on 5/30/2025 at 5:24 pm, LPN YYY revealed that the expired medications and medications with no expiration dates should not be on the cart. She stated the medications would not be effective for the residents, and the residents would continue to have symptoms of their medical conditions. During an interview on 5/30/2025 at 5:45 pm, LPN DD revealed there were missing signatures in the narcotic count sheets. She stated they were to be signed by each nurse at the change of shift. She stated the nurse was responsible for counting the narcotics and checking if there was any missing. She stated that if the nurses did not count the narcotics and if any narcotics were missing, the nurse would be responsible. LPN DD stated the resident could miss a dose of medication example, pain medication, and the resident's pain would not be managed. During an interview on 6/2/2025 at 1:08 pm and on 6/5/2025 at 12:42 pm, the Director of Nursing (DON) revealed that her expectations were for the nurses to sign the narcotic count sheets. She stated each nurse was to check the narcotics and sign the narcotic count sheets because this was for accountability to know which nurse was taking charge of the shift, and to know if the medication was there and the amount. She stated that without the nurse checking the narcotics and signing, the narcotics may not be accounted for. The DON further stated that she expected that expired medications should not be in the medication rooms. She stated there should be a designated bin in the medication rooms for expired medications. She stated that if residents received expired medications, the medication would not be effective for the residents. The DON stated she expected that there should be open dates on glucometer strips to identify when they were opened. During an interview on 6/5/2025 at 12:14 pm, the Assistant Director of Nursing (ADON) revealed that expired medications were not to be in the medication room because the residents could get the medications, and they should not receive expired medications. She stated that if the residents received expired medications, the medications would not be effective, they would not do the job they were supposed to do, and they could be harmful to the residents. The ADON further stated that there should be open dates on glucose strips when they are opened. She said this would affect the residents if there was no open date because the staff would not know the period during which they should be used, and it could give an inaccurate blood sugar reading.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED Based on staff interviews, resident interviews, and record review, the facility failed to ensure that routine and as-nee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED Based on staff interviews, resident interviews, and record review, the facility failed to ensure that routine and as-needed (PRN) medications were available for administration to three of 106 sampled residents (R) (R2, R55, and R394). This deficient practice had the potential to cause delays in physician-ordered medical interventions. Findings included: 1. A review of R2's electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE], and pertinent diagnoses included but were not limited to Alzheimer's Disease, chronic pain syndrome, sickle-cell disorder, and fusion of the spine in the cervical region. A review of R2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R2 was cognitively intact, and that R2 was taking an antidepressant and an opioid medication. A review of R2's care plan, revised 5/8/2025, indicated a focus on R2 being at risk for pain/discomfort related to generalized pain and sickle cell. Goals included that R2's pain will be effectively managed through the next review date. Interventions included but were not limited to administering pain medication as ordered by the physician. A review of R2's care plan, revised 2/18/2025, indicated a focus of R2 on pain medication therapy related to a history of chronic pain. Goals included being free from any discomfort or adverse side effects from the pain medication reaction. Interventions included, but were not limited to, administering medication as ordered. A review of R2's Physician's Orders included, but was not limited to, an order dated 4/4/2025 for Percocet oral tablet 10-325 mg (milligram) (oxycodone with acetaminophen) with directions to give one tablet orally every six hours as needed for pain management related to chronic pain syndrome. A review of R2's April 2025 Medication Administration Record (MAR) revealed several gaps in Percocet administration. A review of R2's May 2025 MAR) revealed several gaps in Percocet administration. During an interview on 5/27/2025 at 11:55 am with R2 revealed that she had concerns about her pain medication not being reordered timely. R2 stated that her Percocet ran out last week causing her to not be able to have it for two days and thus being in more pain. She stated that she went to the Director of Nursing (DON) about this, and the DON said she would be on it. During an interview on 6/2/2025 at 1:08 pm, the DON stated that the nurses on the units are responsible for ordering and reordering the medications in time for the resident to receive it and not allow it to run out. The DON further stated that the medications are to be ordered within a week of the medication finishing, so that the pharmacist has enough time to send the medication before it is finished. She stated that medications for the residents are reordered by faxing or calling the pharmacy. She stated there is a new program that the facility is working on, which was just implemented one to two weeks ago, so that the facility could reorder medication through a link on the EMR directly into the pharmacy database. She stated that there is a fax machine in the medication rooms on each unit, but they are currently not operational. She stated that the main fax machine is located at the front desk, and the nurse is required to fax paper scripts to the pharmacy. The DON further stated there was no set schedule for the medications to be delivered to the facility. The DON further stated that she had instances where the residents ran out of medications, including pain medications. She confirmed that there were gaps in the MAR for some residents who did not receive their pain medication. She confirmed and acknowledged that these medications are PRN, and if the resident did not refuse or say they did not want it at that time, it is likely that the medication was not ordered timely and the facility was waiting on the pharmacy to send the medication and deliver it to the facility. She confirmed that this has happened on a few occasions where the residents did not receive their pain medications because the medications were not ordered timely. The DON confirmed that one resident who has been affected by this is R2. During a phone interview on 6/5/2025 at 6:45 pm, Pharmacy Tech EEE revealed that the facility can refill meds electronically from the EMR, by fax, or by phone. She stated that the pharmacy does not autofill for the facility, and that nurses have to request a refill for medications to be refilled. Pharmacy Tech EEE further stated that after re-ordering, medications are generally delivered to the facility within a 24-48-hour window or same day if they have it in stock. The pharmacy tries to advise nurses to refill medications two days in advance, so residents are not without their medications. 2. A review of R55's EMR revealed R55 was admitted to the facility on [DATE], and pertinent diagnoses included but were not limited to paroxysmal atrial fibrillation, chronic obstructive pulmonary disease (COPD), hypertension, osteoarthritis, and long-term use of anticoagulants. A review of R55's quarterly MDS assessment dated [DATE] revealed a BIMS of 15, which indicates R55 was cognitively intact, and that R55 was taking an anticoagulant, a hypoglycemic, and an opioid medication. A review of R55's care plan, revised 5/2/2025, indicated a focus on R55 having hypertension and paroxysmal atrial fibrillation. Goals included that R55 will remain free from signs and symptoms of hypertension through the review date. Interventions included but were not limited to give R55 anti-hypertensive medications as ordered to monitor side effects such as orthostatic hypotension and increased heart rate (tachycardia), and effectiveness, and to not discontinue medication abruptly but to begin tapering off. A review of R55's care plan, revised 5/2/2025, indicated a focus on R55 at risk for pain/discomfort related to generalized pain and osteoarthritis. Goals included for R55's pain to be effectively managed through the next review date. Interventions included but were not limited to administering R55 pain medication as ordered by the physician. A review of R55's care plan, revised 5/2/2025, indicated a focus of R55 on anticoagulant therapy related to atrial fibrillation. Goals included that R55 will be free from discomfort or adverse reactions related to anticoagulant use. Interventions included but were not limited to taking/giving medication at the same time each day. A review of R55's Physician's Orders included but was not limited to an order dated 1/1/2024 for budesonide inhalation suspension 0.5mg/2ml (milliliters) with directions to inhale 2ml orally every 12 hours for shortness of breath related to chronic obstructive pulmonary disease, an order dated 12/24/2024 for Eliquis oral tablet 2.5 mg (apixaban) with instructions to give one tablet by mouth two times a day for anticoagulant, an order dated 5/25/2025 for hydrocortisone external cream 2.5% topical with directions to apply to left leg topically every day and evening shift for erythema for two weeks, an order dated 12/24/2024 for lisinopril oral tablet 20 mg with directions to give one tablet by mouth one time a day for hypertension, an order dated 12/24/2024 for metoprolol tartrate oral tablet 100 mg with directions to give one tablet by mouth two times a day for hypertension, an order dated 3/4/2024 for Percocet oral tablet 7.5-325 mg (oxycodone with acetaminophen) with directions to give one tablet by mouth every six hours as needed for pain, an order dated 12/11/2023 for Zyrtec allergy oral tablet 10 mg with directions to give one tablet by mouth one time a day for allergies. A review of R55's January 2025 MAR revealed a four-day gap, a nine-day gap, and a five-day gap in her Percocet administration. A review of R55's February 2025 MAR revealed two five-day gaps and a six-day gap in her Percocet administration. A review of R55's May 2025 MAR revealed several holes in medication administrations for Eliquis and budesonide with the code of 13, indicating the medications were not administered. A review of R55's June 2025 MAR revealed budesonide, hydrocortisone, Zyrtec, and Eliquis with the code of 13, indicating the medications were not administered. During an interview on 5/27/2025 at 12:41 pm with R55 revealed she has sometimes gone four to ten days without her medications and had concerns regarding re-ordering her medications. R55 stated that she is out of metoprolol, her heart medication, today and was told yesterday there was one dose left. R55 further stated that not having her metoprolol usually makes her heart rate fluctuate. She added that she went ten days without her pain medication, Percocet, in January. She went without her lisinopril in February or March for about six days, which caused her blood pressure to go up. R55 further stated she has been without her blood thinner, Eliquis, so many times, and once went five days without it a few months ago. R55 added that she recently went six days without the medication for her nebulizer medication, budesonide, which led her to start wheezing and use her inhaler, which she uses only when she is without her nebulizer. R55 clarified that all these medications are scheduled except for her PRN Percocet. R55 stated that she was a nurse for 51 years and would sometimes call the pharmacy herself during times when she went without her medications for about five days, so she knows that the re-ordering is done. During an interview on 5/28/2025 at 4:53 pm with R55 revealed that she is still without her metoprolol, which would be the 2nd day without it. R55 stated she asked the nurse to call the pharmacy again and will personally call the pharmacy tomorrow. She stated she has experienced issues with medication re-ordering for the whole eight years as a resident in the facility. R55 stated she has been to the hospital three times without getting her budesonide in 2023. She stated she currently has about four doses of budesonide left. When asked if she feels different due to missing doses of her metoprolol, she stated that today her heart rate is 95, but her normal range is 60s to 80s. She stated that this morning her heart rate was 111, and last night it was 115. She stated that she told the Certified Medication Aide Technician (CMAT) on duty that her heart rate was high, and the CMAT told her she would call the pharmacy again. R55 further stated that she asks for her Percocet twice a day. During an interview with R55 on 5/29/2025 at 9:53 am revealed that she received her metoprolol this morning. During an interview on 6/2/2025 at 1:08 pm, the DON stated that the nurses on the units are responsible for ordering and reordering the medications in time for the resident to receive them and not allow them to run out. The DON further stated that the medications are to be ordered within a week of the medication finishing, so that the pharmacist has enough time to send the medication before it is finished. She stated that medications for the residents are reordered by faxing or calling the pharmacy. She stated there is a new program that the facility is working on, which was just implemented one to two weeks ago, so that the facility could reorder medication through a link on the EMR directly into the pharmacy database. She stated that there is a fax machine in the medication rooms on each unit, but they are currently not operational. She stated that the main fax machine is located at the front desk, and the nurse is required to fax paper scripts to the pharmacy. The DON further stated there was no set schedule for the medications to be delivered to the facility. The DON further stated that she had instances where the residents ran out of medications, including pain medications. There is a pyxis, and the nurse is to follow up with the pharmacy, which will give the nurse a code or a number to remove medications from the pyxis if it is available in the pyxis, which is replenished by the pharmacist monthly. If the medication is not in the pyxis, the resident is offered an alternative until the medication is received from the pharmacy. The DON checked the gaps in R55's MAR and confirmed that there were days the resident did not receive Percocet. She confirmed and acknowledged that this medication is PRN, and if the resident did not refuse or say they did not want it at that time, it is likely that the medication was not ordered timely manner and the facility was waiting on the pharmacy to send the medication and deliver it to the facility. She confirmed that this has happened on a few occasions where the residents did not receive their pain medications because the medications were not ordered timely. During an interview on 6/5/2025 at 1:59 pm, R55 revealed she went four to five days without her budesonide and finally received it today. She reiterated that the last time this medication was unavailable to her, she began wheezing. She also stated that her Zyrtec and hydrocortisone were unavailable to her today. During an interview on 6/5/2025 at 2:15 pm, Licensed Practical Nurse (LPN) WW confirmed that the budesonide was not available from 5/31/2025 to 6/3/2025. She also confirmed that the Zyrtec and hydrocortisone were unavailable on 6/3/2025. During a phone interview on 6/5/2025 at 6:45 pm, Pharmacy Tech EEE revealed that the facility can refill meds electronically from the EMR, by fax, or by phone. She stated that the pharmacy does not autofill for the facility, and that nurses have to request a refill for medications to be refilled. Pharmacy Tech EEE further stated that after re-ordering, medications are generally delivered to the facility within a 24-48-hour window or same day if they have it in stock. The pharmacy tries to advise nurses to refill medications two days in advance, so residents are not without their medications. During an interview on 6/6/2025 at 9:12 am, the DON confirmed that R55's lisinopril, Eliquis, metoprolol, and budesonide medications most likely were not available to be administered to her. The DON stated that there is a known issue with these medications not being available due to reordering issues. The DON further stated that potential negative outcomes include a lack of stability for the residents. 3. A review of R394's EMR revealed she was admitted to the facility on [DATE] with pertinent diagnoses including Parkinson's Disease. A review of R394's Discharge MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates R394 was cognitively intact. A review of R394's physician orders revealed an order dated 7/4/2024 for Rytary oral capsule extended release 36.25-145 mg (carbidopa-levodopa) with directions to give two capsules by mouth three times a day for Parkinson's. A review of the MAR dated August 2024 revealed holes in the MAR for ten doses consecutively from 8/6/2024 to 8/9/2024. A review of the hospitalization record dated 8/14/2024 revealed R394 went to the emergency room on 8/14/2024 for muscle spasms. During an interview on 6/6/2025 at 9:58 am, the DON revealed that R394 resided at the facility months before she started working at the facility. She confirmed the emergency room visit was for muscle spasms on 8/14/2024. The DON also confirmed some holes in R394's 8/2024 MAR for her Parkinson's medications leading up to the hospitalization, and confirmed from the MAR that it is possible these medications were not administered timely manner or due to availability.
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 F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and resident interviews, facility records, and review of facility policy titled Temperatu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and resident interviews, facility records, and review of facility policy titled Temperatures, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance, and provide meals that were palatable, attractive, and held at a safe and appetizing temperature. Specifically, the facility failed to ensure that food items served for breakfast were at or above 135 degrees Fahrenheit (F). These deficient practices had the potential to affect 207 of the 212 residents receiving an oral diet. Findings included: A review of the undated facility policy titled Temperatures revealed that All hot food items must be cooked to appropriate temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Food should be transported as quickly as possible to maintain the temperature for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e., hot/cold carts, pellet systems, insulated plate bases and domes, etc.). A review of the Georgia Department of Public Health Food Service Establishment Inspection report dated 12/3/2024 indicated compliance status No under section 3-1B. Food received at proper temperature, 5-1A. Proper cooking time and temperature, 5-1B. Proper reheating procedure for hot holding, and 6-1C. Proper cooling time and temperature. During an observation and interview on 5/27/2025 at 1:32 pm, Resident (R) 9 shared that the food delivered to the rooms is mostly cold, requires reheating, and is not covered. A tray was observed with food that was visible outside of the top cover. Review of resident Quarterly Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact and able to answer questions appropriately. During a breakfast meal service observation and the examination of the Steam Temperature Table were taken by the Assistant Dietary Manager GGGG conducted food temperature checks on 5/29/2025 at 7:26 am, revealed: Puree eggs, initially at 128 degrees F, were reheated and subsequently retested at 143 degrees F. Mechanical sausage, which started at 95 degrees F, was reheated and then retested at 155 degrees F. Omelet eggs, also beginning at 95 degrees F, were reheated and retested at 100 degrees F, followed by another retest at 147 degrees F. The waffle, initially at 103 degrees F, was reheated and retested at 146 degrees F. At the time of receiving the food, the temperature meal tray delivery to the residents had already begun. A review of sampled test breakfast tray on 5/29/2025, at 8:51 am, revealed test tray that was retrieved from Fourth floor cart food temperatures were not within professional guidelines as evidenced by the following: Omelet at 116-degree F, Grits at 114-degree F, and Oatmeal at 110-degree F. All temperatures were taken by the Dietary Manager and confirmed at time of observation. During an observation on 5/29/2025, at 8:56 am, on the third floor revealed that there was no bottom base to the plate warmer sitting in the cart; awaiting to be distributed. During an observation on 6/6/2025, at 1:11 pm, revealed that a food tray was being delivered to the second floor on top of a warmer storage cart without a bottom base plate warmer. During an interview on 5/28/2025, at 2:30 pm, members of the resident council meeting expressed that weekend food was cold and unsatisfactory, stating, You better have money and Uber because of extended wait times. During an interview on 6/3/2025, at 9:36 am, Dietary Aid (DA) IIII revealed that she was responsible for preparing breakfast and lunch. During the morning hours, breakfast is typically served with eggs, grits, oatmeal, and bread. Unfortunately, the steam table does not maintain the proper temperature; there seems to be an issue with the wells, as the bottom of the pan remains hot while the top surface does not. Many residents have reported that their food is cold, but the Certified Nurse Assistant or nurses often neglect to reheat and return the food to the kitchen to be replated, which sometimes forces me to ensure there is enough food available instead of relying on them to reheat it in the microwave on the floor. During an interview on 6/3/2025, at 09:56 am, DA JJJJ confirmed that he was responsible for the food carts' delivery to the floors, which involves notifying the nurse and initiating the sign-off process for the first cart. DA JJJJ explained that certain floors execute their distribution process differently from our established policy; they will not serve food to residents until all carts are present on the floor, while others will proceed differently. During an interview on 6/9/2025 at 2:02 pm, the Administrator stated that he was aware of complaints from residents regarding the food being served cold. Further interview indicated that he anticipated the residents' meals to be served hot according to their preferences, both when delivered to their rooms and in the dining room. The Administrator mentioned that he would assess the process, implement a Performance Improvement Plan (PIP), and investigate the necessary repairs for the various equipment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, and reviews of the he facility policies titled General Food Preparation and Handling, Uniform Policy, and Food Brought in from the Outside, the facility failed...
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Based on observations, staff interviews, and reviews of the he facility policies titled General Food Preparation and Handling, Uniform Policy, and Food Brought in from the Outside, the facility failed to properly discard expired food and ensure that food items were labeled and dated in the kitchen refrigerator, freezer, dry storage, and emergency supply area. The facility also failed to maintain sanitary practices concerning hand hygiene, covering of hair with restraints, and up-to-date sanitizer test strips for dietary staff in the kitchen. These deficiencies had the potential to impact 207 out of the 212 residents who were on an oral diet. Findings included: A review of the undated policy titled General Food Preparation and Handling indicated in section Food Preparation-H. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact with prepared foods. A review of the undated policy titled Uniform Policy indicated that all employees will adhere to the Food & Nutrition policy on the proper wearing of a uniform required to work in the department. Dietary Aids and Floor Supervisor: hair nets. Cooks: hair nets or approved chef hats, in black. A review of the undated policy titled Food Brought in from Outside revealed that food or beverages should be labeled and dated to monitor for food safety. Food and beverages that have past the manufacturer's expiration date should be thrown away. During the kitchen initial brief tour conducted on 5/27/2025, at 9:53 am with the Dietary Manager (DM), it was observed upon entering that the Assistant Dietary Manager (ADM) GGGG was not wearing a beard net. DM confirmed during observation that all dietary staff should be wearing beard guards and hair restraints in the kitchen. Observation in the dry storage pantry revealed unlabeled and undated items, which included one 11.3 oz turkey gravy, two 14 oz chicken gravies, three 24 oz country gravies, seven 2.75 oz au jus gravy mixes, and 13 unlabeled silver packets as confirmed by the DM; seasonings from rice packets, along with two 24-oz lemonades, one of which had been opened, and an observation of one unlabeled and undated opened 5-pound bag of dry pasta. Furthermore, there were two 15-oz cans of white potatoes with an expiration date of December 2023. The Dietary Manager validated that all findings in the dry storage did not have an open or expiration date on items. The refrigerator revealed an unlabeled and undated opened 5-gallon container of pickles, along with 5 pounds of open cheese, which consisted of unwrapped yellowish slices of block cheese, and a one-gallon container of a brown liquid identified as onion soup, also without labels or dates. Furthermore, there was a 4-quart egg salad with an expiration date of 5/23/2025. The Dietary Manager verified all observations concerning the unlabeled and undated items and stated during the interview that she instructs staff to only indicate the date opened on packages. The freezer revealed there was one opened 5-pound bag of diced onions that was unlabeled, undated, with no expiration information, along with 32 prepared beverages, four 40-oz baby baker potatoes, four bags containing six bagels each, and four 5-pound bags of brown liquids identified as gravy. Additionally, two opened 5-pound bags of triangle hash brown were observed unwrapped and without labels. During an observation on 5/28/2025, at 4:42 pm in the kitchenette located on the fifth floor, multiple unlabeled and undated items were found in the residents' refrigerator. In the refrigerator, there were two bagged food items that were both unlabeled and undated food substances, along with one plastic container. During an observation on 5/28/2025 at 4:50 pm in the kitchenette located on the fourth floor, there was observed six unlabeled and undated brown paper bags were observed along with three plastic bags with an unknown food substance. Additionally, there were five 8-oz milk cartons with an expired date of 5/25/2025 (two cartons of skim milk and three cartons of whole milk). During an observation on 5/28/2025 at 5:00 pm, in the kitchenette located on the third floor, there was an unlabeled and undated box of pizza, a Styrofoam plate, and three plastic bags with food substance. There was also an expired box of chicken dated 5/27/2025. During an observation on 5/28/2025 at 5:08 pm in the kitchenette located on the second floor, there was an uncovered peanut butter and jelly sandwich with an expired date of 5/22/2025, two unlabeled and undated brown paper bags with an unknown food substance, and in the freezer was a 12-oz chicken roll box with an expired date of 3/3/2025. The Dietary manager confirmed this observation and stated that the kitchen staff was not responsible for the kitchenettes on the floors; that the CNAs and nursing staff are responsible. During an observation on 5/30/2025, at 8:10 am, ADM GGGG conducted a test of the sanitizing sink using Hydrion QT-40 test strips. The expiration date for the first test strip was expired with the date 6/1/2023, while the second attempt with a different set of test strips had expired on 5/1/2022. ADM GGGG confirmed that he was supposed to check the inventory, including the test strips, when the company was called to install the new system approximately two to three months ago, but he must have overlooked this task. ADM GGGG also confirmed that all capsules had expired. During an observation on 5/30/2025 at 8:17 am, [NAME] IIII was seen handling eggs and turkey bacon with her hands while preparing meals for residents; no kitchen utensils were observed for the selection. An emergency food check was conducted on 6/2/2025 at 8:40 am for unlabeled, dated, or expired items. Two boxes of 120-count chips were observed with an expiration date of 5/6/2025. Two (6 count) one-gallon waters were observed with an expiration date of 2/28/2025. Completed tour of emergency water supply. The Dietary Manager revealed the facility does not have enough emergency water supply on hand to support the requirement of a minimum of one gallon per day per resident. During an observation on 6/8/2025 at 1:00 pm, of the Assistant Manager and without beard guard, and the Dietary Aid without beard guard and hair net. During an interview on 6/3/2025 at 9:24 am, the Dietary Aid (DA) HHHH revealed that the dietary staff were expected to ensure that the labeled tasks were completed. DA HHHH confirmed that she observed instances where tasks were not completed. DA HHHH stated that failure to adhere to food handling could lead to cross-contamination. DA HHHH confirmed she was unaware that the test strips in the bag had expired, as she typically tests the sanitizer in the three-compartment sinks. DA HHHH stated that test strips were provided by the company, and when the company came in a couple of months ago, the staff assumed the strips were valid, but they did not check. During an interview on 6/3/2025, at 9:36 am, with Dietary Aid/Cook IIII stated that breakfast was typically served with eggs, grits, oatmeal, and bread. She stated that meat was only provided with breakfast on certain days unless a resident specifically requested it. DA IIII stated that the reason she used her hands during serving was due to a lack of sufficient utensils, such as tongs and scoops, although she had been informed that an order had been placed. She stated, We also face significant challenges in keeping plates and forks, as they are frequently left in residents' rooms. A sweep is conducted every two to three months, but I suspect that the CNAs are not retrieving them from the residents' rooms. During an interview conducted on 6/9/2025 at 12:28 pm, the Assistant Dietary Manager GGGG revealed that the staff were without management for several months, and they lacked support from corporate.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insect...
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Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. The facility census was 212. Findings included: During an observation and interview were conducted on 5/27/2025, at 9:53 am, following the initial tour of the kitchen area. It was noted that the area surrounding the dumpster was littered with trash, discarded food, bedding, and various other debris. Additionally, the presence of gnats and flies was observed around the dumpster. During the interview with the Dietary Manager, it was clarified that the kitchen does not bear responsibility for the dumpster; it is the maintenance responsibility. She also mentioned that trash collection occurs on Mondays and Fridays. During an observation on 5/29/2025, at 7:13 am, the dumpster was observed with the presence of discarded food, a white plastic facility fixture, and a red broom lying in the debris. Additionally, gnats and flies were observed surrounding the dumpster. During an observation on 5/30/2025 at 8:00 am, the dumpster indicated the ongoing presence of discarded food, plastic facility fixtures, gloves lying on the ground, and debris scattered on the ground around the dumpster. During an interview conducted on 6/9/2025 at 8:37 am, the Maintenance Director confirmed that his department is responsible for the upkeep of the facility's grounds, which includes the area surrounding the dumpster. He also indicated that the housekeeping department is responsible for maintaining the cleanliness of the premises. The Maintenance Director acknowledged the presence of trash in the dumpster area, noting the existence of discarded food, debris, and the presence of both flies and gnats. He stated that his team will take action to resolve these issues and improve their efforts. The Maintenance mentioned that he has received verbal reporting of rodent sightings; however, he cannot personally confirm any such observations. During an interview on 6/9/2025 at 2:02 pm, the Administrator confirmed that the maintenance and housekeeping personnel are tasked with keeping the dumpster area clean and devoid of debris. The Administrator disclosed that he was aware of the presence of trash, debris, gloves, and discarded food, but he had communicated this to the staff. The Administrator further explained that pests and rodents could pose a risk due to the state of the dumpster, which might allow them to enter the building, although he is uncertain if there would be any actual risks.
CONCERN
(F)
📢 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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and review of the facility's policy titled, Coordination- Pre-admission Sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review and review of the facility's policy titled, Coordination- Pre-admission Screening and Resident Review (PASARR) Program, the facility failed to coordinate/ incorporate PASARR recommendations into for four of four resident (R) (R12, R104, R117, and R33) assessment, care planning and transitions of care. This failure had the potential to cause duplication of services and failure to provide the services necessary for individuals with mental disorders, intellectual disability, or a related condition for level two residents. Findings included: A review of the undated facility policy titled Coordination Pre-admission Screening and Resident Review (PASARR) Program revealed that the facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and efforts. Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a residence assessment, care planning, and transitions of care. 1. A review of the electronic medical record (EMR) records for R12 revealed that he was admitted on [DATE] with diagnoses that include bipolar disorder, schizoaffective disorder, morbid obesity, anxiety disorder, induced subacute dyskinesia, and drug-induced secondary parkinsonism. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed A Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive deficits. Section A of the MDS revealed that R12's PASARR II assessment indicated No. Section D revealed that R12 very rarely suffers from social isolation. Section E reveals no behavior exhibited. Section GG revealed lower extremities impairment on both sides, wheelchair, dependent with lower body dressing, showers, and toilet hygiene. Section N reveals antipsychotic, antiplatelet, and anticonvulsant medication use. A review of the care plan dated 4/4/2025 revealed that R12 was at risk for altered mood or behavior related to the diagnosis of schizoaffective disorder, bipolar disorder, anxiety disorder, and insomnia, and that R12 would have an improved mood state, happier, with no signs or symptoms of depression, anxiety, or sadness through the review date. The interventions included administering medications as ordered, monitoring/documenting for side effects, and assessing effectiveness. Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) and educate the resident regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. Focus area revealed, has an Activities of Daily Living (ADL) self-care performance deficit, personal assistance myself except for. The outcome states, Residents' needs will be met. The interventions include assisting R12 with ADL care as needed, Physical Therapy/ Occupational Therapy (PT/ OT) evaluation and treatment as per MD orders. A review of the physician orders revealed Abilify oral tablet 10 milligrams (mg), HCL 100 mg, Depakote delayed release 500 mg, give one tablet daily, and Depakote 500 mg, give four tablets by mouth at bedtime for schizoaffective disorder. A review of the PASARR II recommendations, dated 8/20/2024 revealed, There's diagnosis of bipolar disorder and he's been taking psychotropic medications consistent with such diagnosis, to include two psychotropics; for this reason and due to onset of major stressors and possibility of extended stay, specialized mental health services are recommended during stay. Specifically, psychiatric care for assessment and medication monitoring, individual counseling for adjustment and coping and other emotional support and the development of an individualized care plan, one incorporating his needs and preferences for improved and sustained health stability, behavioral and physical, behavioral health monitoring is recommended. Follow up with the outpatient psychiatric provider is recommended. Initial observation and interview on 5/27/2025 at 12:19 pm with R12 revealed him lying in bed staring at the ceiling. R12 stated that he would like to get out of bed every day, but they get him up once a week whenever they can due to the Hoyer and short staff and due to his weight. He stated that he mostly stays in bed and gets very few visits from staff, but they come whenever he rings for help. R12 stated that he is from Kentucky but likes being here in Georgia because this is where his wife is from, and she passed away, and being here makes me feel close to her when I feel sad. R12 further stated that they would like to do activities or some kind of recreation with other people. During an observation on 5/28/2025 at 11:01 am, R12 was lying in bed watching TV. He stated that he informed the Certified Nursing Assistant (CNA) that he would like to get out of bed today, but was told that they were short-staffed and so she couldn't get him up. R12 stated that he understands and is just grateful to be able to stay here so he can be close to his wife. 2. A review of the facilities' admission records R104 revealed that R104 was admitted to the facility on [DATE] with diagnoses that include dementia with agitation, paranoid schizophrenia, major depressive disorder, hallucinations, and cognitive communication deficit. A review of R104 admission MDS assessment dated [DATE], revealed a BIMS score of 11, indicating minimal cognitive deficits. Section A of the MDS revealed that R104 PASARR II assessment indicated No. A review of R104's care plan, revised on 6/6/2025, revealed a focused area stating, has a diagnosis of paranoid schizophrenia, brief psychotic disorder, hallucinations, and a problem related to social environment. Level II. Outcome revealed, will have fewer episodes of behaviors through the review date. Interventions included administering medications as ordered. Monitor/document for side effects and effectiveness, anticipate and meet needs, approach in a calm manner, document behaviors and resident response to interventions. Focus area states, diagnosis of paranoid schizophrenia, hallucinations and brief psychotic disorder. Outcome reveal, will remain free of drug related complications, including movement disorder, discomfort, hypertension, Constipation or cognitive impairment to review date. Interventions include, administer medications as ordered. Monitor/ document for side effects and effectiveness, observe for hypotension tardive dyskinesia, excessive sedation, or AMS; promptly report such to the MD, observe for signs of hallucinations or other psychotic episodes; Promptly report such to the MD. Focus area also includes, uses antidepressant medications for poor appetite. Outcome states will show decreased episodes of sign and symptoms of depression through the review date. Interventions include, educate the resident/family/caregiver about risks, benefits and the side effects and/ or toxic symptoms of (Specific: antidepressant drugs being given), give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, Constipation, urinary retention, suicidal ideations. Monitor/document/report to MD PRN ongoing signs and symptoms of depression on altered by antidepressant meds: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/ comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, change in condition, change in weight/ appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, constant reassurance. A review of the physician orders revealed mirtazapine 15 milligrams one tablet at bedtime for poor appetite, melatonin tablet 3 mg by mouth at bedtime for sleep. A review of the PASARR II recommendations dated 11/30/2021 revealed that it should be noted that R104 Presentation could be considered as behavioral and psychological symptoms of dementia; however, given that psychiatric medication management has been beneficial and that schizophrenia is reported to be a historical diagnosis the following specialized mental health services are recommended: behavioral health assessment/ Service plan development for ongoing assessment of R104 needs and development of an individualized treatment plan. Her son should be included in all treatment and transition planning:- Diagnostic/ ongoing psychiatric care to assess R104's mental status, monitor her psychiatric symptoms, and manage her psychotropic medications. 3. A review of R117's admission records revealed that R117 was admitted to the facility on [DATE] with a diagnosis that included bipolar disorder, intellectual disabilities, Ogilvie syndrome, and chronic pain. A review of R117 admission MDS, dated [DATE], revealed a BIMS score of 15, indicating no cognitive deficits. Section A of the MDS revealed that R117 PASARR II assessment indicated No. Brief review of R117 care plan, last reviewed on 5/27/2025, revealed a focus area stating, has impaired cognitive function/ dementia or impaired thought process related to bipolar disorder, intellectual disabilities, disease process, acute respiratory failure with hypoxia. Resident has a PASSR [sic] level 2 related to severe mental illness. The outcome states, will maintain current level of cognitive function through the review date. Interventions include, refer resident to cycle therapy for PASRR support services, administer meds as ordered, ask yes/ no questions in order to determine the residents needs, break tasks into one step at a time, cue, reorient and provides as needed, keep the routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion, and present just one thought, idea, question or command at a time. A review of the Physician's orders revealed the use of mirtazapine 15MG, 0.5 tablet daily for depression, Seroquel 100 MG, 1.5 Tab 2 times daily for bipolar disorder, Buspirone HCL 5MG, one tablet three times a day related to bipolar disorder. A review of R117 PASARR II recommendations, dated 8/8/2023, revealed, due to her long history of mental illness and recent changes in her psychiatric medications I am recommending PASRR (behavioral health) services. The recommendations are as follows: a behavioral health assessment that includes her goals and preferences. As psychiatrist to continue to monitor psychiatric medications and manage psychiatric symptoms. Her intellectual limitation should be addressed in MD S. She may require long time or repetition to learn new information. Regarding undesired behaviors, the SNF should learn what triggers these behaviors and try to minimize them if possible. In addition, offer positive reinforcements with the desired behaviors is exhibited. 4. A review of the admission records for R33, revealed an admission date of 4/11/2025 with diagnosis that include, schizophrenia, major depressive disorder, mild cognitive impairment, and hemi plegia and hemiparesis following cerebral infarction. A review of R33 admission MDS, dated [DATE], revealed BIMS score of 12 indicating minimal cognitive deficits. Section A of the MDS revealed that R33 PASARR II assessment indicated No. A review of R33's care plan last revised on 6/6/2025 revealed a focus area stating, has diagnosis schizophrenia/ schizoaffective disorder; Resident exhibiting signs and symptoms of vulgar and verbally aggressive behaviors. PASARR level II. Outcome states, resident will be free from increased silent symptoms of impulsivity, poor coping skills and verbal aggression toward others through next review. The interventions include, calling staff out of their names, knocking items off medication cart and the desk area--ER evaluation. Do not encroach nor argue w/ the resident to allow for calming, make notifications to residents RP of residents exhibited behaviors, as appropriate and provide reality orientation to resident, as tolerated and refer resident for geri psych support provider services as appropriate. Focus area reveals, has impaired cognitive function/ dementia or impaired thought process related to impaired decision making, neurological symptoms. Outcome states, will be able to communicate basic needs on a daily basis through the review date. Interventions include, administer meds as ordered, ask yes/ no questions in order to determine needs, break tasks into one step at a time, cue, reorient and supervise as needed, discuss concerns about confusion, disease process, NIH placement with R33/ family/ caregivers. Focus area reveals, has mood problem related to schizophrenia, depression. Outcome states, will have improved mood state (happier, calmer appearance, no signs or symptoms of depression, anxiety or sadness) through the review date. Interventions include, administer medications as ordered. Monitor/ document for side effects and effectiveness, educate R33/ family/ caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, and maintenance. Monitor/ record mood to determine if problems seem to be related to external causes, i.e., medications, treatments, concerns over diagnosis. Monitor/ record/ report to MD PRN acute episode feelings of sadness; Loss of pleasure and interest in activity; Feelings of worthlessness or guilt; Changing appetite/reading habits; Change in sleeping habits; diminished ability to concentrate; Change in psychomotor skills, monitor/ record/ report to MD PRN mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. A review of the physician's orders revealed the use of Seroquel 150 milligrams two times per day for aggressive behaviors. A review of R33 PASARR II dated 12/15/2021, recommendations reveal that due to symptoms of schizophrenia and major depressive disorder, including agitation, verbal aggression, and paranoia, specialized psychiatric services are recommended. Recommended specialized services for SMI include behavioral health assessment/ service plan development to assess history, symptoms, needs, and to develop an individualized plan of care. Individual counseling to help recognize triggers for mood episodes, depression, anxiety, and coping. During an interview on 6/2/2025 at 12:08 pm, the Social Worker (SSW) MM and SSW LLL revealed that it is the responsibility of the social workers to complete and maintain the resident's MDS and care plan. SSW LLL stated that they had previously covered only short-term residents and, only recently, about a few months been assigned to other residents in the building. She stated that she is a bit familiar with the residents and is still getting to know them. SSW MM stated that the Social Services Director (SSD) would be better suitable to assist with the responses. During an interview on 6/2/2025 at 12:19 pm, SSD DDDD stated that all four residents R12, R33, R117 and R104 currently had a PASARR II with recommendations on the care plan completed by the social work department and that all recommendations were accepted and is being followed. SSD DDDD stated that they have psychological services through ***** Healthcare services at least monthly and has recommendation for inhouse psychological services overseen by a psychiatrist as needed. SSD DDDD admitted that the recommendations documented in the EMR differ from those listed on the care plans but stated that a PASARR II is usually picked up on admission and captured by the MDS department; therefore, she was not sure why it wasn't. SSD DDDD also stated that social work completes the parts on the MDS they are responsible for and the MDS team should do the rest, but she was unsure who completes what areas. During an interview on 6/2/2025 at 1:08 pm, MDS Coordinator KKK revealed that she was new to MDS and had only been working in the facility since October 2024. MDS KKK confirmed that R12, R104, R33, and R117 were all coded as No on their admission MDS assessment. She stated that all assessments were completed before she worked in the facility, but denies ever looking at his admission records since then. MDS KKK stated that she is still learning the MDS process and usually follows whatever was done on the previous assessment.
CONCERN
(F)
📢 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
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on record review, staff interviews and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to develop and implement action pl...
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Based on record review, staff interviews and review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, the facility failed to develop and implement action plans; measure the success of actions and track performance; conduct at least one process Improvement Plan (PIP) and regularly review, analyze and act on data collected for three of 106 sampled residents (R) (R80, R2, R55, and R392) not receiving scheduled medications. Findings included: A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, documented that the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. 1. A review of R80's medication administration record for several days during August 2024, September 2024, March 2025, and May 2025 revealed missing signatures on the Medication Administration Record (MAR). A review of the Nurses Notes (NN) dated 8/6/2024 revealed that medication was out of stock. A review of the NN dated 11/10/2024 revealed that medication not administered, waiting for pharmacy delivery, phone call to pharmacy and MD. A review of the NN dated 11/11/2024 revealed oxycodone HCL tablet given 5 mg by mouth before wound care every Monday, Wednesday, and Friday for wound care to be given before wound care Med on order. A review of the NN dated 5/5/2025 revealed Medication is on order. A review of the NN dated 5/28/2025 revealed oxycodone HCL tablet, give 5 mg by mouth every six hours for pain awaiting pharmacy. A review of the NN dated 5/31/2025 revealed oxycodone HCL tablet, given 5 mg by mouth every six hours for pain, was unavailable. 2. A review of R2's April 2025 MAR revealed several gaps in Percocet administration. A review of R2's May 2025 MAR revealed several gaps in Percocet administration. 3. A review of R55's January 2025 MAR revealed a four-day gap, a nine-day gap, and a five-day gap in her Percocet administration. A review of R55's February 2025 MAR revealed two five-day gaps and a six-day gap in her Percocet administration.A review of R55's May 2025 MAR revealed several holes in medication administrations for Eliquis and budesonide with the code of 13, indicating the medications were not administered. A review of R55's June 2025 MAR revealed budesonide, hydrocortisone, Zyrtec, and Eliquis with the code of 13, indicating the medications were not administered. 4. A review of R392's August 2024 MAR revealed holes in the MAR for ten doses consecutively from 8/6/2024 to 8/9/2024. A review of the QAPI minutes dated 5/2/2025 revealed that it was documented on the agenda to address residents not receiving their medications. The minutes reflected that the administrator documented that multiple medications were unavailable, it was an ongoing issue, and they were to develop a PIP. During an interview on 6/2/2025 at 1:08 pm, the Director of Nursing (DON) revealed that she started working at the facility in February 2025, and she confirmed that since then, there were instances when the residents were out of medications, including pain medications. She confirmed and acknowledged that there were gaps in the MAR for the residents, and if the residents did not refuse or say they did not want it at a specific time, it was likely that the medications were not ordered in a timely manner, and the facility was waiting on the pharmacy to deliver the medications to the facility. She confirmed that this had happened on a few occasions when the residents did not receive their medications because the medications were not ordered timely manner. She stated that the nurses on the units were responsible for ordering and reordering the medications in time for the resident to receive them and not allow them to run out. The DON stated that medications for the residents were reordered by faxing the order to the pharmacy or by calling the pharmacy. She stated that there was a fax machine in the medication rooms on each unit, but they were not operational yet. She stated that the main fax machine was at the front desk on the first floor, and the staff were required to fax the paper script to the pharmacy for reordering the medications from that fax machine. She stated there is a pyxis on the second floor and it is available 24 hours with additional medications for the facility. The DON further stated there was no set schedule for the medications to get to the facility, and it was dependent on different variables, such as if the medications were ordered early enough. During an interview on 6/5/2025 at 1:08 pm, the Administrator revealed that he was aware there were residents in the facility who were not receiving their medications in a timely manner. He stated that when he started on 4/22/2025, he was made aware of this issue. He stated the issue was discussed in QAPI, and he went through the minutes of QAPI and stated that in January 2025, there was documentation of issues involved with the residents not receiving their medications. He stated that the January meeting was held on 1/31/2025, which reflected the issues that took place in December 2024. The January meeting did not have any interventions mentioned about residents not receiving their medication, and there was also no PIP. He stated QAPI met on 3/28/2025, for February 2025, and there was no intervention mentioned there either. The next meeting was on 5/2/2025, which would have addressed the issue in April 2025. The administrator confirmed there were no PIPs in place to address the issue of residents not receiving their medications. He confirmed that the issue was placed on the agenda in the 5/2/2025 meeting to address the issues involved. The administrator again confirmed that there was no PIP in place from January 2025 to the present, 6/5/2025. He stated that in the 5/2/2025 QAPI meeting, the Medical Director was present, and she expressed her concerns that medications were unavailable to the residents and inquired about what was going on with it. An investigation was conducted on 5/21/2025, and they found that the fax machine was not working. The fax machine and the Pyxes were not working at the same time, so the nurses could not get medications out of the Pyxes, and they could not fax scripts to the pharmacy for ordering medications since both the fax machine and the Pyxes were down at the same time. He stated the pyxis machine was not working from April 2025 to May 2025, and it was fixed on 5/22/2025. He stated that the investigation pointed to the Certified Medication Assistant Technicians (CMAT) not ordering or reordering medications before they were finished. He stated that a few of the CMATS were terminated, and in-service training was provided to other CMATs as well as the nurses regarding ordering and reordering medications. He stated the in-service included when and how to order medications, as well as the need to notify the nurse right away before medications were completed, so that they may be ordered from the pharmacy. The in-service also included for the nurses and the CMATs to look for missing medications in the central storage areas where they would have multivitamins and other over the counter medications as well as getting someone to look in the pyxes in the meantime before they say that medications were not available at all and also in-service was done to order medications in the facility's electronic health record system. He stated that when residents do not receive their medications, it is considered a medication error. The Administrator confirmed that since the QAPI meeting on 5/2/2025, there were still residents who were not receiving their medications. He confirmed that there was no effective follow-up to ensure that the interventions that were put in place were effective. He confirmed the interventions were not effective since there were residents who were still not receiving their medications in the month of May 2025 and as recently as 6/6/2025. He stated that an audit should have been done as one of the interventions addressed in the 5/2/2025 QAPI meeting, and he confirmed that there was no documentation that an audit was done, and he was unaware if the audit was done. He confirmed there was no PIP in place to address the issue, and he confirmed that there was no efficient or effective follow-up to ensure that the issue was addressed. He confirmed the QAPI system was not effective.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, records review and review of the facility's policies titled Infection Prev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, records review and review of the facility's policies titled Infection Prevention and Control Program, Standard Precautions, Water Management Program, Wound Care, Hand Hygiene, Pressure Ulcer Treatment, and Housekeeping and Laundry Services, the facility failed to maintain infection control processes and procedures related to (1) failing to maintain a sanitary living environment for four of ten resident rooms (224, 225, 227 and 305); (2) failed to comply with proper hand hygiene practices; (3) failed to comply with appropriate infection control practices regarding laundry services; (4) failed to maintain an effective Infection Prevention and Control Program (ICPC), and Antibiotic Stewardship program and a Water Management Program; and (5) failed to maintain a clean field and practice proper enhanced barrier precautions during wound care for two residents (R) R206 and R146. This failure had the potential to put all residents, staff, visitors, and volunteers at an increased risk of infection. The facility census was 212. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program (IPCP) revealed that the elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying recording and correcting (ICP) incidents, investigating and reporting communicable diseases and conducting an annual review of the ICP program; that the infection prevention and control committee is responsible for reviewing and providing feedback on the overall program; and that surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include whether physician management of infection is optimal, whether antibiotic usage patterns need to be changed because of the development of resistant strains, whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion, and whether there is appropriate follow-up of acute infections. The committee meets monthly and consists of team members from across disciplines, including the medical director. Surveillance will be ongoing, systemic collection, analysis, interpretation, and dissemination of data to: monitor trends of infection and pathogen, detect outbreaks, monitor staff adherence to IPC practices, identify performance improvement opportunities, track progress towards priorities, and identification on annual IPC risk assessment. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews. Data gathered during surveillance is used to oversee infections and spot trends. Important facets of infection prevention include: identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, enhancing screening for possible significant pathogens, immunizing residents and staff to try to prevent illness, implementing appropriate isolation precautions when necessary and following established general and disease specific guidelines such as those of the Center for Disease Control (CDC). Our antibiotic stewardship program promotes appropriate use of antibiotics, includes a system of monitoring to improve outcomes and reduce antibiotic resistance (ensuring antibiotics are prescribed for the correct indication, dose, and duration to appropriately treat residents), and includes the development of protocols and a system to monitor antibiotic use. A review of the facility policy titled Standard Precautions dated April 2022 revealed that standard precautions will be used in the care of all residents regardless of their diagnosis or presumed infection status. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, or mucous membranes. The policy interpretation and implementation revealed, wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Remove gloves promptly after use, before touching non-contaminated items in environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Where a gown is used to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, excretions, or cause soiling of clothing. Ensure that environmental surfaces, bed rails, bedside equipment, and other frequently touched surfaces are promptly cleaned. Handle, transport and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and avoids transfer of microorganisms to other residents and environments. A review of the undated facility policy titled Water Management Program (Legionella) Policy Template revealed that Legionella and other waterborne pathogens, such as Pseudomonas original PSA, spread through droplets of water and contaminated devices using facility water, such as ice machines and showers. The facility's water management program is overseen by the water management team. The team consists of internal and external partners who play a role in the water management system for our facility. The water management team consists of the following representatives: Infection Control Officer, Facility building manager/ Facilities Director, Medical Director, Facility Administrator, Risk Manager/ Regulatory/Manager, Local water department representative, and Water maintenance contractor representative. The facility conducts a weekly review of all culture results for cases of identified Legionella. All cases of healthcare-associated pneumonia are reviewed for involvement of Pseudomonas species or Legionella. The infection control officer reviews surveillance reports monthly with the Quality Improvement/Infection Prevention Committee and with the Water Management Program Team. The Water Management Team reviews the facility water system and program design annually and makes appropriate changes based on applicable results, regulations, and standards. The Water Management Program is approved annually by the Quality Improvement/ Infection Prevention Committee. A review of the facility policy titled Housekeeping and Laundry Services dated August 2022 revealed that the facility will provide housekeeping and laundry services necessary to maintain a sanitary, orderly, and comfortable interior to include: Clean bed and bath linens that are in good condition. A review of the facility policy titled Wound Care, with a revised date of October 2010, documented that it is the facility's procedure to use disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table and place all items to be used during procedure on the clean field. A review of the facility policy titled Standard Precautions dated April 2022 documented that the process is that staff will wear a gown (clean, non-sterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions or cause soiling of clothing. A review of the facility policy titled Pressure ulcer treatment dated April 2022 documented that this procedure may involve potential/ direct exposure to blood, body fluids, infectious disease . Protective Barriers That May Be Needed: Gown (as needed); equipment and supplies; and personal protective equipment. 1. During the initial tour of the facility on 5/27/2025 at 10:30 am, a foul odor was observed on every floor. room [ROOM NUMBER] was observed with linen soiled with a brown and yellow substance on the resident's bed. room [ROOM NUMBER] was observed with a large amount of yellow liquid on the floor under the resident's wheelchair. Observation of room [ROOM NUMBER] revealed brown stains on the privacy curtains and walls. room [ROOM NUMBER] was also observed with brown stains on the wall behind the bed from the floor to the ceiling, as well as on the privacy curtain. During an observation on 5/27/2025 at 3:00 pm, a foul odor was observed on every floor. room [ROOM NUMBER] was observed with the bed made up, and the linen was observed to be soiled with a brown and yellow substance. room [ROOM NUMBER] was observed with a moderate amount of yellow liquid on the floor under the resident's wheelchair. Observation on room [ROOM NUMBER] observed with brown stains on the privacy curtains and walls, and room [ROOM NUMBER] was observed with brown stains on the wall and privacy curtain. During an observation on 5/28/2025 at 5:30 pm revealed a foul odor remained on every floor. Linen soiled with brown and yellow stains remained on the bed in room [ROOM NUMBER], large yellow and brown stains remained on the floor of room [ROOM NUMBER], along with a small amount of liquid and dried markings on the floor under the resident's wheelchair. Observation of room [ROOM NUMBER] revealed that the brown stains on the privacy curtains and walls remained in room [ROOM NUMBER]. During an interview on 5/29/25 at 12:09 pm with the Director of Environmental Services (EVS) and the MD. The MD revealed that his facility rounds are done daily on each floor and that he has a designated person who does the rounds to make sure all the beds are working, and all equipment is working properly. He stated that he has been working in the facility for about 30 days and was aware of the many tasks to be done to get the facility up to code, but admits that building requires a lot of work. EVS Director stated that his rounds are done every two hours daily to make sure the work is being done. He stated that each floor has a full-time employee who has been working in the facility for a while. EVS director stated that he has a good team and they have been doing a great job keeping the facility up, but admits that his assistant could be doing a better job at holding people accountable for things not being done. During a facility tour on 5/29/2025 at 2:20 pm with the MD and EVS Director revealed both confirmed brown and yellow stains on curtains and walls, as well as yellow liquid with dried brown areas on the floors. Both confirmed the increased number of flying insects throughout the facility and foul odor on each unit. EVS director admitted that his assistant could be doing a better job at rounding and holding individuals accountable for tasks not done. He stated that he has not done any in-service on IP or proper cleaning techniques this year and that the educator usually does this, but he wasn't aware of when it was last done. MD stated that he currently has a long list of work orders that he is addressing, and painting the walls was one of them. He also stated that the entire building needs renovating, and he is tackling one task at a time. 2. During an observation/ Interview on 6/2/2025 at 9:16 am with Certified Nursing Assistant (CNA) CCCCC revealed her emerging from room [ROOM NUMBER] still wearing her gloves and no PPE. Further observation revealed a sign on the door of room [ROOM NUMBER] indicating Enhanced Barrier Precautions. CNA CCCCC stated that I don't know why that sign is there, but it's not supposed to be right there. CNA CCCCC stated that she is unsure why the sign was there when the resident does not have an infection. She also stated that she does not remember when the infection control in-service was given last and was unaware of what barrier precautions mean or why PPE was required. 3. During an observation of the laundry room on 5/29/2025 at 12:25 pm, accompanied by the Environmental Services Director (EVS) revealed four commercial dryers with one down and not in use. Two commercial washers were observed in use with laundry solutions provided by Clean Slate. No personal protective equipment (PPE) was observed to be readily available in the laundry room. A single box of gloves was observed propped under a large fan blowing air toward the soiled laundry bins. Clothes were observed in plastic bags on the floor of the laundry room, and the eye wash station was observed with no piping connection or eye wash liquid available. The faucet was observed with water pouring onto the floor of the laundry room. Clean and dirty laundry were observed entering and exiting through the same door with no designated separation/ sorting area. Four bins containing soiled laundry/ linen were observed toward the entrance of the door, with one nestled in between the two dryers, with an empty bin in front. Air vent observed with large amounts of dust and dander. A large amount of lint was observed in the dryer lint trap. During an interview/ Observation on 5/29/2025 at 12:34 pm with Laundry Tech (LT) YY revealed him removing bags containing clothing from the soiled bin and placing them onto the floor. No PPE was observed being used. LT YY stated that he uses gloves to sort the laundry when they are not in bags, but admits to not using a mask, gown, or goggles unless he sees that there is blood. He admits that the clothing in the bags on the floor of the laundry room was, in fact, residents' clothing and stated, That's how they come down for washing. He denies receiving IP education within the past year but admits to receiving it in the past. He stated that the bin in front of the soiled bin nestled in-between the dryers was for clean laundry removed from the washers or dryers. LT YY also stated that he cleans the lint traps every three hours, but admits to not keeping a record of the removal. During an interview on 5/29/2025 at 12:45 pm with the EVS director revealed that he has been working in the facility for two years and that he is currently down two positions in housekeeping, but has part-timers that have been covering the shifts as well as his assistant and me. He stated that he currently has only two laundry staff working because one was off. We do our own laundry in the facility, and there are three full-time laundry attendants during the day and two part-timers in the evening who distribute the laundry. He admitted that he is aware of the eye wash station and that he has made many changes to the facility since taking the position, but is unable to change everything. EVS director stated that he speaks to the staff about IP in the morning meetings, but has no documentation to prove it. EVS director stated that the laundry room only has one door; therefore, there is nothing I can do about that. He stated that he checks the lint trap himself but admits to not keeping records. He also stated that his assistant could do a better job at holding people accountable for not doing their jobs. During an interview on 5/29/2025 at 1:08 pm with LT BBBBB revealed that he had only started working at the facility today but had received in-services during orientation on laundry services, using PPE, hand hygiene, and cross-contamination. 4. During an observation on 5/28/2025 at 4:00 pm, review of the infection prevention (IP) records revealed that there is no line listing or infection tracing being monitored according to the regulations of infection control and prevention. Infection plotting graph observed with no use of an infection surveillance checklist, nor a data collection tool being used to track current or past infections. The staff and resident immunization records were not available, nor were there records of COVID-19 monitoring, tracking, or teaching. No documentation of immunization for Flu, Pneumonia, or Covid-19 vaccine being offered, or record of administration for staff or residents. Antibiotic stewardship policy/ protocols program, an ICPC committee, water management program, nor Antibiotic stewardship tracing and surveillance. During an interview on 5/29/2025 at 11:11 am with the Staff Development/ Infection Control Nurse (IP) revealed that she started on April 16, 2025, initially as part-time time then recently accepted the full-time position. IP stated that this is her first IP job, but she has been certified since 11/6/2022. IP admits to not having any COVID-19 monitoring or education document, as she is still getting herself together. She also stated that she has no documentation or update of education that was presented to staff regarding the offering of the vaccine, nor did she have access to a refusal list. IP admits to not having an infectious disease tracking system or percentage rate, but stated she recently got McGeer's forms but has not used them yet. IP stated that she is aware of the criteria but admits to not having the ABT stewardship program or a committee at this time and therefore has not been using it. IP stated that she is aware that there is much work to be done in order to get up to standard, and it will take some time. She also stated that the facility has not had an IP since July of 2024 and that the corporate office had someone assisting periodically with IP issues, but admits that as of this time, no one seems to have knowledge of who it was or what was done. IP stated that all the documents from the past IP books disappeared when the previous IP left, which is why she is unable to locate the appropriate data required and was using the little information she currently has as she is still learning this role. IP also stated that she was unaware of the incorporation of the water management program with infection control and stated she thought that was the job of the Maintenance Director (MD). During an interview on 5/29/2025 at 1:46 pm with the MD revealed that he was not aware of any practices done on a regular basis to address the prevention of legionella disease. MD stated that he has only been working in the facility for about 30 days and has not heard anything about water management. MD stated that he was told by the previous MD that someone came out in January to check the boiler and placed a sticker there, but was not sure what it meant. He stated that he mainly concentrates on fixing the building, but will get with the administrator to go over the topic. MD stated that this is the first time it has been brought to his attention that he is responsible for the dead lags, but stated that he was aware of it being a thing where he used to work. 5. During an observation of wound care on 5/31/2025 at 12:39 am, Licensed Practical Nurse (LPN) TTT was observed providing wound care to R206. During the observation, there was an enhanced barrier precaution sign on R206's door, and LPN TTT did not put on a gown to conduct wound care. During wound care, LPN TTT did not sanitize her hands after removing used gloves and before putting on a clean pair of gloves. Further observations revealed LPN TTT placed a clean pad on the resident's bed with the dressing supplies, and R206's right foot was on top of the pad and touching the supplies at times during the wound care. During an interview on 5/31/2025 at 1:00 pm, LPN TTT stated she did not know she was supposed to wear a gown during wound care, and after reading the sign on the door, she was now aware she should have worn it. She stated there was no personal protective equipment (PPE) available to use since none was in the hallways, near the residents' rooms, or any PPE that was easily accessible. She confirmed and verified she did not sanitize her hands between glove changes, which would prevent infection of the resident. LPN TTT confirmed she placed a pad on R206's bed and stated that instead of placing a pad on the resident's bed, she should have used a bedside table to prevent contamination of her clean field. She stated she should have cleaned the resident's bedside table and used it instead of placing the pad with her dressing supplies on R206's bed. She further stated that the resident's foot on the pad with supplies and placing dirty things on the pad would cause infection to the resident. During an interview on 6/5/2025 at 12:14 pm, the Assistant Director of Nursing (ADON) stated that the nurses should ensure proper precautions and practices were followed during care to ensure the residents' conditions are not worsened. During an interview on 6/5/2025 at 12:42 pm, the Director of Nursing (Don) stated that she expected the nurses to practice and maintain standards of practice during all procedures. A review of medical record for R146 revealed R146 was admitted to the facility on [DATE] with BIMS score of 99 due to diagnosis of aphasia and dysphagia. R146 has diagnoses that include, but are not limited to, aphasia following cerebral infarction, dysphasia, pedal ulcers, and pressure ulcer of sacral region, stage four. Observation completed on 6/2/2025 at 2:29 pm, of wound care and infection control practices for R146.R146 was observed laying in bed on his back, alert and watching television. He was greeted by certified medication assistant technician (CMAT) CC, who was working as a certified nurse assistant this shift, and licensed practical nurse (LPN) DD. LPN DD cleaned bedside table with Sani-cloth and allowed to air dry. CMAT CC opened sterile dressing with clean gloved hands. Placed wound cleanser bottle on table, along with rolled gauze, ABD pads and collagen pads. Removed soiled gloves, washed hands and placed clean gloves on. Observed care was initiated without following full enhanced barrier precautions. LPN DD removed gloves and left room to obtained disposable gowns to continue care. CMAT CC and LPN DD initiated full enhanced barrier precaution protocol after care began by doning gowns, gloves and masks. CMAT CC prepared a wash basin with water only. CMAT CC removed soiled linen and dropped into plastic bag on the floor. CMAT CC and LPN DD turned R146 to his left side. R146 was observed with visible stool in rectal area. CMAT CC used gloved right hand to take a wash cloth and moistened with water from the basin to remove the stool. LPN DD removed all dressings from sacral and buttock area, dated 5/30/2025. CMAT CC grabbed unlabeled perineal wash bottle from roommates bedside table, with same soiled gloved hand used to remove stool and proceeded to spray his buttocks area and wiped with a clean cloth towel. LPN DD proceeded to spray all open wounds with wound cleanser. CMAT CC removed soiled gloves and donned clean gloves and double layered with a second set of gloves on both hands. CMAT CC and LPN DD began to prep gauze for application, opening the packs and handling the sterile gauze with clean gloved hands and stacking it. LPN DD used drain sponge to pat wound areas dry. LPN DD placed collagen gauze in the sacral wound followed by a sterile abdominal gauze. CMAT CC moved the wash basin with dirty water and placed on bedside table used for dressing supplies. While LPN DD reached for outer wound dressing, CMAT CC used her soiled gloved hands to remove the abdominal gauze from the stage IV wound bed, folded it in half and reapplied to the wound bed. LPN DD covered the abdominal gauze with a cover dressing. Wound dressings were not dated. A dressing was observed on right upper back dated 5/30/2025. LPN DD did not change it. LPN DD removed gown and gloves and donned clean gown and gloves. While wash basin with dirty water remained on bedside table used for dressing supplies, LPN DD proceeded to prepare dressings for right calf and left foot wound care. CMAT CC also placed perineal wash bottle used for perineal care on the bedside table along with wash basin with soiled water and clean dressings used for wound care. LPN DD proceeded to wash left heel with wound cleanser while CMAT CC held left leg up for access. LPN DD dressed left heel wound with Santyl and dry dressing. LPN DD did not date the wound dressing. LPN DD removed gloves and washed hands. CMAT CC began assisting LPN DD in opening additional wound dressings wearing soiled gloves. CMAT CC proceeded to remove old dressing from right upper calf. LPN DD donned clean gloves and proceeded to prepare collagen dressing for application. With clean gloves, LPN DD moved the perineal wash bottle that was handled CMAT CC during perineal care, to the end of the bedside table, and picked up wound cleanser bottle to wash wound. LPN DD removed soiled gloves and donned clean gloves. CMAT CC opened wound dressing for LPN DD, handed it to the nurse to apply to the wound and proceeded to raise the right leg again with no change of gloves. LPN DD applied and secured the wound dressing to the right leg and CMAT CC lowered the right leg. LPN DD began cleaning off the bedside table with both perineal and wound cleanser bottles still on bedside table. LPN DD removed gloves, cleaned hands with soap and water and donned clean gloves. CMAT CC positioned R146 with clean linen. LPN DD exited the room with wound care supplies in left hand and soiled bag in right hand wearing no gloves. Interview completed on 6/2/2025 at 3:40 pm with LPN DD, who recalled infection control observations during wound care that were not in compliance. She confirmed that they should have entered the room prepared with all personal protective equipment (PPE) for enhanced barrier precautions before beginning perineal and wound care. She confirmed that CC CMAT double gloved stating, I know they are not supposed to do that. She confirmed that the perineal wash bottle and wash basin with dirty water, handled by CMAT CC with soiled gloves, were placed on the clean bedside table alongside the wound care dressing supplies. She confirmed that she forgot to date the wound dressings prior to exiting the room. She confirmed that to promote healing she should make sure she is using good infection control practices and reposition frequently to make sure the resident offloads to promote wound healing.
CONCERN
(F)
📢 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
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to establish an Infection Prevention and ...
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Based on observations, staff interviews, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to establish an Infection Prevention and Control Program (IPCP) and an Antibiotic Stewardship program. The facility failed to develop and implement protocols to optimize and monitor the treatment of infections and reduce the risk of adverse events from unnecessary or inappropriate use of antibiotics. This failure had the potential to place all residents, staff, visitors, contracted staff, and volunteers at risk for infection and the development of antibiotic-resistant organisms. The facility census was 212. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program revealed that The elements of the Infection Prevention and Control Program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying, reporting and correcting ICP incidents, investigating and reporting communicable diseases and conducting an annual review of the IPC program. The facility will record infections based on policies and procedures for system of surveillance and data to be collected by SBAR criteria and antibiotic stewardship program for infection site, pathogen, signs and symptoms, resident location and summary analysis of number of residents who developed infection; Staff observations; identification of unusual outcomes, trends and patterns; and how the data will be communicated/shared. This will be presented to the infection prevention and control committee monthly. Our antibiotic stewardship program promotes appropriate use of antibiotics, includes a system of monitoring to improve outcomes and reduce antibiotic resistance (ensuring antibiotics are prescribed for correct indications, dose, and duration to appropriately treat residents) and includes the development of protocols and a system to monitor antibiotic use. Antibiotic stewardship protocols include: reports related to monitoring antibiotic usage and resistance data, monitoring of antibiotic use, frequency and mode or mechanism of feedback to prescribing practitioners regarding antibiotic resistant data, their antibiotic use and their compliance with facility antibiotic use protocols, standardized tools and criteria for assessing for infections, and modes and frequency of education on facilities antibiotic stewardship program and protocols. IPCP and its standards, policies, and procedures will be reviewed annually to ensure effectiveness and that they are in accordance with current standards of practice. Periodic facility assessment may identify components of IPCP that need updating related to changes in population or facility characteristics. A review on 5/28/2025 at 4:00 pm of the infection prevention (IP) records revealed that there is no line listing or infection tracing being monitored according to the regulations of the infection control and prevention program. Infection plotting graph observed with no use of an infection surveillance checklist, being used percentage rate calculation of current infections documented. The staff and resident immunization records were not available, along with data for the last Coronavirus disease (COVID-19) outbreak and monitoring. Antibiotic stewardship program policy and protocols, along with the signed committee program, were also not available for evaluation. During an interview on 5/29/2025 at 11:11 am, the Infection Control Preventionist Nurse (ICPN) revealed that she was hired by the facility on 4/16/2025, initially as part-time, and that she recently accepted the full-time position. She stated that this was her first Infection Preventionist job, but has been certified as an ICPN since 11/6/2022. She admits to not having an infectious disease tracking system or percentage rate, but stated she recently got the forms and has not implemented them yet. IP stated that she was aware of the Mc. Greer's criteria, but admits to not having the Antibiotic Stewardship Program or a committee at this time, and therefore has not been using it. She stated the facility has not had an Infection Control Program since July 2024 and that she is working on forming an Infection Control Committee. She further stated that all the immunization records from the past years could not be found and stated that everything disappeared when the previous (ICPN) left, so she had to start from scratch with creating and developing the program. She stated that she is currently keeping a running log of residents currently on antibiotics, but admits to it not being updated this past month (May 2025). During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she was aware of the Infection Control Program issues and missing documentation. She stated that she was made aware that an interim corporate personnel member had been visiting the facility and assisting with the Infection Control Program, but that the individual had been terminated. The DON stated, It is possible she either took or destroyed all the documentation. The DON confirmed that she was not certified as an ICPN and stated that it was her expectation for the ICPN to start from the bottom and work on everything related to infection control. The DON stated that she did not have contact information for the previous ICPN.
CONCERN
(F)
📢 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 F0883
(Tag F0883)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews, records review and review of the facility policy titled Infection Prevention and Control Program (IPCP), the facility failed to minimize the risk of influenza ...
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Based on observations, staff interviews, records review and review of the facility policy titled Infection Prevention and Control Program (IPCP), the facility failed to minimize the risk of influenza and pneumococcal disease by ensuring that four of four newly admitted residents (R) (R48, R54, R96 and R217) residents (R) and staff were educated on the risks and benefits of immunizations; were provided opportunities to receive immunizations; and failed to maintain documentation of the information/education provided, the administration of, or the refusal of vaccinations. This failure placed the entire facility at risk for increased complications or even death related to an outbreak of the influenza or pneumococcal virus. Findings included: A review of the undated facility policy titled Infection Prevention and Control Program revealed the following: Immunization is a form of primary prevention. Widespread use of the influenza vaccine in the nursing facility is strongly encouraged. Policies and procedures for immunization include the following: Process for administering the vaccines, who should be vaccinated, contraindications to vaccination, potential facility liability and release from liability, obtaining direct and proxy consent, and how often, monitoring for side effects of vaccination, and availability of the vaccine, and who pays for it. During a review of the electronic medical record (EMR) for residents admitted to the facility within the last 30 days, it was revealed that the immunization records for R48, R54, R96 and R217 contained no documentation of vaccines being received, offered, declined, or contraindicated and there was no documentation in the EMR indicating that education was provided to residents or their representatives. During a review of the information provided by the facility related to the facility's Infection Control Program, there was no documentation presented related resident immunization records or information related to vaccines being offered to staff or residents; there was no documentation related to vaccine monitoring or vaccine education; and there was no documentation related to tracking or trending i.e. line listing of monitoring. During an interview on 5/29/2025 at 11:11 am, the Staff Development Nurse/Infection Control Preventionist Nurse (ICPN) revealed that she was hired on 4/16/2025 as part-time and only recently accepted the full-time ICPN position. She stated that she has been certified as an Infection Preventionist since 11/6/2022, but had no formal training in the field and was awaiting a friend to come and help her. She stated that the friend was scheduled to come earlier that week, but was canceled due to the state survey team arriving. She admitted to not having any documentation of offering the vaccines, resident refusals, or contraindications for staff or residents for this influenza season. The ICPN stated that she did not have an infection tracking system and was not aware if there were any outbreaks in the facility. She stated the facility has not had an Infection Control Program since July 2024 and that she is working on forming an Infection Control Committee. She further stated that all the immunization records from the past years could not be found and stated that everything disappeared when the previous (ICPN) left, so she had to start from scratch with creating and developing the program. A review of the EMR revealed that R54 presented with a Brief Interview of Mental Status (BIMS) score of 15, indicating that R54 is cognitively intact. During an interview on 6/1/2025 at 5:00 am, R54 stated that he was never offered any vaccines on admission. He stated that if it had been offered, he may have opted to receive the vaccinations, but confirmed he was not provided with that information. During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she has been working at the facility since 2/17/2025. She confirmed that she was aware of the Infection Control Program concerns regarding missing information. She stated that there was an individual in the ICPN role when she started, but that the individual was terminated. The DON stated that it was a possibility that the terminated employee either took the information with her when she left or destroyed all the documentation.
CONCERN
(F)
📢 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 F0887
(Tag F0887)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews, records review, and a review of the facility's policy titled Infection Prevention and Control Program, the facility failed to develop and implement policies an...
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Based on observations, staff interviews, records review, and a review of the facility's policy titled Infection Prevention and Control Program, the facility failed to develop and implement policies and procedures to ensure the availability of Coronavirus disease (COVID-19) vaccine to all staff and residents, offer COVID-19 vaccine, educate staff and residents/resident representatives regarding the risk, benefits and potential side effects of the COVID-19 vaccine and keep proper documentation surrounding vaccination, refusal or contraindications for four of four sampled residents (R) (R48, R54, R96 and R217). Findings included: A review of the undated facility policy titled Infection Prevention and Control (IPC) Program revealed that, The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, employee health and safety, identifying, recording and correcting IPC incidents, investigating and reporting communicable diseases and conducting an annual review of the IPC program. Outbreak management is a process that consists of: determining the presence of an outbreak, managing the affected residents, preventing the spread to other residents, documenting information about the outbreak, reporting the information to appropriate state and local authorities. when required, educating the staff and the public, monitoring for reoccurrences, reviewing the care after the outbreak has subsided, and recommending new or revised policies to handle similar events in the future. During a review of the records provided by the Infection Control Preventionist Nurse (ICPN) on 5/28/2025 at 4:00 pm, it was determined that there were no current residents in the facility with a positive diagnosis of COVID-19. The documentation revealed that there was no record indicating the last COVID-19 outbreak nor its monitoring. During an interview with the ICPN, at this time she stated that she was unaware of any policies or procedures related to COVID-19 handling, and COVID-19 education was not readily available nor was there documentation on information for management present for review. She provided the Infection Control Book and confirmed that the book contained no education material for the COVID-19 vaccine; no immunization record related to residents and/or staff being offered, receiving, or declining the vaccine; and no guidelines on management, monitoring, or preventing a COVID-19 outbreak. A review of all new admissions within the last 30 days revealed four out of four residents (R48, R54, R96 and R217) had no documentation in their Electronic Medical Records (EMR) indication that the COVID-19 immunization was offered, received, or declined and no documentation that the education was provided to residents or their representatives regarding the risk and benefits of the vaccine. During an interview on 5/29/2025 at 11:11 am, the ICPN revealed that she was hired by the facility on 4/16/2025, initially as part-time, and that she recently accepted the full-time position. She stated that this was her first Infection Preventionist job, but has been certified as an ICPN since 11/6/2022. She confirmed that she had not developed or implemented an Infection Control Program; that she did not know about the last COVID-19 outbreak in the facility; and that she was not aware of the policies and procedures surrounding COVID-19. She stated that she was aware that there should be monitoring, but had not initiated any at this time. She stated that there was much work to be done to get up to standard and that it will take some time. She stated that the facility has not had an ICPN since July 2024 and that no one had knowledge of the records or monitoring because the Infection Control books disappeared when the previous IPCN left, which is why she is unable to locate the appropriate data required. She stated that she will be receiving some assistance from a friend in the coming days, who will educate her on how to properly do the job. During an interview on 6/2/2025 at 9:32 am, the Director of Nursing (DON) revealed that she was aware of the Infection Control Program issues and missing documentation. She stated that she was made aware that an interim corporate personnel member had been visiting the facility and assisting with the Infection Control Program, but that the individual had been terminated. The DON stated, It is possible she either took or destroyed all the documentation. The DON confirmed that she was not certified as an ICPN and stated that it was her expectation for the ICPN to start from the bottom and work on everything related to infection control. The DON stated that she did not have contact information for the previous ICPN.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of facility policies titled Safe Environment and Maintenance se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and review of facility policies titled Safe Environment and Maintenance service, the facility failed to maintain a safe, functional, and sanitary environment in 14 of 108 resident rooms (214, 217, 218, 224, 225, 226, 322, 325, 326, 405, 417, 421, 505, and 526) related to resident rooms containing debris in packaged terminal air conditioner (PTAC) units, dirty air vents in common areas, and holes/cracks in drywall and doors. Findings included: A review of the facility policy titled Safe Environment revealed the following: Policy Statement: The facility will provide (9)(a) housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A review of the facility policy titled Maintenance service dated 3/6/2018, under Policy Statement revealed: Maintenance Service shall be provided to all areas of the building, grounds, and equipment. Under Policy Interpretation 2. (d) Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. 2. (i) Providing routinely scheduled maintenance service to all areas. During observations on 5/29/2025 between 9:00 am and 10:00 am, the facility's PTAC air filters in the resident rooms 214, 217, 218, 224, 225, 226, 405, 417, 421, 505, and 526 were observed to have soiled air filters with a thick accumulation of dust, dirt, and debris. Originally white, the air filters appeared dark due to contaminants. When lifted for inspection, they released visible dust clouds and were clogged with a dense layer of grime. During an interview and observation on 5/29/2025 at 12:25 pm, the Maintenance Director confirmed the buildup on PTAC filters in rooms 214, 217, 218, 224, 225, 226, 405, 417, 421, 505, and 526. It was also confirmed that the PTAC unit was not working in room [ROOM NUMBER]; there were multiple stained and missing ceiling tiles in rooms [ROOM NUMBER], and throughout the facility; and there were torn window screens and chipped paint throughout the facility. Continued observation also revealed a broken door to room [ROOM NUMBER], a hole in the wall in room [ROOM NUMBER], and the toilet not working in room [ROOM NUMBER]. During the interview at this time, the Maintenance Director revealed that it was the responsibility of the maintenance department to change and clean the PTAC filters and make sure they were working properly. He stated that the maintenance department was also responsible for changing stained ceiling tiles, replacing missing ceiling tiles, and repairing all broken items in the facility. During an observation and interview on 6/2/2025 at 1:45 pm, a family member of the resident in room [ROOM NUMBER]A revealed that the resident has been at the facility since 2020 and stated that the room is never cleaned. She stated that there were times when she cleaned the room herself. She went on to say that there were cobwebs in the corners, sticky substances on the wall and floor. A review of the facility's grievances log revealed that there have been multiple reports/grievances regarding the uncleanliness of the room and odors throughout the facility. An observation on 6/8/2025 at 11:35 am revealed stained ceiling tiles in the residents' room on the third floor. An observation on 6/8/2025 at 11:43 am revealed stained ceiling tiles in the hallway by the shower room on the fourth floor. An observation on 6/8/2025 at 11:44 am revealed an air vent on the fourth floor to the left of the elevator with gray and black debris and dust on it. An observation on 6/8/2025 at 11:50 am revealed an air vent on the fifth floor to the left of the elevator with gray and black debris and dust on it. During an interview on 6/9/2025 at 1:10 pm, the Administrator revealed he expects the maintenance department or the housekeeping department to report any environmental issues in TELS and address the concern right away.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0568
(Tag F0568)
Minor procedural issue · This affected most or all residents
Based on resident and family interviews, record review, staff interviews, and review of the facility policy titled Resident Rights Policy, the facility failed to provide quarterly resident trust fund ...
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Based on resident and family interviews, record review, staff interviews, and review of the facility policy titled Resident Rights Policy, the facility failed to provide quarterly resident trust fund statements to 2 of 2 residents (R) R36 and R148 who have a resident account in the facility and are cognitively intact. Findings included: A review of the facility policy titled Resident Rights Policy with a revised date of 10/8/2022 documented that each resident has the right to be treated with dignity and respect as it relates to Protection/Management of personal funds and Accounting and Records of Personal Funds. During the Resident Council interview on 5/28/2025 at 2:30 pm, the residents revealed they are only aware of their Personal Funds account balances if they ask. It was revealed in the meeting that they used to get quarterly statements years ago, but not anymore. The residents' council agreed that they do not receive quarterly statements. During an interview on 6/2/2025 at 1:45 pm, R36 revealed she has not received her quarterly statements. During a phone interview on 5/31/2025 at 1:18 pm, the representative of R148 revealed there is a lack of response from the facility, and she has not received quarterly statements from the facility. During an interview on 6/5/2025 at 5:30 pm, the Interim Business Office Manager (BOM) revealed she has been in this position since April 2025 and that she will sometimes work remotely because she is the regional BOM. She revealed that if a resident wants funds, the receptionist gives out the funds at any time, 24 hrs a day. She further revealed the assistant BOM is solely responsible for giving out the quarterly statements, but since she is on vacation, she is unsure of how she actually makes an account of how the resident receives it. The BOM stated there are no documents that show the residents received their quarterly statements. During an interview on 6/5/2025 at 5:30 pm, the Regional Medicaid Specialist revealed she has not mailed any quarterly statements. She confirmed that the last statements should have been mailed out in March 2025, so the next ones should go out at the end of June 2025. Furthermore, she revealed there is no record of quarterly statements given to the residents from the previous BOM. They are not sure of what happened to the records.
Mar 2025
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploita...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation of Residents, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for two of 31 sampled Residents (R) (R29 and R30).
Findings include:
Review of the policy titled Abuse, Neglect and Exploitation of Residents revised date of 10/24/2022 revealed under Policy Statement: It is the policy of the facility that acts of physical, verbal, mental and financial abuse including neglect and exploitation directed against residents are absolutely prohibited. Each resident has the right to be free from verbal abuse. Under Responsibilities: Residents will not be subjected to abuse by anyone, including but not limited to staff. All personnel (including volunteers) in all departments will be alert to indicators of suspected or actual abuse, neglect and exploitation. If abuse is suspected, personnel will report their observations to their supervisor immediately and without delay.
1. Review of the admission Record for R29 revealed she was admitted to the facility with diagnoses of but not limited to depression and hypertension.
Review of the resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 15, which indicated R29 was cognitively intact.
Review of the Facility Incident Report Form dated 1/28/2025 revealed: R29 reported to the Social Worker on 1/27/2025 at approximately 1:00 pm Certified Medication Aide Tech (CMAT) LL came into R29's room on 1/24/2025 at approximately 3:00 pm and called her an inappropriate racial slur. Further review of the report revealed the Social Worker interviewed residents who resided near R29 regarding CMAT LL's treatment. The residents described her as an angry person with personal problems. The CMAT's coworkers were interviewed and reported that the CMAT didn't get along with any of the staff on the unit. They reported that she always seemed defensive and was quick to argue. There was no documentation that CMAT LL's behavior was reported prior to the incident with R29.
An observation and interview on 2/25/2025 at 11:09 am with R29 revealed the incident with CMAT LL only happened once. R29 stated she and CMAT LL got into a verbal altercation. The resident stated CMAT LL called her names and told R29, you will respect me. The resident stated she had not seen the CMAT since the incident. The resident stated any interaction with staff that made her feel uncomfortable, she would ask to speak to the Social Worker and report the incident immediately.
2. Review of R30's most recent quarterly MDS dated [DATE] revealed a BIMS score was assessed as 15, which indicated R30 was cognitively intact.
Review of the admission Record for R30 revealed he was admitted to the with diagnoses of but not limited to essential (primary) hypertension and heart failure.
Review of the Facility Incident Report Form dated 1/29/2025 revealed R30 reported to the Interim Director of Nursing over the weekend (1/25/2025-1/26/2025) that he exited the elevator, and his wheelchair accidentally bumped into CMAT LL. R30 reported that CMAT LL cussed him out. The resident reported that he apologized to CMAT LL and kept moving in his wheelchair. Further review of the report revealed the Administrator interviewed the staff that worked on the weekend of the incident. The staff reported CMAT LL as having a quick temper and being very verbal. Staff members reported that CMAT LL was quite argumentative with the residents.
An interview on 2/25/2025 at 11:20 am with R30 revealed he recalled the incident with CMAT LL. He stated he exited the elevator in a wheelchair and accidentally bumped into CMAT LL. He stated as he went to apologize, CMAT LL started cussing him out. The resident stated he did not report to anyone on that day. He stated a couple days later he saw the Director of Nursing (DON) and reported the incident. The resident was able to tell the surveyor who his Social Worker was, and he was aware he could also report concerns to the Social Worker or his nurse. He stated in the future he will report in real time to the nurse. He stated nothing that extreme had ever happened before.
Cross Refer to F-Tags F607, F729, and 940
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on staff interviews and review of the facility policies titled, Abuse, Neglect and Exploitation of Residents and Background Screening and Investigation, and the Human Resource Director Job descr...
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Based on staff interviews and review of the facility policies titled, Abuse, Neglect and Exploitation of Residents and Background Screening and Investigation, and the Human Resource Director Job description, the facility failed to have two of fourteen employee files selected on site for review, failed to ensure that a criminal background check was completed for one of two Registered Nurses (RN) and one of one Licensed Practical Nurse (LPN), failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for two of two Administrators, three of three Certified Medication Aide Techs, one of one Certified Nursing Assistants (CNA), one of one Regional Director of Business Development, and one of one Maintenance Director. The facility also failed to re-fingerprint two of two CNAs whose fingerprint checks had not been retained under Rap Back per the Rules and Regulations of the State of Georgia.
Findings include:
Review of the facility policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure: A. Seven Components of Prevention and Detection: 1. Screening (Refer to: Nurse Aide Registry and Criminal Background Checks): All employees undergo a criminal background check.
Review of the facility policy titled Background Screening and Investigation with a revision dated March 2019 revealed under Policy Statement: Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents (direct access employees). Under Policy Interpretation and Implementation: . 2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment.
Review of the Human Resource Director Job Description revealed: Pre-Employment Functions: Conduct reference checking, abuse registry checks, and certification/ licensure checks (if applicable), prior to giving a job offer. Conduct criminal background checks, as required, on all post-offer applicants.
During a record review on 3/19/2025 at 3:30 pm with the Human Resource Director of twelve of the fourteen selected employee files revealed the following:
1. Registered Nurse SS's employee file revealed a hire date of 2/5/2025, full-time as the Minimum Data Set (MDS) Director. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the RN's employee file revealed there was no criminal background check conducted.
2. License Practical Nurse TT's employee file revealed a hire date of 12/10/2024, full-time as the MDS Coordinator. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the LPN's employee file revealed there was no criminal background check conducted.
3. Administrator BB's employee file revealed a hire date of 1/9/2025, full-time as the Administrator. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the Administrator's employee file revealed no GCHEXS fingerprint check was conducted.
4. Administrator CC did not have an employee file in the facility to review.
5. Certified Medication Aide Tech LL did not have an employee file in the facility to review.
6. Certified Medication Aide Tech MM's employee file revealed a hire date of 9/11/2024, full- time CMAT to administer medications to the residents in the facility. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the CMAT's employee file revealed no GCHEXS fingerprint check was conducted.
7. Certified Medication Aide Tech NN's employee file revealed a hire date of 1/27/2023, full-time CMAT to administer medications to the residents in the facility. Further review of the CMAT's employee file revealed no GCHEXS fingerprint check was conducted.
8. Certified Nursing Assistant QQ's employee file revealed a rehire date of 10/23/2024 as a full- time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed no GCHEXS fingerprint check was conducted.
9. Regional Director of Business Development HH's employee file revealed a hire date of 5/1/2024 full-time as the admission Coordinator. Further review of the employee's file revealed no GCHEXS fingerprint check was conducted.
10. Maintenance Director RR's employee file revealed a hire date of 9/12/2024 full-time, hired to maintain the building which includes the residents' rooms. The offer letter revealed the job was contingent on successfully passing a background check. Further review of the employee's file revealed no GCHEXS fingerprint check was conducted.
11. Certified Nursing Assistant OO's employee file revealed a hire date of 3/14/2011 as a full- time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed the last satisfactory GCHEXS fingerprint check was conducted on 5/21/2021.
12. Certified Nursing Assistant PP's employee file revealed a hire date of 11/15/2021 as a full-time CNA hired to perform direct resident care duties. Further review of the CNA's employee file revealed the last satisfactory GCHEXS fingerprint check was conducted on 5/21/2021.
An interview on 2/20/2025 at 12:34 pm with the Regional Human Resource/Payroll Director II revealed she oversaw the function of human resources in fourteen facilities. Some of the responsibilities included training newly hired human resource directors on processes and procedures in the human resource department and resolving any human resource issues that the facility may have. Also, she conducted audits on employee files to ensure that the files had everything in place (I9, policies, ensure certifications, license, and background checks). She stated the last employee working in the human resource department was not doing the job. The Regional Human Resource/Payroll Director stated she realized that the background checks and/or fingerprints check were not being done. The person was terminated, and the facility just recently hired another Human Resource Director. She stated the human resource department will be cleaned up, organized and an audit will be done to ensure that the employee files were meeting the State of Georgia and Federal requirements. The Regional Human Resource/Payroll Director confirmed that the employees' fingerprints had not been retained under the Rap Back program, and she was unable to produce an employee roster for the surveyor to review. She stated she will commit to weekly and monthly audits of the employee files to ensure all processes are in place.
An interview on 2/25/2025 at 4:44 pm with the Regional Human Resource/Payroll Director II confirmed that RN SS and LPN TT did not have a criminal background check. She confirmed that Administrator BB, Administrator CC, CMAT LL, CMAT MM, CMAT NN, CNA QQ Regional Director of Business Development HH, and Maintenance Director RR did not have a GCHEXS Fingerprint check conducted. She also confirmed CNA OO, and CNA PP did not have an up-to-date satisfactory GCHEXS.
Per an email correspondence dated 3/7/2025 with __ Unit Manager WW revealed the system showed no background checks had been completed for the facility.
Review of the employee files on 2/19/2025 with the Human Resource Director, the files of Administrator CC and CMAT LL were not located in the facility and unavailable for the surveyor to review.
An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files, the HRD stated she was hired on 2/10/2025. The HRD stated she could not locate Administrator CC and CMAT LL employee files. She stated she would continue to look for the files and let the surveyor know if the employee files were located.
An interview on 2/25/2025 at 4:44 pm with the Regional Director of Human Resource and Payroll confirmed that Administrator CC and CMAT LL's employee files could not be located.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure physician's orders were followed for two of 31 sample...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure physician's orders were followed for two of 31 sampled Residents (R) (R1 and R29) to obtain laboratory tests.
Findings include:
1. Review of the admission Record for R1 revealed she was admitted to the facility with diagnoses of but not limited to nonrheumatic aortic (valve) insufficiency and chronic systolic (congestive) heart failure.
Review of the resident's most recent quarterly assessment Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was assessed as 14, which indicated R1 was cognitively intact.
Review of R1's Electronic Medical Record (EMR) Order Summary Report revealed a physician order for Coumadin oral tablet 7.5 milligrams (mg) (warfarin sodium) Give 7.5 mg orally in the evening for blood thinner.
Review of the Clinical Physician Orders PT/INR on 2/6/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Clinical Physician Orders obtain PT/INR (prothrombin time test (PT) measures the time it takes for a clot to form in a blood sample, while an INR is a calculation based on the results of a PT test) on 2/9/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Clinical Physician Orders PT/INR on 2/16/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Clinical Physician Orders PT/INR stat (immediately) on 2/19/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Clinical Physician Orders PT/INR on 3/1/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Clinical Physician Orders for R1 dated 3/27/2024 INR every Friday. No documented results for 4/5/2024, 4/12/2024, 5/3/2024, 5/10/2024 were located in R1's EMR.
Review of the Clinical Physician Orders PT/INR on 4/8/2024 for R1 revealed no documented results were located in R1's EMR.
Review of the Nurse Practitioner Progress Note dated 4/5/2024 revealed: I came to see and evaluate R1 for chronic co-morbidities that includes nonrheumatic aortic valve insufficiency, chronic systolic congestive heart failure, to avoid rehospitalization, and to monitor patient's overall condition. The facility lab has been slacking with INR draws, I had a conversation with their nurse manager regarding INR every week, she called the lab and reiterated that this should be done every Friday, and since they missed her Friday draw, they will do it on Monday, we will continue to monitor.
2. Review of the admission Record for R29 revealed she was admitted to the facility with diagnoses of but not limited to bipolar disorder, depression, and diabetes mellitus.
Review of the resident's most recent quarterly MDS assessment dated [DATE] revealed a BIMS score was assessed as 15, which indicated R29 was cognitively intact.
Review of the Clinical Physician Orders dated 1/15/2025 UA/CS (urine analysis/culture and sensitivity), CBC (complete blood count), CMP (comprehensive metabolic panel) for new onset of confusion. No documented results were located in R29's EMR.
Review of the Clinical Physician Orders dated 1/24/2025 routine labs: CBC, CMP, thyroid stimulating hormone, glycated hemoglobin, lipid panel, vitamin D 25, Hydroxyprogesterone (is a form of progestin), type 2 diabetes mellitus screening, Hyperlipidemia (high cholesterol) on 1/27/2025 for R29. No documented results were located in R29's EMR.
An interview on 2/25/2025 at 10:22 am with the Unit Manager (UM) XX stated the phlebotomist came Monday through Friday and drew the blood work for residents with a physician order. She stated the Physician or Nurse Practitioner would give an order for the test to be performed. The order was entered into the resident's EMR. The person entering the order must also enter the order into the laboratory's electronic system that would generate the requisition with the order. The requisition was placed in the lab book under the tab of the date the lab was to be drawn. UM XX stated each unit had their own lab book. When the phlebotomist arrived, they would check the Specimen Log for that day, obtain tests accordingly, and sign off on the Specimen Log. UM XX stated if the requisition was in the book, the residents' name did not have to be on the Specimen Log.
An interview on 2/25/2025 at 10:45 am with License Practical Nurse (LPN) YY stated she does remember R1's PT/INR tests were not being drawn.
An interview on 2/25/2025 at 12:40 pm with the Interim DON (IDON) FF revealed she was aware of the issues with the physician orders for laboratory testing not being carried out. She stated because she was new to the facility she needed an opportunity to meet with the laboratory manager and get a clear understanding of the processes and re-educate the staff. She stated the facility does have a meeting with the laboratory manager within the next couple of days. The IDON stated the facility does not have a written policy/process for obtaining laboratory test.
An interview on 2/28/2025 at 9:46 am with the Assistant Manager AAA of __ Laboratory stated the manager has been communicating with the IDON and the ADON regarding the issues with testing not being performed as ordered by the physician. She stated one of the problems was the facility was not using the Specimen Log correctly when a lab test was ordered by the physician. She stated the log must be completed with the resident's name, room number and the test to be completed. She stated the phlebotomists have been instructed to make a copy of the log for record keeping. She stated the logs were not completed with the information.
An interview on 3/4/2025 at 4:00 pm, the IDON confirmed the physician order for laboratory test for R1's and R29's blood work was not obtained. She stated the facility did meet with the laboratory manager regarding the lab process. She stated the staff were being re-educated on the lab process to ensure that the physician orders were being completed.
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 F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, and review of the facility's policy titled, Abuse, Neglect and Exploitation of Residents and the Human Resource Director Job description, the facility failed ...
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Based on record review, staff interviews, and review of the facility's policy titled, Abuse, Neglect and Exploitation of Residents and the Human Resource Director Job description, the facility failed to ensure that one of six employee files selected for review had evidence they were verified with the State of Georgia's Nurse Aide Registry.
Findings include:
Review of the facility's policy titled Abuse, Neglect and Exploitation of Residents with a review date of 10/24/2022 revealed under IV. Procedure: A. Seven Components of Prevention and Detection: 1. Screening: The facility screens potential employees to determine their appropriateness in working with individuals with specific conditions and needs: CNA Registry is contacted to confirm the aides' enrollment and status on the registry.
Review of the facility's Human Resource Director Job description revealed: Pre-Employment Functions: Conduct reference checking, abuse registry checks, and certification/ licensure checks (if applicable), prior to giving job offer.
During a record review of the employee files revealed the facility could not locate an employee file for CMAT (Certified Medication Administration Tech) LL.
An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files revealed that the HRD stated she could not locate an employee file for CMAT LL. The Human Resource Director stated she could not locate an identification, hire date, timecard, separation notice, a certification for a CNA (Certified Nursing Assistant), or CMAT that was requested by the surveyor. The HRD stated a search was done on the Georgia CNA registry and CMAT LL had no certifications in the name she provided to the facility.
An interview on 2/25/2025 at 4:44 pm with the Regional Human Resource/Payroll Director II confirmed that CMAT LL did not have an employee file and could not be located on the CNA registry.
CONCERN
(F)
📢 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 F0579
(Tag F0579)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and the review of the facility documents titled, admission Packet, admiss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and the review of the facility documents titled, admission Packet, admission Packets & Compliance Advance Directive Audit, the job description, admission Marketing Director (non-clinical), and emails, the facility failed to provide and obtain signatures of six of 31 sampled Residents (R) (R24, R25, R26, R27, R28, and R31) admission packets that contained written information about how to apply for and use Medicare and Medicaid benefits.
Findings include:
Review of the document titled admission Packet Table of Contents revealed the packet included but not limited to: admission agreement, Medicare and Medicaid programs, arbitration of disputes, Grievances, and resident rights.
Review of the document titled admission Packets & Compliance Advance Directive Audit dated 2/3/2025 provided to the surveyor revealed sixty-one residents do not have a signed admission packet that includes but not limited to Medicare and Medicaid programs. Six residents were selected for review (R24, R25, R26, R27, R28, and R31).
Review of the document titled admission Marketing Director (non-clinical) revealed under General Purpose: Manage the facility's inquiry and admission process. Essential Job Functions: The following list of duties is not all-inclusive: Obtain appropriate admission papers and signatures from residents or responsible parties prior to admission. Maintain a working knowledge of Federal and State regulations and reimbursement (Medicare and Medicaid).
Review of the email dated 1/28/2025 at 2:46 pm revealed: an email was sent from the Regional Director of Medical Records to the facility's Medical Records and Administrator. The following were carbon copied (CC); Chief Executive Officer, [NAME] President of Clinical Operations, Chief Nursing Office, and one other person. Subject: admission Packets. Good afternoon, please do an audit to make sure the facility has admission and Consents on all residents. Without the Admissions paperwork, the facility does not have consent to treat. Please have this completed by the end of day tomorrow, 1/29/ 2025.
Review of the email dated 1/28/2025 at 2:50 pm revealed: an email was sent from the Administrator BB. The Administrator responded to the Regional Director of Medical Records email above. The following were CC; Chief Executive Officer, [NAME] President of Clinical Operations, Chief Nursing Office, and one other person. Subject: Re: admission Packets. __ and I had a discussion about this issue last week. I asked her (Medical Records Director) to compile a list of residents missing admission documentation so we can take it to Quality Assessment and Performance Improvement (QAPI), BUT, we have to focus on getting Treatment Consents first and as soon as possible on every one of them (residents).
1. An interview on 2/19/2025 at 10:50 am with R27 revealed he was pleasant and agreed to speak with the surveyor. The resident stated he was admitted to the facility from the __. The resident stated he cannot remember the exact day he was transferred from the __ to the facility. The resident stated since he had been a resident in the facility no one had spoken with him about admission paperwork, and he had not been asked to sign any paperwork.
Review of the admission Record for R27 revealed he was admitted to the facility on [DATE] and the primary payer source was Medicare Part A.
Review of R27's Electronic Medical Record (EMR) under the Miscellaneous tab revealed there was no signed admission paperwork.
Review of R27's Order Summary revealed a physician order dated 12/16/2024 to admit to this Nursing and Rehabilitation Facility.
2. An interview on 2/19/2025 at 11:04 am with R25 revealed he was pleasant and agreed to speak with the surveyor. The resident stated he had been at the facility too long. He stated he had never been asked to sign any papers since he has been in the facility.
Review of the admission Record for R25 revealed he was admitted to the facility on [DATE] and the primary payer Medicaid pending.
Review of R25's EMR under the Miscellaneous tab revealed there was no signed admission paperwork.
Review of R25's Order Summary revealed a physician order dated 10/10/2024 to admit to Skilled Medicare Part A level skilled services.
3. An interview on 2/19/2024 at 11:20 am with R26 revealed him lying in bed. His affect was flat and his mood was sad. The resident stated he did not feel up to talking but would answer one or two questions. The resident stated he did not sign his admission paperwork.
Review of the admission Record for R26 revealed he was admitted to the facility on [DATE] with a readmission date of 1/16/2025. The resident's primary payer is Medicaid pending.
Review of R26's EMR under the miscellaneous tab revealed there was no signed admission paperwork.
Review of R26's Order Summary revealed a physician order dated 7/26/2024 to admit to this Nursing and Rehabilitation Facility.
4. An interview on 2/19/2025 at 11:25 am with R24 revealed he was pleasant and agreed to speak with the surveyor. The resident stated he was admitted to the facility around two months ago. The resident stated since he had been a resident in the facility no one had spoken with him about admission paperwork, and he had not been asked to sign any paperwork.
Review of the admission Record for R24 revealed he was admitted to the facility on [DATE] and the primary payer source was Medicare Part A.
Review of R24's EMR under the Miscellaneous tab revealed there was no signed admission paperwork.
Review of R24's Order Summary revealed a physician order dated 12/16/2024 to admit to this Nursing and Rehabilitation Facility.
5. Review of the admission Record for R28 revealed she was admitted to the facility on [DATE] and the primary payer source was Medicare Part A. The resident was discharged from the facility on 2/13/2025.
Review of R28 EMR under the Miscellaneous tab revealed there was no signed admission paperwork.
Review of R28's Order Summary revealed a physician order dated 12/28/2024 to admit to Skilled Medicare Part A level skilled services.
6. Review of the admission Record for R31 revealed he was admitted to the facility on [DATE] and primary payer was Medicare replacement.
Review of R31's EMR under the Miscellaneous tab revealed there was no signed admission paperwork.
Review of R31 Order Summary a physician order dated 2/3/2025 to admit to this Nursing and Rehabilitation Facility.
An interview on 2/18/2025 at 1:10 pm with the Medical Records Director KK, she stated a problem with the resident's EMR was identified with the last survey team of missing physician notes. Upon starting the job, an audit was initiated to ensure that the charts had the admission agreements, hospital records, physician notes, etc. She stated while conducting the audit she identified that the admission packets were not uploaded to some of the resident's EMR's. She stated this was reported to the Regional Director of Medical Records. She stated the previous Administrator BB asked that she audit the charts again in January 2025 for residents signed admission paperwork. She stated an audit was completed and a list was compiled and given to the Administrator.
An interview on 2/18/2025 at 2:10 pm with the Regional Director of Business Development HH revealed the process prior to a potential resident being admitted to the facility. Referrals were reviewed via an online platform. After reviewing the potential resident was offered a bed. The admission packet should be signed within 72 hours of the resident being admitted to the facility. The admission paperwork was signed electronically, if the potential resident was unable to sign the admission paperwork the admission Director would send the packet to the responsible party and/or family member requesting that all signed documents be returned within 72 hours. She stated the admission Director was responsible for making sure that the admission packet had been signed. The Director of Business Development stated if there was no admission Director employed at the facility it would be the responsibility of the Regional Director of Business Development to ensure that the admission packets were signed. The Director of Business Development stated the Administrator of the facility should also be responsible to ensure that the resident admission packet had been signed. She stated she was not sure what prompted the facility to audit the resident's admission packet for completeness. She stated the audits started around December of 2024. She stated she did receive a copy of the last audit two weeks ago. She stated a copy of the audit was also sent to her immediate supervisor, the [NAME] President of Business Development, who was addressing the issue of the admission packets not being sign.
An interview on 2/19/2025 at 3:50 pm with the [NAME] President of Business Development GG revealed he could not locate the signed admission paperwork for R24, R25, R26, R27, R28, and R31. He stated the facility has had three Administrators and three admission Directors within the past year. The three Administrators and the Medical Records Department were keeping management aware of the missing admission agreements. The previous admission Directors could not keep up with the pace of the department and when the previous admission Directors reached out for help, there was no assistance. He stated the [NAME] President of Clinical Operations had the department on a weekly audit for all new admissions going forward to ensure the admission paperwork was signed. He stated the facility was working on getting the sixty-one residents listed on the audit admission packets signed.
CONCERN
(F)
📢 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 F0940
(Tag F0940)
Could have caused harm · This affected most or all residents
Based on staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia,...
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Based on staff interviews and review of the facility's policies titled, Nursing Care Center Pharmacy Policy and Procedure Manual, Facility Assessment and Rules and Regulations of the State Of Georgia, the facility failed to provide evidence of implementation and maintenance of an effective training program for three of thirty Certified Medication Aide Techs (CMAT LL, CMAT MM, and CMAT NN) selected for review of their medication administration skills competency check off. The deficient practice had potential to adversely affect the care given to all residents in the facility. The facility census was 208 residents.
Review of the facility's Nursing Care Center Pharmacy Policy and Procedure Manual dated January 2024 revealed under Consultant Pharmacist Services Provider Requirements: Observe medication administration pass as outlined in the contract to assist in the assessment and improvement in nursing staff medication administration and submit a report to nursing administration.
Review of the Facility Assessment dated 8/5/2025 revealed a listed acuity - diseases, conditions and treatments, cognitive, mental, and behavioral status, cultural, ethnic, and religious factors which the facility is equipped to care for. Staffing plan: 3.2. staffs the facility to meet the needs of its resident population. Listed below is the facility's general approach to staging to ensure they have sufficient staff to meet the needs of the residents at any given time. The following tables provide a snapshot of the staffing needed to meet this expectation and resident acuity: Certified Nursing Assistants & Medication Technicians 20 per day/average. Staff training/education, competencies, and required skill sets: 3.4. The facility has a variety of training/educational requirements and opportunities for staff. The facility maintains and reviews no less than annually a listing of required training for all staff, as well as department-specific training requirements. Medication administration - injectable, oral, subcutaneous, topical.
Review of the Rules and Regulations of the State Of Georgia Subject 111-8-56 Nursing Homes Rule 111-8-56-.01 Definitions (bb) Certified Medication Aide is a person who is a Georgia certified nurse aide and in good standing with the department who has successfully completed a state-approved medication aide training program, successfully passed a written competency examination and has demonstrated the requisite clinical skills to serve as a medication aide and who is registered on the Georgia Certified Medication Aide Registry. Rule 111-8-56-.04 Nursing Services: (f) A nursing home that employs one or more certified medication aides to administer medications in accordance with this code section shall ensure that each certified medication aide receives ongoing medication training as prescribed by the department. A registered professional nurse or pharmacist shall conduct quarterly unannounced medication administration observations and report any issues to the nursing home administrator. (g) A nursing home that employs certified medication aides the nursing home shall annually conduct a comprehensive clinical skills competency review of each certified medication aide employed by such nursing home.
The surveyor requested completed clinical staff skill competency check offs for CMAT LL, CMAT MM, and CMAT NN from the facility. They were not provided.
An interview on 2/19/2025 at 3:30 pm with the Human Resource Director (HRD) while reviewing the selected employee files revealed the HRD stated CMAT LL's employee file could not be located. She stated there was not a skill competency check off for CMAT MM and CMAT NN in the employee's file.
An interview on 2/20/2025 at 9:56 am with CMAT BBB stated she has worked as a CMAT for the past year. The CMAT stated she does not recall signing a skill competency check off.
An interview on 2/25/2025 at 4:44 pm with the Regional Director of Human Resource and Payroll confirmed that CMAT LL's employee file could not be located. She also confirmed there were no skills competency check offs in CMAT MM's or CMAT NN's employee file.
An interview on 2/28/2025 at 11:05 am with the Consultant Pharmacist CCC revealed she did not observe medication pass with the CMATs. She stated if the facility wanted her to observe a medication pass, it was done upon request with a fee. She stated an observation of a medication pass would be something the Nurse Consultant would conduct. The Consultant Pharmacist stated she would have the Nurse Consultant call the surveyor. There was no follow up from the nurse consultant.
Administrator CC was unavailable for an interview.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation and staff interviews, the facility failed to have up-to-date facility staffing information posted on 2/11/2025. On 2/12/2025, the staffing information posted was unreadable. In ad...
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Based on observation and staff interviews, the facility failed to have up-to-date facility staffing information posted on 2/11/2025. On 2/12/2025, the staffing information posted was unreadable. In addition, the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months.
Findings include:
An observation on 2/11/2025 at 10:50 am upon the surveyor entering the facility revealed staffing information was not posted in a prominent place readily accessible to residents and visitors.
An observation on 2/12/25 at 9:47 am staffing information was not posted in a prominent place readily accessible to residents and visitors.
An observation and interview on 2/12/2025 at 12:25 pm with the Staffing Coordinator stated she was responsible for posting the staffing information. The staffing Coordinator stated the staffing information was posted at the Receptionist desk. An observation with the Staffing Coordinator of an 8-inch x 11-inch white piece of paper, in landscape view, with dark print was posted at the receptionist area. The Staffing Coordinator confirmed the print was so small that she was unable to read the writing.
An observation and interview on 2/12/2025 at 12:30 pm with an Employee VV in the receptionist area. Employee VV confirmed that the writing on the 8-inch x 11-inch white piece of paper in landscape view with dark print posted at the receptionist area was too small to read.
An observation and interview on 2/12/2025 at 12:35 pm with the Staffing Coordinator revealed she did not keep the posted staffing information. She stated she removed the posted staffing information and discarded the sheet. The Staffing Coordinator stated she was not aware that the posted staffing information should be available for surveyor's review for eighteen months.
Aug 2024
23 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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on resident, and staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation the facility failed to protect the residents' right to be free from mi...
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Based on resident, and staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation the facility failed to protect the residents' right to be free from misappropriation of property by facility staff for one of four sampled residents (R) (R32).
Findings included:
During a review of the facility's policy titled, 'Abuse, Neglect and Exploitation revised on 3/1/2024, it is documented that misappropriation of resident's property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money with the resident's consent.
A review of R32's Electronic Medical Record (EMR) revealed an original admission date of 5/13/2021 with multiple diagnoses of but not limited to chronic obstructive pulmonary disease, heart failure, anxiety hypertension, type II diabetes, and chronic pain. R32's Brief Interview for Mental Status (BIMS) was 15; indicating R32 was cognitively intact.
A review of the Facility Reportable Incident (FRI) dated 1/23/2024 revealed that R32 notified social services of unauthorized charges on their account. It is documented that R32 gave their FSA card to Former Activities Assistant (AA) OOOO to do some shopping for R32 at a local store. R32 states that Former AA OOOO did not return the FSA card. Additionally, R32 noticed some cash app charges R32 did not authorize. The investigation showed that Former AA OOOO linked their Cash app Kanary account to R32's card and subsequently a total of $830 was sent through the cash app. R32 called the FSA card and all transactions were reported to the fraud department.
During an interview on 7/10/2024 at 2:35 pm, the Administrator stated that the police came to interview them at the facility about the allegation regarding R32 in April 2024. To the Administrator's knowledge, the police did not have a final report yet and the incident happened in January 2024.
During an interview on 7/15/2024 at 10:43 am, the Former Social Service Director (SSD) revealed that the Former Activities Assistant (AA) OOOO connected their Cash app account to R32's bank account. The Former SSD also revealed the Former AA OOOO never returned to the facility after it was brought to the facility's attention that Former AA OOOO misappropriated R32's funds. Former AA OOOO told Former SSD over the phone R32 gave her permission. When the Former SSD followed up with R32, s/he denied giving the Former AA OOOO permission for the amount taken from R32's account.
A record review of the Former AA OOOO employee file revealed that their employment was terminated on 1/23/2024.
During an interview on 7/16/2024 at 11:17 am, the Former SSD revealed that s/he conducted an in-service with employees and R32 after the investigation was completed and sustained. The Former AA OOOO was also officially terminated.
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 F0603
(Tag F0603)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the policy titled Abuse Prevention Policy Instruction, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the policy titled Abuse Prevention Policy Instruction, the facility failed to ensure that one of five sampled residents (R) (R11) was free from involuntary seclusion.
Findings included:
A review of the facility policy titled, Abuse Neglect and Exploitation - Work Instruction last revised on 11/15/2022, documented that Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The resident has the right to be free from . Involuntary seclusion. Involuntary Seclusion means separation of a resident from another resident or his/her room or confinement to his/her room (with or without roommates) against the resident's will or the will of the resident's legal representative.
A review of the clinical record revealed that R11 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease Dementia with Psychotic disturbance and a history of falls.
A review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented that R11's Brief Interview for Mental Status (BIMS) score was 10 out of 15, indicating moderate cognitive impairment.
A review of R11's care plan created by MDS Director CCC and dated 12/25/2023 revealed that R11 had an Activities of Daily Living (ADL) self-care performance deficit due to confusion and dementia with impaired cognition; R11 required staff participation to reposition and turn in bed; R11 was a high risk for falls due to confusion and was unaware of safety needs; and that staff were to maintain a clear pathway, free of obstacles in R11's room due to falls. The assessment further revealed that R11 had a fall on 1/1/2024 and 1/4/2024.
During an interview on 7/9/2024 at 10:14 am, Resident Representative (RR)63 revealed that on 1/9/2024 she visited R11 at the facility and discovered that R11 was barricaded with multiple wheelchairs in his room. RR63 had photographs on her mobile device of R11 barricaded in the room by the wheelchairs. RR63 stated she filed a formal complaint to the director of nursing (DON) OOO and the former Administrator WWW.
During an interview on 7/12/2024 at 3:15 pm, Certified Nursing Assistant (CNA) KKK revealed she had assisted R11 with care and R11 was unable to perform ADL care without assistance. CNA KKK stated there were multiple wheelchairs in R11's room however R11 did not have a roommate. She stated that the resident was in isolation at that due to COVID. CNA KKK stated the chairs in R11's room obstructed his movement, and she did not know who placed them in R11's room.
During an interview on 7/13/2024 at 2:15 pm, CNA LLL revealed that R11 repeatedly tried to get out of bed without assistance and presented with confusion. CNA LLL stated that on one occasion, R11's family member said R11 was barricaded with wheelchairs in his room and was unable to get out. She stated that she remembered that the family member reported the incident to the DON. CNA LLL stated that she did not know where the extra wheelchairs came from or who put them in the resident's room.
During an interview on 7/15/2024 at 10:46 am former social services director (SSD) NNN revealed that she worked at the facility from 2022 to June 2024. SSD NNN revealed she remembered R11 and RR63. She stated that RR63 informed management that staff had barricaded R11 with wheelchairs in his room and she believed that a grievance was destroyed by DON OOO and the previous administrator WWW. SSD NNN stated she reported the incident regarding R11 to the DON OOO but nothing was done. SSD NNN stated both Administrator WWW and DON OOO were aware that staff kept R11 barricaded in his room with wheelchairs and that she considered this a form of abuse.
During an interview on 7/17/2024 at 10:27 am, DON OOO revealed she was the DON for three weeks in January 2024 and that she was made aware that R11 was barricaded in his room when RR63 came to her visibly upset and made a formal complaint. She stated that there were at least three wheelchairs in R11's room and she pulled out two of the three. DON OOO stated she did not know why staff had the wheelchairs in R11's room. DON OOO confirmed that she did not write the grievance and did not conduct a formal investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and resident's representative in writing of the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital for one of five sampled residents (R) (R15).
Findings included:
A review of the facility's policy titled, Admission, Transfer and Discharge Registry Policy dated 11/28/2017 and last revised on 10/20/2022, documented that the facility office shall maintain a current Admission, Transfer, and Discharge Register and updates in the electronic health record. The facility must document in the discharge notice the reason for the transfer/discharge, the place to which the resident was transferred/discharged , and the length of the resident's stay. The discharge plan will be monitored and revised as necessary throughout the patient /resident stay. Initiation of a discharge while a resident is in the hospital must be based on the resident's current condition when the resident seeks to return to the facility. The facility must have evidence that the resident's status at the time the resident seeks to return to the facility (not at the time the resident was transferred to acute care) meets one of the criteria for discharge. The facility must provide, in the notice, the specific location to which the resident is being transferred or discharged (such as the name of the new provider or description and/or address if the location is a residence and Inquiries concerning admissions, transfers, and/or discharges should be referred to the Medical Records office.
A review of the Electronic Medical Record (EMR) revealed that R15 was admitted to the facility on [DATE] with the diagnosis of dementia, psychotic disturbance, a personal history of transient ischemic attack, and cerebral infarction.
A review of R15's discharge Minimum Data Set (MDS) dated [DATE] list revealed the resident was discharged from the facility to an acute care hospital with a return anticipated on 01/22/2024
A review of the EMR revealed that there was no discharge notice information related to R15 being sent out to the hospital on 1/22/2024.
During an interview on 7/16/2024 at 1:50 pm Social Service Director (SSD) XXX stated R15 there was no record of a discharge notice being given for R15 on 1/22/2024. Residents should be given discharge notices. SSD XXX stated she was responsible for issuing resident discharge notices and concluded, the previous SSD NNN did not provide R15 with discharge notice and concluded NNN did not implement any discharge plans for R15 and did not accurately address R15's discharge plans as outlined in the facility policy.
During an interview on 7/17/2024 at 9:37 am with the Business Office Manager (BOM) QQQ revealed R15 was discharged on 1/22/2024, to the hospital. BOM QQQ stated typically the social worker would write discharge letters and BOM QQQ would get a copy and place the copy on the resident's record. BOM QQQ stated there was no discharge notice applied to R15's record.
During an interview on 7/29/2024 at 4: 07 pm, the Nursing Home Administrator (NHA) AA revealed that facility staff must review the discharge summaries with the family before a resident was discharged . Resident Representatives are required to sign the discharge form, and the facility keeps a copy signed by the family. NHA AA stated a thirty-day notice is given to families or residents who fail to pay their bills and when the facility fails to meet the Resident's needs.
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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide timely respiratory care consistent with professional stand...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide timely respiratory care consistent with professional standards of practice for one of six residents (R) (R45) requiring tracheostomy care.
Findings included:
Resident (R) 45 was admitted to the facility on [DATE] with the diagnoses to include, Encephalopathy, Acute and Chronic Respiratory Failure with Hypoxia, and Encounter for attention to Tracheostomy.
A review of the admission Minimum Data Set (MDS), for R45, dated 7/9/2024 revealed no Brief Interview of Mental Status (BIMS) score conducted, resident is rarely/never understood. Section O.-Special Treatments, Procedures, and Programs documented resident received oxygen therapy, suctioning, and trach care.
A review of R45's Progress Note dated 7/20/2024 at 4:55 pm revealed that nurse observed resident was showing s/s (signs/symptoms) of SOB (shortness of breath) 02 (oxygen): 79-84 percent, nurse asked CNA to call 911, while that was being done resident received suction after nurse listened to lungs and noted they were diminished on the left side. The resident was transferred to hospital .
The resident returned to the facility on 7/26/2024.
During an interview on 7/25/2024 at 6:05 pm, Certified Nursing Assistant (CNA) KKK revealed that s/he was present when R45 was experiencing respiratory distress. No nurse was found on the floor. The staff had to find the supervisor Licensed Practical Nurse (LPN) UUU as there was no licensed nurse on the unit. The resident's trach was overflowing with phlegm. LPN UUU came into the resident's room and started suctioning the resident and that didn't work. CNA YYY started beating on the resident's chest to loosen it (chest percussion). CNA KKK stated that it took about 10 minutes, on other floors, to find a pulse oximeter machine.
During an interview on 7/27/2024 at 3:30 pm, LPN UUU revealed that s/he normally worked the fifth floor. LPN UUU stated that s/he worked the morning and evening shifts that day. The evening shift was when LPN UUU was assigned to work the fourth floor and perform supervisory duties over the other three floors. LPN UUU stated that s/he was not on the fourth floor, where R45 was located when a CNA came to find them. LPN UUU confirmed there were no nurses on the floor when s/he arrived on fourth the floor, just CNAs and Certified Medication Aides (CMA). R45 had a pulse but oxygen level was 79-84% and lung field functioning was diminishing. 911 was called and the R45 was taken to the hospital.
An interview with Staff Coordinator WWWW on 7/29/2024 at 1:20 pm revealed there are typically two nurses during the day shifts and one nurse for the night shift for each floor. That means there are four nurses and a nurse supervisor. If a nurse calls out, then there are CMA's, and the nurse supervisor takes that floor if the nurse does not show up.
Interview with Respiratory Therapist (RT) YY on 7/30/2024 at 3:40 pm revealed R45 was sent to the hospital again on 7/29/2024. He was sweating and warm to the touch. His oxygen was low, and he didn't look right. He did not fight during oral care, so we knew that was not his normal self. After suctioning, the covers were removed. His oxygen saturation was in the low 90's and after the suctioning, the oxygen saturation was at 95 percent, and they made sure his oxygen was on. The nurse took it from there. R45 had been suctioned previously and the suction cap was in the trash. He had a moderate amount of mucous. He has had a copious amount of secretions. His lungs are usually coarse or rhonchi, and after suctioning, they become clear. It didn't get to the point where they thought it was uncontrollable.
An interview with Administrator AA on 8/1/2024 at 1:14 pm revealed the policy is when the supervisor is on the cart, then they are on the cart and not supervising. If the nurse calls out, the nursing supervisor should come in and work the floor. It is not acceptable to not have a nurse on each floor.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and a review of facility policy titled Activities of Daily Living (ADL), the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and a review of facility policy titled Activities of Daily Living (ADL), the facility failed to ensure incontinent care was provided promptly for two of 10 residents (R) (R35 and R36) sampled for ADL care. This failure placed the residents at risk for skin breakdown and a diminished quality of life.
Findings included:
A review of the facility policy titled Activities of Daily Living (ADLs) dated November 2022 documented the following: Each resident shall receive care and services to sustain and maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan. Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including hygiene bathing, grooming and oral care, mobility, transfer, ambulation, elimination/toileting, dining, eating, and communication functions. The facility will create and sustain an environment that humanizes and promotes individual plans of care to promote quality of life for all residents. The facility will ensure that all staff, across all shifts and departments, are trained on the principles of quality of life to honor and support each resident.
1. A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R35 was readmitted to the facility on [DATE] with a diagnosis of urinary tract infection, adult failure to thrive, and a stroke with right-sided paralysis and aphasia (loss of ability to express speech).
A review of the Annual Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 5/14/2024 revealed R35 had a staff assessed Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The resident was dependent on toileting hygiene.
During an observation and interview on 7/18/2024 at 11:39 am, R35 pushed the button on her call light as she had gestured that she needed to have her brief changed. When standing next to R35 there was a strong urine odor when she pushed her blankets away. At 12:22 pm Certified Nursing Assistant (CNA) DDDD answered the call light; however, instead of asking R35 if she needed assistance, she asked R35's roommate. CNA DDDD was asked why she did not ask R35 if she needed assistance, CNA DDDD stated, All she wants is her meal tray, we have her on a schedule. At 12:26 pm CNA CCCC entered the room, did not turn off the call light, and stated, Her aide is CNA BBBB, I am going to find her, but the lunch trays are here also. If I can't find her, then I will think of something. Incontinent care was not provided to R35. At 12:34 pm, CNA BBBB entered the room and did not address R35 but spoke to her roommate. R35 was pointing to her brief. CNA BBBB stated, I had to go downstairs to get more extra-large briefs and more gloves. I will do R35 as soon as I do another resident. At 12:34 pm, CNA BBBB returned to R35 and provided incontinent care. CNA BBBB was asked when the last time were they provided incontinent care to R35. CNA BBBB stated, It was done from 8:30 am to 9:00 am this morning. R35's skin was free of breakdown.
A review of the Point of Care documentation (CNA documentation) for toileting on 7/18/2024 revealed no documentation of incontinent care having been provided since midnight.
During an interview on 7/24/2024 at 11:38 am, the Director of Nursing (DON) stated, Staff are to sign off as we have a 'buddy' system, and they are to give a small report to the person covering for them when they are off the floor. It is supposed to be teamwork.
During an interview on 7/29/2024 at 9:24 am the Administrator AA stated, My expectation is the staff are to do rounds on the residents frequently, at least every two hours, and provide incontinent care timely.
2. A review of the Face Sheet for R36 revealed resident was admitted to the facility on [DATE] with diagnoses including cellulitis and bullous pemphigoid (a rare skin condition causing fluid-filled blisters).
A review of R36 Quarterly Minimum Data Set (MDS) dated [DATE], showed a BIMS score of 15, indicating cognitively intact. Section G - Functional Status revealed that R36 required maximum assistance with toileting and personal hygiene.
During observation and interview on 6/26/2024 at 5:15 pm, R36, a resident on the fourth floor, lay on the edge of the bed, the bed cover was covered with dark brown stains, and there was a presence of a foul odor in the room. R36 was naked and clothed in a soaked brief with dark brown stains, his head was tilted sideways facing down. R35 had layers of redness from the neck area to his ankles with edges of red and dark sores. R36 stated, I can't get staff to change my diaper and stated his bed sheets needed to be changed and continued he had been laying on his bowel movement since, Saturday. R36 stated he had to lay on one side all weekend because the sheets were soiled and needed to be changed.
During an interview on 6/26/2024 at 5:25 pm, Licensed Practical Nurse (LPN) DD stated facility policy required all the trays to be picked up first before assisting residents with incontinent care. LPN DD stated staff were not allowed to stop passing trays and attend to residents who required bowel or urinary incontinence care.
Observations and interview on 6/26/2024 at 5:28 pm revealed CNA HH entered R36's room and stated R36 had been waiting for the wound care nurse. CNA HH was aware R36 had requested a brief change and LPN DD was made aware at the beginning of the shift. CNA HH stated she worked the 3:00 pm to 11:00 pm shift. CNA HH revealed the nurse must clean his wounds before the CNA assists R36 with incontinent care.
During an interview on 6/26/2024 at 5:35 pm on the fourth floor, LPN EE stated any resident who required incontinent care during meal service, would have to wait until all the trays had been picked up. LPN EE stated staff run the risk of cross-contamination when staff provide incontinent care during mealtimes. LPN EE stated she was aware R36 had a bowel movement and had dried feces around his bed.
Observation and interview on 6/26/2024 at 6:49 pm, showed LPN DD walking with CNA JJ toward R36's room. LPN DD stated staff had completed passing trays and she was ready to assist R36 with wound care and dressing change. LPN DD stated she had been the only treatment nurse for two weeks and was unable to assist all the residents who required wound care assistance promptly. LPN DD explained facility added one more additional staff on 6/25/2024, LPN EE, and she was training LPN EE on wound care. Continued observations showed LPN DD gloved up and washed R36 with a soaked cloth while CNA JJ repositioned R36 and removed the brief which revealed dry feces around the brief and R36's waist area.
During an interview on 6/26/2024 at 7:15 pm, CNA JJ stated he was instructed that LPN DD had to be present during incontinent care on R36 due to his diagnosis related to his skin condition.
During an interview on 7/30/2024 at 9:14 am, Administrator AA revealed she expected staff to change residents who had experienced a bowel movement immediately or as soon as possible. Administrator AA stated staff are expected to stop passing out trays and assist any resident who required assistance with incontinence care. She was unaware R36 had been left soiled and stated she would have addressed the situation immediately had she been made aware. Administrator AA stated she did not approve any delay in care at 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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure the tube feeding pump was turned o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, the facility failed to ensure the tube feeding pump was turned on during the hours that the resident was to receive nutrition, per the physician's orders for one of one sampled resident (R) (R53) with parental nutrition. This failure placed the resident at risk for weight loss.
Findings included:
A review of an updated facility policy titled, Enteral Feeding, revealed, .A resident who is fed by a gastrostomy tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal eating skills .
A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE] with diagnoses that included dementia, urinary tract infection, and pressure ulcers.
A review of the Physician Orders located in the Orders tab of the EMR revealed, Enteral Feed .Jevity 1.5 at 66ml/hour for 20 hours, start at 6:00 am and stop at 10:00 PM Dated 5/21/2024.
A review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/6/2024 revealed R53 had a feeding tube and was provided nutrition of greater than 501cc/day.
During an observation on 7/23/2024 at 8:15 am, R53 was observed lying in bed with her eyes closed. The tube feeding pump was located next to the bed, and the tube feeding bag that was hanging was full, however, the pump was in the off position.
During an observation on 7/23/2024 at 10:00 am, the tube feeding pump was in the off position and the tube feeding bag was full.
During an observation on 7/23/24 at 12:15 pm, the tube feeding pump was on and running at 66ml/hr.
During an interview on 7/24/2024 at 11:34 am, the Director of Nursing (DON) was told about the observations with R53's tube feeding pump. She stated, Staff must follow the physician's orders.
During an interview on 7/29/2024 at 9:48 am, the Administrator stated, My expectation is staff should follow physician 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
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Dialysis, Care of the Resident Receiving Dialysis, the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Dialysis, Care of the Resident Receiving Dialysis, the facility failed to ensure the pre/post dialysis communication form was provided to two of two sampled residents (R) (R14 and R52) upon leaving for dialysis.
Findings included:
A review of the facility policy titled, Dialysis, Care of the Resident Receiving Dialysis, revised July 2020 revealed, .To prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage in residents receiving dialysis .Arrange for dialysis as ordered. Send Dialysis Information Transfer Form with resident .
1. A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R14 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dialysis dependent.
A review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date of 12/7/2023 revealed R14 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated she was cognitively intact for daily decision-making and was on dialysis.
A review of the Physician Orders located in the Orders tab of the EMR revealed that R14 went to dialysis on Mondays, Wednesdays, and Fridays.
A review of a 2/7/2024 Nursing Progress Notes located in the Progress Notes tab of the EMR revealed, that R14 was transferred to dialysis and then sent directly to the hospital. There was no documentation that the pre-dialysis communication form and accompanying assessment of the resident in the EMR.
2. A review of the admission Record located in the Profile tab of the EMR revealed that R52 was admitted to the facility on [DATE] with a diagnosis of end-stage renal disease and was dependent on dialysis.
A review of the admission MDS located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 5/14/2024 revealed R52 had a BIMS score of 15 which indicated she was cognitively intact for daily decision-making and received dialysis.
A review of the Physician Orders located in the Orders tab of the EMR did not show any documentation of an order for dialysis.
A review of the Assessments tab, the Miscellaneous tab, and Nursing Progress Notes did not show pre/post dialysis communication form for the following days:
~ May 2024: There were 11 opportunities that R52 went to dialysis and the EMR showed only on four days was a Pre/post dialysis communication form provided to the resident.
~ June 2024: There were nine opportunities that R52 went to dialysis and the EMR showed only three days was a Pre/post dialysis communication form provided to the resident.
~ July 2024: There were 6 opportunities that R52 went to dialysis and the EMR showed only on two days as a Pre/post dialysis communication form provided to the resident.
During an interview on 7/29/2024 at 9:48 am, the Administrator stated that her expectation is the pre-dialysis communication forms are to be filled out entirely and provided to the resident upon transfer to dialysis.
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 F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to ensure physician visits were done ever...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to ensure physician visits were done every 60 days, per the requirement, and documentation of those visits was in the medical record for one of five sampled residents (R)(R53).
Findings included:
A review of the facility policy titled, Staff Privileges, dated April 2024 revealed, .Each physician desiring to participate in staff privileges must abide by the following conditions .Provide medical information necessary to maintain continuous medical care and treatment .Provide the Center with medical information concerning the resident in accordance with admission policies .Prepare and maintain a complete medical record for each resident in accordance with current medical record policies and procedures .Provide regularly scheduled physician visits in accordance with physician services .
A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE] with a diagnosis of dementia.
A review of the Physician Visit Notes located in the Miscellaneous tab of the EMR revealed that the last physician visit was on 4/9/2024. There was no physician visit note from 6/9/2024 to 6/19/2024, as required for the 60-day visit.
During an interview on 7/23/2024 at 8:00 am Medical Records EEEE was asked what her process was regarding ensuring timely physician visits. Medical Records EEEE stated, When the physician comes in, we print them a list with the residents they see. When they are done, they leave the list in my box, so I know the date they were seen. Medical Records EEEE further stated that she does an audit on physician visits every 30-45 days. Medical Records EEEE was asked if the physician's chart was in the facility's EMR. Medical Records EEEE stated, No, only the Medical Director does, however, R53's physician will send us his notes after he visits. Staff EEEE was asked why there was no physician visit documented or visit notes from June. Staff EEEE stated, Well, I can call and have him send the notes. Staff EEEE confirmed there was no documentation in the medical record of a physician visit after 4/9/2024.
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 F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for three days in Janua...
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Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for three days in January 2024.
Findings included:
A review of the December 2023 and January 2024 Facility Two-Week Staffing Grid provided by the Staffing Coordinator and reviewed by the Administrator, revealed that there was no RN coverage for 1/6/2024, 1/7/2024, and 1/20/2024.
During an interview on 7/1/2024 at 1:43 pm, the Administrator stated the facility was using a lot of agency employees so a major goal when she began in March 2024 was to get rid of agency staff and hire full-time employees.
During an interview on 7/17/2024 at 10:29 am, the former Director of Nursing (DON) OOO revealed that s/he had made multiple attempts to reach out to the management company about the lack of staff and RN coverage on multiple shifts. DON OOO stated there were several days s/he had to work multiple shifts to ensure weekend RN coverage and confirmed that there were multiple occasions that no RN was available for the day shift.
During an interview on 7/18/2024 at 1:00 pm the Administrator confirmed that she was aware of the staffing issues at the facility but that this was the first time seeing it on paper.
During an interview on 7/31/2024 at 4:26 pm, the current Director of Nursing (DON) stated there should always be nursing coverage on every floor even if there is a Certified Mediation Technician (CMAT). The DON confirmed that there was a current lack of nurses to cover each floor.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Administration of Medication, the facility failed to ensure that three of five residents (R) (R13, R32, and R67) were free from significant medication errors.
Findings included:
A review of the facility policy titled Administration of Medications last reviewed on 11/15/2022 stated that medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the resident's electronic medication administration record on the appropriate line entry after giving each medication and before administering the next one, or document in wet ink. As required or indicated for a medication, the individual administering the medication will record in the resident's Electronic Medication Administration Record (eMAR): The dates and time the medication was administered; the dosage; the route of administration; The signature and title of the person administering the drug.
1. A review of the Annual Minimum Set Data (MDS) assessment dated [DATE] revealed that R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to muscle weakness, pressure ulcer of sacral region - stage 3, pressure ulcer of left buttock - stage 2, tracheostomy, dysphagia, oropharyngeal phase, gastrostomy, moderate protein-calorie malnutrition, and abnormalities of gait and mobility. The assessment further revealed that R13 had a Brief Interview for Mental Status (BIMS) score of four (severe cognitive impairment); required assistance from one or more staff members with bathing, dressing, toileting, eating, and grooming; was always incontinent of bowel and bladder; and required incontinent care every two hours and as needed.
A review of R13's eMAR for July 2024 revealed nine days that R13's medication had not been administered. The eMAR indicated blanks for 7/2/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/10/2024, 7/17/2024, 7/18/2024, 7/20/2024, and 7/27/2024.
A review of the eMAR dated July 2024 for R13 revealed the following physician's orders and the medications not administered:
* R13 was ordered Aspirin 81 milligram (mg) via a gastrotomy tube (G-tube) once a day. On 7/2/2024, 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Darunavir Oral Tablet 800 mg via G-tube once a day. On 7/2/2024, 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Dolutegravir Sodium 50 mg via G-tube once a day. On 7/2/2024, 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Emtricitabine 200 mg via G-tube once a day. On 7/2/2024, 7/5/2024, 7/7/2024, 7/20/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Ferrous Sulfate oral Solution 5 milliliters (ml) a day. On 7/5/2024 and 7/27/2024 the medication was not administered.
* R13 was ordered Ferrous Sulfate Oral Solution 220 mg/5ml via G-tube once a day. On 7/5/2024 and 7/27/2024 the medication was not administered.
* R13 was ordered [NAME]-Vite 1 mg via G-tube once a day. On 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Ritonavir Oral Packet 100 mg via G-tube once a day. On 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Sertraline HCl 50 mg via G-tube once a day. On 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered Tenofovir Alafenamide Fumarate 25 mg via G-tube once a day. On 7/5/2024, 7/7/2024, and 7/27/2024 the medication was not administered.
* R13 was ordered enteral feed every shift for flush with 5 ml of water between medication administrations via G-tube. On 7/2/2024, 7/5/2024, 7/7/2024, 7/17/2024, 7/18/2024, and 7/27/2024 the flushes between medication were not administered.
* R13 was ordered Jevity 1.5 at 55ml/hour with 150 ml free water flush every four hours. On 7/2/2024, 7/5/2024, 7/7/2024, 7/17/2024, 7/18/2024, and 7/27/2024 the enteral feeding was not administered.
During an interview on 7/16/2024 at 9:49 am, the Director of Nursing (DON) revealed an X on the eMAR meant that the medication was not yet due, or it was not yet ordered. The DON stated checks with initials on the bottom meant that the medication had been administered and if there were any blanks on the eMAR, it would be assumed that the medication had not been administered.
2. A review of R32's Electronic Medical Record (EMR) revealed an original admission date of 5/13/2021 with multiple diagnoses of but not limited to chronic obstructive pulmonary disease, heart failure, anxiety hypertension, type II diabetes, and chronic pain. R32's Brief Interview for Mental Status (BIMS) was 15; indicating R32 was cognitively intact.
A review of R32's Grievance/complaint form dated 1/5/2024 documented that R32 reported not receiving her methadone and Percocet in a couple of days. The complaint was investigated by the Former Director of Nursing (DON) OOO and it was documented that the medication had not been ordered promptly.
A review of R32's nurse note created on 1/5/2024 at 3:44 pm documented, called (doctor) office and on-call answering service; left a message about the 2 narcotics that need scripts; and called (doctor's) phone but got no answer. A message left at the office.
A review of R32's nurse note dated 1/7/2024 at 4:01 pm documented that this writer printed out both scripts for methadone HCL 10MG oral tablet and Percocet 10-325MG. 'Doctor' on call notified, awaiting on call back. Will continue to follow up
A review of R32's Orders Administration note dated 1/8/2024 at 5:31 pm, it was revealed that needs to be ordered on the last pill
A review of R32's progress note dated 1/9/2024 at 3:36 pm, it was documented that Patient was out of methadone, the medication came in this evening around 11:00 AM. The patient stated she didn't get her 600 methadone because she was out of the medication.
During an interview with the DON on 7/16/2024 at 9:49 am, X's on the Medication Administration Record (MAR) mean that it's not yet due and not yet ordered. Checks with initials on the bottom mean administered, blanks all we can assume is the medication was not administered.
A review of R32's eMAR dated January 2024 revealed a physician's order for methadone HCl Oral Tablet of 10 milligrams (mg) given by mouth three times a day for pain. On 1/2/2024, 1/3/2024, 1/5/2024, 1/10/2024, 1/12/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, 1/19/2024, 1/21/2024, 1/25/2024, and 1/30/2024 the medication was not administered either once, twice or three times as ordered.
3. A review of R67's Electronic Medical Record (EMR) revealed an original admission date of 8/8/2017 with multiple diagnoses of but not limited Idiopathic chronic gout, generalized edema, alcoholic cirrhosis of the liver, diabetes mellitus with hyperglycemia, hypo-osmolality, and hyponatremia. R67 Brief Interview for Mental Status (BIMS) was 15; indicating R67 was cognitively intact.
A review of R67's Grievance/complaint form dated 1/4/2024 documented that R67 reported not receiving his oxycontin and gabapentin for 6 days. The complaint was investigated by the Former Director of Nursing (DON) OOO and it was documented that the medication had not been ordered promptly.
A review of R67's eMAR dated December 2023 revealed a physician's order for Gabapentin Oral Capsule 100 milligram (mg) given by mouth one time a day for an anticonvulsant. The order date was 12/8/2023 and discontinued on 1/2/2024. Medication was not given on 12/29/2023.
During an interview on 7/30/2024 at 11:13 am, Certified Medication Technician (CMT) LLLL revealed when the medication gets to the blue strip (approximately eight medications) on the card write it on the paper to give the Charge nurse to reorder or go to the DON. CMT LLLL stated she had tried to reorder medications but only nurses can do that. CMT LLLL stated she had been on the fourth floor for about a week so far and they always have issues with medication being out. CMT LLLL stated if the Administrator note says on order or not available not available is either 9 or 13 on eMAR.
During an interview on 7/30/2024 at 1:50 pm, the Unit Manager, Licensed Practical Nurse (UMLPN) RR there was a dark blue line on the blister packets and that's when nurses should reorder the medication. UMLPN stated some staff waits until it gets down to two to three pills.
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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Influenza and Pneumococcal Immunizations, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy titled Influenza and Pneumococcal Immunizations, the facility failed to assess for eligibility and ensure residents were offered and/or administered influenza and pneumococcal vaccines; and failed to provide documentation that the resident and/or resident representative were informed of the risks verse benefits of refusing the vaccines for two residents of five sampled residents (R) (R28 and R55) reviewed for immunizations. This failure placed residents at risk of complications from being unvaccinated.
Findings included:
A review of the facility policy titled, Influenza and Pneumococcal Immunizations, revised November 2022 revealed, .It is the standard of practice of this facility to offer and administer immunizations to the resident unless it is medically contraindicated to prevent and minimize house acquired infection, unnecessary hospitalization, and even death in the elderly population associated with influenza and incidence of pneumonia .All residents of this facility will be offered the influenza vaccine annually. Assessment will be documented in the facility computer software program, Point Click Care (PCC) within the resident's medical record (immunizations tab) .Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine and when indicated will be offered unless medically contraindicated or the resident has been immunized .The resident/legal representatives have the right to refuse vaccination .If refused, appropriate entries will be documented in the resident's electronic clinical record indicating the date of refusal of the vaccine .
1. A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R28 was originally admitted on [DATE].
A review of the Quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 5/26/2024 revealed R28 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated she was severely impaired in cognition for daily decision-making.
A review of the Immunizations tab in the EMR revealed, Influenza .consent refused, and Pneumovax 23 .consent refused.
A review of the Miscellaneous tab in the EMR revealed no documentation that the resident and/or legal representative were informed of the risks vs benefits of the vaccines and documentation of consent refusal.
A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no immunization history.
During an interview on 7/29/2024 at 9:24 am, the Infection Preventionist (IP) and Administrator confirmed that R28 had no information regarding having been offered/administered the influenza and/or pneumococcal vaccines.
2. A review of the admission Record located in the Profile tab of the EMR revealed that R55 was admitted to the facility on [DATE].
A review of the Medical Diagnosis tab in the EMR, revealed R55 had multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves.)
A review of the Immunizations tab in the EMR revealed, Pneumococcal dose 1 .consent refused and Prevnar 23 .consent refused.
A review of the Miscellaneous tab in the EMR revealed that R55's resident representative had refused consent for the pneumococcal vaccines on 10/10/2018.
A review of the annual MDS located in the MDS tab of the EMR with an ARD of 12/11/2018 revealed R55 had a BIMS score of nine out of 15 which indicated she was moderately impaired in cognition for daily decision-making.
A review of the annual MDS located in the MDS tab of the EMR with an ARD of 7/7/2024 revealed, that R55 had a BIMS score of 13 out of 15 which indicated she was cognitively intact for daily decision-making.
A review of the Miscellaneous tab in the EMR did not show, when R55's cognition improved, had been educated on the risks vs benefits and/or refused consent for the pneumococcal vaccine.
A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no pneumococcal immunization history.
During an interview on 7/29/2024 at 9:24 am, the Administrator and Infection Preventionist were asked if the facility had readdressed the pneumonia vaccines with R55 since 2018. The Administrator stated, No, we haven't. Since we started in May of this year, we are still getting immunizations up and running and getting the documentation together.
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 F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled Testing of Resident and Staff for COVID-19, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled Testing of Resident and Staff for COVID-19, the facility failed to offer/administer or provide documentation of consent or refusal by the resident representative for the COVID-19 vaccines for one of five sampled residents (R) (R28) reviewed for COVID-19 vaccinations. This failure placed the resident at risk for complications related to being unvaccinated.
Findings included:
A review of facility policy titled, Testing of Resident and Staff for COVID-19, revised in May 2023 revealed, .It is the policy of [facility] to maintain and attain best practices in the prevention and spread of infection. The facility follows all recommendations from CMS (Center for Medicare/Medicaid Services), CDC (Center for Disease Control), and state and local regulatory agencies .
A review of the electronic medical record (EMR) revealed that R28 was originally admitted to the facility on [DATE].
A review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/26/2024 revealed R28 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated she was severely impaired in cognition for daily decision-making.
A review of the Immunization tab in the EMR revealed no documentation of the initial COVID-19 vaccines including any boosters for R28.
A review of the Miscellaneous tab in the EMR revealed no documentation that the R28 and/or legal representative were informed of the risks and/or benefits of the vaccines. There was no documentation in the EMR of consent or refusal of vaccines.
A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no immunization history for R28.
During an interview on 7/29/2024 at 9:24 am the Administrator confirmed that R28 had no documented COVID-19 vaccinations or consent/refusals in her medical record.
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 F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on staff interviews and record review, the facility failed to have residents' funds available for withdrawal after hours and on weekends. This failure has the potential to affect 122 residents w...
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Based on staff interviews and record review, the facility failed to have residents' funds available for withdrawal after hours and on weekends. This failure has the potential to affect 122 residents who have trust fund accounts. The facility census was 189.
Findings included:
During an interview on 7/17/2024 at 9:36 am, the Business Office Manager (BOM) stated that the residents do not have access to their funds on the weekends and have been like that since before she got here. The residents were notified in a memo and resident council meeting by the previous Social Service Director. The BOM stated the residents are provided funds on Fridays to cover their weekend spending. When asked why this had been the process, the BOM stated it had been like this before the BOM's tenure at the facility. They currently don't have someone secure enough to handle resident funds on the weekends.
In a phone interview on 7/22/2024 at 10:59 am the Former Administrator (FA) WWW stated that they had a Business Office Manager who had been at the facility for approximately six to seven years that resigned. After their resignation, they did have difficulty securing another Business Office Manager. The FA WWW continued that in the interim, they had a plan in place where funds were left with the receptionist. Per the FM WWW, the facility did have a 24-hour seven-day-a-week receptionist until January 2024.
During an interview on 7/24/2024 at 10:47 am with Resident Council President, R48, it was revealed that the residents do not have access to their funds on the weekends. When asked what they do when they want to access their funds on weekends, R48 stated they were notified to get enough funds for the weekend on Fridays.
In an observation on 7/23/2024 at 11:15 am, the business office hours were noted to be Monday through Friday 9:30 am to 4:30 pm. These business office hours were posted on the door of Accounts Receivable.
In an interview on 7/16/2024 at 11:17 am, the Former Social Service Director (SSD) stated that residents didn't have access to withdraw their funds after 3:00 pm and on the weekends.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations, interviews, record review, and review of facility policies, the facility failed to provide a safe and sanitary homelike environment, when staff failed to provide residents clean...
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Based on observations, interviews, record review, and review of facility policies, the facility failed to provide a safe and sanitary homelike environment, when staff failed to provide residents clean bedding, clean clothing, and clean bath linens on the second and fifth floor; failed to maintain the ceiling/roof in good repair on the second floor and failed to provide an environment free of persistent odors on the third floor. The census was 189.
Findings include:
1. Facility Policy Statement titled Supplies and Equipment, last reviewed August 2023 documented, staff must use assigned equipment and supplies with care to promote safety, and equipment and supplies must be ready for use at all times of the day and night to serve the residents' needs.
A review of the facility policy titled, Residents Rights last revised in 2016 documented the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely.
During an interview on 6/26/2024 at 5:42 pm, Certified Nursing Assistant (CNA) FF, revealed staff had endured extensive problems with linen shortage over the last five months and stated occasionally residents ran out of clean linens.
During an interview on 6/26/2024 at 5:49 pm, CNA GG on the fourth floor revealed linen shortage was a big concern. CNA GG stated linen was kept on the first floor, and the first floor was a restricted area. Staff do run out of clean linens all the time specifically when laundry staff are gone for the day and added nursing staff occasionally must wait for the laundry department to report to work, which usually takes a day. CNA GG stated several residents were kept soiled due to a lack of clean linen.
During an interview on 6/26/2024 at 6:15 pm, CNA HH revealed they got frustrated with the laundry department's ability to keep a sufficient supply of linen for the residents. CNA HH stated there was a lot of uncovered beds in the facility and explained the linen shortage was due to inconsistency with laundry staff and stated the laundry room was always locked.
During the interview on 6/26/2024 at 6:20 pm, CNA II revealed clean linen was a problem on her shift and stated laundry staff were not helpful. CNA II stated the laundry room was not accessible as the laundry staff kept the laundry room locked. Residents were kept soiled for long periods due to a lack of clean linen.
Observation and interview with LPN AAA, who has worked at the facility for three months, of the second-floor linen closet on 6/26/2024 at 8:30 pm revealed no linens at all. LPN AAA stated, This is where the linens are supposed to be. She continues to state that linens have been an issue for some time. The staff have been complaining about it and are hoping to resolve that.
Observation of the fifth-floor linen carts on 6/26/2024 at 8:40 pm revealed three linen carts, one in each hall with bare linen on the carts and no linen in the linen closet. Interview at this time with CNA UUUUU revealed she has worked here for one year. She stated there are no large towels, but staff can go down to get some in the laundry room the carts are refilled for each shift and if more is needed before the cart comes up, they go and get more from another cart. CNA UUUUU acknowledged some linen shortages at times.
During observation and interview on 7/1/2024 at 11:10 am, R49 was dressed in a gown with dark brown stains. R49 stated the facility had not returned her clothes from the laundry department for three days.
During observation and interview on 7/1/2024 at 11:45 am, R50 revealed the facility laundromat was unable to supply linen when needed. R50 stated she used the same sheets for several days at any given time. R50 stated staff always reminded her they were out of clean sheets because there was no staff working in the laundry department.
During an interview on 7/10/2024 at 4:19 pm, the previous Director of Nursing (DON) JJJ revealed, facility administration was aware of complaints regarding soiled residents for extended periods due to lack of sufficient linen at the facility.
An interview with the current DON BB on 7/16/2024 at 10:30 am revealed, in the past, the facility rarely assisted staff with required clean linen.
During an interview on 7/16/2024 at 2:55 pm, Assistant Environmental Services (AES) PPP revealed, in the past the facility had insufficient linen. AES PPP stated a week ago the facility ordered additional linen, enough to supply the residents for seventy-two hours. AES PPP stated prior to the current shipment there was not enough linen for the residents.
Observation and interview on 7/18/2024 at 12:50 pm, R25 stated she did not have clean clothes to wear and explained staff never returned her clothes from the laundromat.
During an interview on 7/22/2024 at 10:59 am, the previous Administrator WWW, revealed she was employed by the facility from January 2024 through March 2024. Administrator WWW revealed during her tenure, the facility struggled with a limited supply of linen. Administrator WWW stated there were piles of dirty residents' linen in the laundry room area.
In an interview on 7/24/2024 at 10:47 am, the Resident Council President, R48, revealed the laundry and linen issues are on the third shift. Staff do not get linens so when the residents have an accident at night they must wait until the morning for fresh linens. R48 stated, I don't know why they do that.
During an interview on 7/30/2024 at 11:13 am, CMA LLLL stated she has been employed at the facility since 6/26/2023 revealed on 7/26/2024, Emergency Medical Technicians (EMTs) brought a patient into the facility, without a bed being made. Staff had to go to the basement to get some linens. The laundry room is locked so they go floor to floor to look for linens. The day shift gets all the linen and the night shift doesn't get any linens.
During an interview on 7/31/2024 at 10: 25 am, Administrator AA continued that the linen shortage is still an issue and will be an issue until they figure out what is causing the inventory to be low. Just recently someone threw three bags of clean linen in the trash.
A review of a Purchase Order created on 6/7/2024 and delivered on 6/29/2024 revealed the following 12 each/dozen:
Bath Towels: 14
Draw sheets: 15
Fitted sheets: 5
Flat sheets: 15
Patient gowns: 2
Pillowcase: 15
Reusable under pads: 5
Wash clothes: 1
A review of the document titled Linen Inventory revealed an inventory list from 5/2/2024, 6/1/2024, and 7/1/2024. The document included bath towels, washcloths, pads, fitted, flat, and draw sheets, pillows, pillowcases, gowns, blanks, and bath blankets. Several categories were noted to have items missing or thrown out. It was also noted that they need more linen on hand and more education for staff on linen use. More linens were ordered based on the 7/1/2024 inventory.
A review of email communication dated 7/16/2024 from the EVS Director revealed Laundry Staff TTTTT was hired on 7/16/2024 and Laundry Staff SSSSS returned from FMLA on 7/15/2024, who is assigned to residents' personal clothes. In addition, five staff members were on-site today, 7/16/2024, for laundry services.
2. Observation of the R25's bathroom on the second floor on 7/18/2024 at 12:50 pm, showed the bathroom ceiling drooped down. The ceiling was noted with dark brown stains. An interview with R25 revealed she had been in the same room since 2/14/2024. R25 explained the roof had leaked and there was water damage.
During an interview on 7/23/2024 at 2:10 pm with the Maintenance Director (MD) VV revealed the roof needed to be replaced. Maintenance Director VV stated there was evidence of water damage in the R25's room. He stated the room would be addressed as soon as possible.
3. Review of the updated facility policy titled Housekeeping Policies and Procedures-Scheduled Cleaning, it is documented that the facility will maintain a clean and appropriate environment that facilitates the prevention and control of infections. It also allows for the resident of this facility to reside in a home that maximizes their comfort and provides them a clean-homelike environment.
A review of the Resident Council Meeting minutes dated 4/24/2024 at 4:30 pm, documented want rooms and hallways to smell good. The residents have asked for the hallway to smell good.
During an observation on 7/23/2024 from 10:27 am to 11:43 am, an offensive odor was permeating through the third floor of the facility. This initial observation was made heading to an interview in the Activities Director's office at 10:27 am that is located on the third floor of the facility. After the interview ended at 11:43 am, the odor was still notable.
During an observation on 7/24/2024 at 10:47 am through 12:02 pm, an offensive odor was permeating through the third floor of the facility.
During an Interview on 7/24/2024 at 10:47 am, R48 confirmed the offensive odor that had been notable on that third floor. R48 stated that housekeeping does not perform deep cleaning of resident rooms and suspects housekeeping has not mopped the floors in a long time.
Interview on 7/25/2024 at 2:08 pm, Housekeeping IIII stated they have worked all four floors at the facility. Housekeeping IIII confirmed that there was a smell on the third floor, however, the housekeeping staff tried to manage it by washing the bases down.
An interview with Administrator AA on 8/1/2024 at 1:14 pm revealed when she first started at this facility, there were complaints about odors in the elevators and all the halls. At that time, they started doing deep cleaning on all the halls. She was unaware of any current complaints on the third floor. The third floor is scheduled for deep cleaning on Thursdays; however, no deep cleaning has been done since the surveyors were in the building.
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 F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy titled, Hydration and the Elderly and High-Risk ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy titled, Hydration and the Elderly and High-Risk Population, the facility failed to ensure hydration was easily accessible for four of eight sampled residents (R) (R34, R37, R38, and R48) reviewed for hydration. This failure placed the residents at risk of dehydration and increased health complications.
Findings included:
A review of an undated facility policy titled, Hydration and the Elderly and High-Risk Population, revealed that residents with physical limitations, dementia, or Alzheimer's Dementia may not understand they feel thirsty and may not have the ability to request a drink. They may not have the physical ability to reach for a glass of water .Dehydration can affect the overall physical and nutritional status .A resident may become more confused, may fall, or develop a urinary tract infection if he/she becomes dehydrated. The facility team must work closely to address concerns as they are identified, have fluids available, and offer fluids throughout the day in various ways.
1. A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R34 was readmitted to the facility on [DATE] with diagnoses that included stroke with right-sided paralysis, adult failure to thrive, and urinary tract infections.
A review of the 3/22/2022 Dehydration Care Plan located in the Care Plan tab of the EMR revealed, R34 is at risk for dehydration or potential fluid deficit related to Medication side effects, infection, and risk for recurrent infection. Interventions included: Encourage R34 to drink fluids of choice of tea, juice, and water.
A review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/14/2024 revealed R34 had a staff assessed Brief Interview of Mental Status (BIMS) score of three which indicated she was severely impaired in cognition for daily decision-making, had no swallowing difficulties, and had a urinary tract infection (UTI) in the previous 30 days.
During an observation on 7/18/2024 at 11:35 am, R34 was lying in bed awake. There were no cups or pitchers of water on her over-bed table or end table. R34 used hand gestures to indicate that she could not hold a cup due to her paralyzed arm. R34 was asked if she needed a cup with a handle, and she nodded yes.
A review of Point of Care (Certified Nursing Assistant (CNA) documentation) revealed no documentation of monitoring fluid intake either between meals or at meals.
During an interview on 7/18/2024 at 12:37 pm, CNA BBBB stated, R34 doesn't like water on her over bed table. I have told them she needed to water on the other table. CNA BBBB was asked if she could hand a cup on her own. CNA BBBB stated, I have told them a handled cup would be better.
During an interview on 7/24/2024 at 12:01 pm, the Director of Nursing (DON) stated, R34 needs adaptive equipment for hydration. They also need to provide more liquids at the meals, at least three on each tray. The DON was asked how much liquid they currently provide on meal trays. She stated, Only one glass of liquid on the breakfast tray. The DON further stated, They need at least three, a glass of juice, cup of coffee/tea, water or milk on the trays.
During an interview on 7/25/2024 at 8:48 am, the Nurse Practitioner (NP) was asked about R34's hydration needs. The NP stated, I was just talking about hydration with the nurse today. You need to get them more water. The NP further stated, I think it could be better as a lot of people can't reach the cup, especially if they have paralysis. The NP was asked about an adaptive cup for R34 related to the paralysis. She stated, Rehab should be more involved in adaptive cups for her.
2. A review of the R37 face sheet revealed that R37 was admitted on [DATE] with the following diagnoses: multiple sclerosis, chronic kidney disease, and congestive heart failure.
A review of R37's care plan dated 6/6/2024 LPN QQQQ documented that R37 will be free of symptoms of dehydration and maintain moist mucous membranes, and good skin turgor, the care plan directed staff to encourage fluids unless clinically contraindicated. The care directed staff to monitor for signs and symptoms of dehydration, decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes.
A review of the admission MDS assessment dated [DATE] revealed R37's BIMS score was six out of fifteen which indicated R37 was severely impaired in her cognition and daily decision-making skills and required assistance with eating and drinking.
During an observation on 6/26/2024 at 6:28 pm revealed a ticket menu for R37 documented Thursday Dinner and dated 6/27/2024, the menu included hot dog on bun, [NAME], mustard 2 pc, baked beans 4 oz, creamy coleslaw- 4 oz, fruit cup ½ cup, coffee 8 oz and 8 oz whole milk. Observation of the R37 tray showed there were no liquids served. R37 stated staff did not offer him anything to drink and concluded staff rarely offered liquids during meals.
3. A review of the R38 face sheet admission Record revealed R38 was admitted on [DATE] with the following diagnosis: pressure ulcer of left buttock, quadriplegia, and gastroesophageal reflux disease.
A review of the admission MDS assessment dated [DATE] revealed R38's BIMS score was fifteen out of fifteen which indicated R38 was cognitively intact.
During observation and interview on 6/26/2024 at 6:35 pm revealed there were no liquids on R38's tray and R38 stated the food he was served was not nutritious stated he has a wound and stated he desires to eat a proper diet for his wounds to heal. R38 stated staff rarely offered water to drink during meals.
4. A review of the R48 face sheet admission Record revealed the following diagnosis: Paraplegia, Constipation, and Peripheral Vascular Disease.
A review of the MDS dated [DATE] revealed R48 had a staff assessed BIMS score of fifteen which indicated she was cognitively intact in her daily decision-making skills.
During an interview with NP VVV on 7/1/2024 at 11:50 am revealed that NP VVV raised dehydration concerns to facility staff on several occasions. NP VVV stated that the staff needed to make sure residents were getting sufficient water regularly. NP VVV revealed residents were not getting enough water and added dehydration was a major cause of dry mouth, fatigue, headaches, and joint pain.
During observation and interview on 7/1/2024 from12:01 pm through 12:45 pm, R48 revealed she was the resident council president, R48 stated, that during meals residents were never offered sufficient liquids with their meals, and dietary staff usually offered one 8-ounce cup of liquid with every meal. R48 stated on numerous occasions staff failed to offer liquids with melas and staff rarely passed out ice and water in between meals.
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 F0837
(Tag F0837)
Could have caused harm · This affected multiple residents
Based on record reviews and interviews, the governing body failed to ensure that the facility had adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meal...
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Based on record reviews and interviews, the governing body failed to ensure that the facility had adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meals for residents in a timely manner. The facility census was 189.
Findings included:
A review of the contract between the facility and (name) Care Services Group for dietary services revealed that the agreement was established on 7/1/2023. The agreement outlined that, Commencing on 7/1/2023 (the 'Start Date'), (name) will provide such dining management, supervision, labor, materials, and supplies as (name) as required, to provide the services identified on Exhibit A hereto ('Services') in accordance with the terms of this Agreement.
A review of the contract between the facility and (name) Care Services Group for housekeeping and laundry services revealed that the agreement was established on 7/1/2023. The agreement outlined that, Commencing on 7/1/2023 (the 'Start Date'), (name) will provide management and consulting services to Client in connection with Client's performance of housekeeping and laundry services on the premises of the Facility, and (b) procure and purchase the supplies and materials necessary for Client to perform the housekeeping and laundry services on the premises of each Facility. The agreement further stated, Ownership of all existing housekeeping equipment will be transferred by Client to (name) and (name) will allow Client to use such equipment to perform housekeeping and laundry services at each facility. Any repair of, replacement of, or addition to, housekeeping equipment will be (name's) responsibility.
A review of the list of (name) Services Dietary Managers from 9/1/2023 to the present revealed that there had been five dietary managers since September 2023 with managers being employed for two to three months.
A review of an email (dated 3/12/2024 at 1:36 pm) between Environmental Services addressed to the Administrator revealed an acknowledgment of invoices for towels and washcloths that were delivered on 2/20/2024.
A review of an email (dated 5/21/2024 at 10:30 am) between Environmental Services addressed to the Administrator revealed a request for approval for an order of small equipment needed and linen that was ordered to replace linens that had been discarded, under pads, fitted, and flat sheets, and gowns. It was noted that the order was created on 4/17/2024.
A review of an email (dated 6/3/2024 at 11:08 am) between Environmental Services addressed to the Administrator revealed a request for cleaning materials, laundry chemicals, staffing, small equipment including vacuums, mop sticks, house-keeping carts and wet/dry vac and paper towels/tissue dispensers.
A review of an email (dated 6/3/2024 at 1:57 pm) between Environmental Services addressed to the Administrator revealed a step-request for approval to order linens. Once the approval was given by the Administrator, then a second approval would be needed. It was noted that the order was approved by the Administrator at 2:20 pm on the same day.
A review of an email (dated 6/3/2024 at 2:27 pm) between Environmental Services addressed to the Administrator and the second party revealed that approval was requested due to the facility needing linens.
A review of an email (dated 6/11/2024) between the Administrator and Regional Food Service Director (RFSD) WW revealed that the Administrator was reaching out to the staff of (name) Services Care Group due to the dietary staff shortage. The email explained that the new Dietary Manager (DM) ZZZZ was becoming overwhelmed, and the fear was that she would leave soon.
A review of the supply invoices from October 2023 showed that there was an order placed for linens including pillowcases, flat and fitted sheets, towels, and washcloths.
A review of the supply invoices for briefs only showed that briefs were purchased on 5/4/2024 (60 cases), 6/1/2024 (45 cases), 6/8/2024 (47 cases), 6/15/2024 (42 cases), 6/22/2024 (38 cases). Additional briefs were purchased during other supply orders to include on 1/8/2024 (6 cases), 1/13/2024 (29 cases), 1/20/20024 (26 cases), 1/27/2024 (33 cases), on 2/3/2024 (40 cases), 2/10/2024 (50 cases), 2/17/2024 (35 cases), 2/24/2024 (32 cases), 3/2/2024 (40 cases), 3/16/2024 (40 cases), 3/23/2024 (60 cases), 3/28/2024 (16 cases), 4/06/2024 (45 cases), 4/13/2024 (50 cases), 4/20/2024 (40 cases), 4/27/2024 (40 cases), 5/11/2024 (47 cases), 5/25/2024 (40 cases).
During an interview on 6/26/2024 at 6:46 pm Assistant Environment Services (AES) PPP stated that she currently has six staff members including herself. AES PPP stated that they have done a massive hiring of about 10 people but are waiting for the background checks to clear. AES PPP stated that most of the current staff works from 7 am to 3 pm, two staff who works from 4 pm to 12 am, and one staff who works from 11 pm to 7 am. AES PPP also stated that residents on the 5th floor primarily dress out in their personal clothing daily and it's the residents on the other floors who utilize the gowns.
During an interview on 7/1/2024 at 1:43 pm with the Administrator AA stated that the vendor company cannot retain staff, and the staff leave for numerous reasons, but mainly because of the pay. Administrator AA stated that the staff work a lot of overtime because they're short-staffed. Administrator AA stated that she had the labor board on her back calling her, and she would explain that the company is a vendor company. Administrator AA further explained that the vendor company doesn't pay the staff according to how they work, for example, if the staff worked 89 hours and 90 hours they're going to pay them for 70 hours. Administrator AA further stated that is one of the issues that they have. She stated that they get them in, and can recruit them, but they won't stay. She stated that she doesn't think that anyone stays past two weeks after they get that first check, and the checks are not always on time. Administrator AA stated her hands were tied. Administrator AA stated that she has had to use her own money to buy pads, silverware, paper plates, and linens for the residents. Administrator AA stated that she was tired of buying the above items with her own money, but the residents are the only reason she stays because the residents deserve better. She stated that she is currently waiting to receive approximately $4800 of her personal money back for items that she has purchased. She stated that it is rumored that the vendor company is related to the member(s) of Corporate and despite what is not being done, Corporate will not employ another company. Administrator AA stated that the corporation micromanages.
During an interview on 7/13/2024 at 2:30 pm, the previous Administrator MMM, revealed she was employed at the facility from 10/23/2023 to 1/4/2024. During that period, the facility was unable to assist staff with adequate clean linen for the residents. Administrator MMM stated she placed several orders through corporate which were never approved. There was a facility-wide shortage of towels and there were no face cloths. Residents had no sheets to change or to cover themselves in bed. The facility had no clean linen and residents had no clean clothes and some residents lay on uncovered mattresses with no bed sheets. Administrator MMM made several requests to corporate, and her requests were never honored.
During an interview on 7/15/2024 at 10:46 am, with the previous Social Services Director (SSD) NNN revealed she worked at the facility from 2022 through June 2024. SSD NNN revealed she wrote several grievances that were brought to her attention, regarding the shortage of linen, and nothing was done at the corporate level. According to SSD NNN, the facility never purchased wipes for resident's use. NNN stated orders were never placed, received, or purchased. According to NNN, some housekeeping (HK) staff failed to report to work due to a lack of compensation. NNN added, that there were piles of dirty personal clothing and dirty linen in the laundry, and residents were left with no clothes to change and clean linen to use.
During an interview on 7/16/2024 at 2:58 pm, the AES PPP stated that there were instances where staff in housekeeping and laundry were not getting paid for the hours they had clocked in for. She stated that because of this, staff had walked off the job. AES PPP stated it was my understanding that sometimes CNAs would sign up to volunteer to work on the dietary department and laundry for a few days.
During an interview on 7/16/2024 at 4:03 pm Regional Director of Clinical Operations (RDCO) DDDDD stated that she had been in her current position since 2021. RDCO DDDDD was asked her opinion of what were some things that could be done to improve things at the facility, and she stated was more staff. When asked about the issues in dietary, housekeeping, and laundry department, the response was they needs more staff. When asked what kind of resources was needed for the building to improve upon the current issues, they stated the facility needs staffing and training and regional coverage to support the building. When asked about how she resolves issues in her building that she covers when it comes ot the dietary, laundry, and housekeeping issues, the regional stated she has the facility administrator would talk to the Chief Executive Officer (CEO) or Chief Operating Officer (COO) of the management company, and they would work with (name) on the issues that were brought up.
During an interview on 7/22/2024 at 10:59 am with previous Administrator WWW (acting Administrator from January 2024 to March 2024) who stated that she was the administrator at two different periods as the [NAME] President (VP) of Clinical Operations. Administrator WWW stated that there was an issue with linens. She stated that she and another former employee toured the laundry and noted that the facility had to use emergency items. Administrator WWW stated that there was a time when the washing machine was down. She stated that the washing machine needed to be repaired and it took three to four weeks for that to happen. Administrator WWW also noted that laundry services were not provided at that time. There were extensive issues with linens, laundry and the Registered Dietitian (RD) nutritional services were suspended due to non-payment. Administrator WWW lastly stated that in August or September of last year, a request was placed in for the flooring to be redone. She stated that they had to have the foundation drilled out, the pipe repaired, and then they had to have a whole new flooring put in. She stated that they got estimates from two companies. The estimates were submitted to corporate because the residents could not go into the dining room and enjoy their meals in the dining room. Administrator WWW stated that the residents were having to be fed in the nursing units in the day rooms. She reiterated that she knew that it was August or September of last year when they began getting the quotes to repair the flooring. She lastly noted that the Administrator before her may have started getting the initial estimates before her.
Subsequent information provided noted that the initial quote for the vinyl plank flooring was given on 10/31/2023. The roofing estimate was given on 1/23/2024.
During an interview on 7/23/2024 at 2:10 pm with the Maintenance Director (MD) VV revealed the roof needed to be replaced.
During an interview on 7/23/2024 at 1:37 pm Certified Nursing Assistant (CNA) UUUU stated that about two weeks ago the food was late, due to staffing. When we run into staffing problems in the kitchen, none of us are too good to go into the kitchen. CNA UUUU stated that the Sunday (6/23/2024) before surveyors entered the building, she had to help in the kitchen.
During an interview on 7/29/2024 at 1:20 pm Certified Medication Administration (CMA) VVVV stated that when the facility switched over to the new company, we didn't get paid on our pay date and it was very late in the day, and some staff members walked out. CMA VVVV stated that this occurred around January 2024 but stated that she wasn't in the facility at that time due to being on vacation at that time, but she heard about it when she came back. CMA VVVV further stated that the prior administrator and Director of Nursing (DON) were offering bonuses, and the new company did not give out the bonuses.
During the Quality Assurance Performance (QAPI) interview on 7/31/2024 at 10:06 am with Administrator AA revealed that issues that have been identified for the months of May, June, and July 2024 included laundry, linens, housekeeping, supplies and dietary issues.
During an interview on 7/31/2024 at 6:37 pm Central Supply (CS) XXXX stated that he orders supplies every week, and it is mostly briefs and wipes. CS XXXX stated that the staff were using too many briefs and wipes. CS XXXX stated that he would put out the briefs and wipes out on a Friday and when he would return on a Monday, the supplies would be gone.
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
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement, the facility failed to implement an effective Quality Assurance and Performance Impro...
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Based on record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program to resolve ongoing concerns related to resident grievances and laundry services. The facility census was 189.
Findings included:
A review of the updated facility policy titled, Quality Assurance Performance Improvement Plan documented this facility's leadership intends to conduct an ongoing quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified programs and identify opportunities for improvement.
A review of Resident Council minutes dated 9/27/2023, 10/24/2023, 11/29/2023, 12/27/2023, 2/28/2024, 3/27/2024, 4/24/2024, and 5/29/2024 revealed continued concerns related to laundry, missing clothing items, linen, and diaper shortage, and shortage of personnel and supplies.
A review of the QA Committee Minutes for May 2024 revealed extra linen needed to be ordered.
Interview on 7/16/2024 at 11:17 am, the previous Social Services Director (SSD) NNN provided an account of several months where the facility experienced a linen shortage. She stated it had been a problem since November 2023 and remained a constant problem until s/he left in June 2024. Several grievances were provided to the housekeeping manager; however, they were never returned to the previous SSD NNN. Grievances regarding personal clothing and linen were provided to the housekeeping manager during the morning report where the Administrator was present. SSD NNN provided details from her notes regarding the continued concerns related to linen shortage, missing personal clothing, and shortage of briefs from 2/3/2024 through 3/3/2024.
During an interview on 7/31/2024 at 10:06 am, Administrator AA stated that the issues identified in the May 2024, June 2024, and July 2024 QAPI meetings included laundry, linen, supplies, maintenance issues, and dietary issues. She stated that based on what is in the QAPI meeting agenda, the issues identified in February 2024 included maintenance, and not responding timely to grievances. In January 2024, the issues identified included staffing issues due to them utilizing agency and linen issues.
During the interview on 7/31/2024 at 10: 25 am, Administrator AA revealed that supplies and linen shortage is still an issue and will be an issue till they figure out what is causing the inventory to be low. Just recently someone threw 3 bags of clean linen in the trash.
Cross Refer F585 and F584.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy titled, Enhanced Barrier Precautions, the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during care for one of three residents (R) (R53) reviewed for high-contact care.
Findings included:
A review of facility in-service training titled, Enhanced Barrier Precautions, dated March 2024, revealed, .Enhanced Barrier Precautions (EBP)- include the use of gloves and gown when caring for residents with chronic wounds or indwelling medical devices during high-contact resident activities .Residents requiring EBP (gowns and gloves for care) include chronic wounds, wounds with dressings . Gloves and gowns are to be worn when providing the following high-contact resident activities. Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting. Any care that requires close contact .
A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R53 was admitted to the facility on [DATE] with diagnoses that included a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), a gastrostomy tube (a feeding tube which provides nutrition to people who cannot eat by mouth) and dementia.
A review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/6/2024 revealed R53 was severely impaired in cognition, was dependent on staff for all activities of daily living (ADL) care, had one stage four pressure ulcer, and received nutrition via a gastrostomy tube.
During an observation on 7/23/2024 at 10:00 am, Certified Nursing Assistant (CNA) YYY and CNA GG were observed setting up supplies to give R53 a bed bath. Neither CNA was observed to be wearing a gown. CNA YYY removed her gloves and left the room, upon returning to the bedside, she donned new gloves without using hand hygiene. CNA YYY removed R53's brief and with the same gloves, cleaned the front peri area. R53 was turned onto her right side by CNA GG and the soiled brief, with feces, was removed. CNA YYY did not remove her soiled gloves after she placed the soiled brief into the plastic bag. With the same gloves, and without performing hand hygiene, CNA YYY removed the draw sheet, obtained a clean washcloth, and cleaned her buttocks. CNA YYY and CNA GG were asked if they had been in-serviced on EBP and what the requirements were when providing high-contact care, such as a bed bath. CNA YYY shrugged and stated, I don't know.
During the same observation, at 10:09 am, Licensed Practical Nurse (LPN) EE entered the room and set up her supplies to perform wound care on R53. LPN EE placed her supplies on the overbed using a barrier, however, the supplies were next to the plastic container being used by CNA YYY for R53's bath. LPN EE applied double gloves but was not observed to wear a gown during the high-contact care. LPN EE was asked if she was aware of the EBP requirements when providing high-contact care such as wound care. LPN EE stated, Barrier precautions are resident-to-resident, and you are supposed to wear a gown when providing high-touch care. LPN EE was asked if she wore a gown during wound care. She stated, No, I didn't. LPN EE further stated that the Infection Preventionist (IP) was going around and putting up signs. LPN EE stated, I don't think there was a gown for me to use on the cart outside the door. LPN EE was asked if the facility had enough personal protective equipment (PPE) such as gowns and gloves, which were readily available for staff use. LPN EE stated, Yes.
An observation of the linen cart, outside R53's room, revealed there were no gowns for staff use during high-contact care, and there was no PPE cart readily available outside the resident room.
During an interview on 7/23/2024 at 10:40 am, the IP stated, I think there has been confusion related to EBP. We might need to reevaluate EBP. I am going to get with the Administrator and change the policy. The IP was asked what she meant by reevaluate. She stated, To get rid of EBP.
During an interview on 7/29/2024 at 9:24 am the IP confirmed that she and the Unit managers on each floor are responsible for educating on EBP.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on Staff/Resident interviews, record review, and review of the facility's policies titled, Resident Grievances and Resident Council and Family Group, the facility failed to ensure that resident ...
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Based on Staff/Resident interviews, record review, and review of the facility's policies titled, Resident Grievances and Resident Council and Family Group, the facility failed to ensure that resident grievances were resolved within 72 hours.
Findings included:
During a review of the facility's policy titled, Resident Grievances, revised 12/20/2020, it was revealed that the intent of this policy is to support each resident's right to voice grievances of any nature with the assurance that the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress towards resolution. The policy continued to state, the grievance review period will be completed within 72 hours, unless explanation is provided to the induvial as to why the review period requires an extension period.
During a review of the facility's policy titled, Resident Council and Family Group, revised 5/8/2024, it was revealed that the facility will consider the views of a resident or family group and act promptly upon the grievances and recommendations of such group concerning issues of resident care of life in the facility.
A review of Resident Council minutes dated 9/27/2023 at 3:00 pm revealed that the topics of discussion include laundry, meals regarding the sandwiches that have been served at night, the facility cleanliness, and implementation of the color-coded hags per floor.
A review of Resident council minutes dated 10/24/2023 at 2:30 pm revealed that the topics of discussion include missing clothing items and linen and diaper shortage
A review of Resident Council minutes dated 11/29/2023 at 3:00 pm revealed that the topics of discussion include laundry issues regarding personal items not being returned to the residents.
A review of Resident Council minutes dated 12/27/2023 at 3:00 pm revealed that the topics of discussion include cold food, offensive odors in the facility, food palatability, and staff shortage.
A review of Resident Council minutes dated 2/28/2024 at 3:00 pm revealed that the topics of discussion included a shortage of personnel and supplies, and no linens and briefs.
A review of Resident Council minutes dated 3/27/2024 at 4:00 pm revealed that the topics of discussion included laundry bags and supplies on the floors.
A review of Resident Council minutes dated 4/24/2024 at 4:30 pm revealed topics of discussion to include the dining hall menu, offensive odor, color-coded laundry bags per floor for laundry and linen, and inquiry about the completion of the dining room.
A review of Resident Council minutes dated 5/29/2024 at 3:00 pm revealed the topics of discussion included, the dining room opening and residents assisting in making food menus.
During an interview on 6/27/2024 at 9:48 am, the Facility Ombudsman (FO) III revealed that the dining room has been out of service since October 2023. Under each new Administrator, the FO III stated each would say they were working on it. Some of the residents have stated they do not like eating in their rooms, because they did like the experience of dining with others and have also stated concerns with the increase of bugs in their rooms. Residents and family members have complained that quite often their meal tickets do not match what is served. This includes the main meals. The food is also cold, they're not being served on hot plates. The meals are also served on paper plates with a paper plate covering them.
During an interview on date 2:27 pm to 3:35 pm, revealed either Social Service (SS) XXX or Social Service (SS) WWWW will fill out the grievance form and give them to the respective department heads. Once the grievance is initiated, SS XXX will make the department head aware of the time frame in which a grievance should be completed. Per SS XXX, the grievance should be completed within 48 hours.
On 7/2/2024 at 11:58 am, the FO III, revealed the major complaints the residents have had were about the food quantity, quality, and timing. Additionally, the residents have stated the issues with housekeeping and laundry persist.
During an interview on 7/8/2024 at 3:40 pm, the Administrator stated anybody can file a grievance. They can slide it under the administrator's door or under the social workers door. Administrators usually get a copy and then give it to their department because they have 72 hours to get them turned back into me and then I usually go over them with my social workers. The grievances that come from the Resident council meetings are processed the same way a grievance is process.
During an interview on 7/15/2024 at 10:43 am, the Former Social Service Director (SSD) confirmed the food at the facility had been ridiculous.
During an interview on 7/16/2024 at 11:17 am, the Former SSD provided an account of several months. Linen shortage had been a problem since November 2023 and remained a constant problem until s/he left in June 2024. Several grievances were provided to the housekeeping manager; however, they were never returned to the former SSD. The following grievances regarding personal clothing and linen were provided to the housekeeping manager during the morning report where the Administrator was present. The former SSD provided the following details below from her notes:
2/3/2024- No linen for the weekend- staffing using bedspreads, pillowcases, and sheets to bathe residents
2/26/2024 - No Linen for the weekend
3/3/2024- Missing Personal Clothing
3/7/2024- Missing clothing
3/18/2024- No linen
4/3/2024- No linen
2/2/2024- Briefs- Multiple issues with not having briefs for residents.
Administrator and Central Supply notified.
Weekend of 2/17/2024- No Briefs
Weekend of 3/2/2024- No Briefs
Weekend of 3/23/2024- No briefs
During an interview on 7/22/2024, the Former Administrator WWW stated extensive issues with linens, laundry, and Registered Dietician nutritional services were suspended due to non-payment. The Former Administrator WWW stated the facility acquired a third-party vendor in September 2023. This vendor provided the facility staffing needs for the Housekeeping, Laundry, and Dietary departments. Since that happened, a lot of issues with those specific departments. The Former Administrator WWW also stated that the washing machine in the laundry was broken and took approximately three to four weeks to fix. The Former Administrator also added that the dining room floors had initiated the floors to be fixed in August/September of 2023.
During an interview on 7/24/2024 at 10:47 am, the Resident Council President, R48, revealed that meals have been an issue for a very long time. The portions are small the food is undercooked and served cold. R48 stated the residents have brought up the food issues for a long time and it doesn't seem to be getting resolved. R48 added that the food for about a week or two while the survey team was in the facility had improved but is curious to see what happens after the survey team leaves. R48 stated there is a lack of organization in the kitchen. As far as the laundry and linen issues, R48 stated the third shift do no get linens so when the residents have an accident at night they must wait till the morning for fresh linens. R48 stated, I don't know why they do that.
During an interview on 7/30/2024 at 11:13 am, Certified Medication Technician (CMT) LLLL stated they have issues with supplies regarding briefs and linens daily. The staff must go to other floors to see if they have some extra supplies there.
CONCERN
(F)
📢 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 most or all residents
Based on staff interviews, record reviews, and a review of the facility's Assessment tool the facility failed to have sufficient direct care staff coverage to achieve the highest practicable level of ...
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Based on staff interviews, record reviews, and a review of the facility's Assessment tool the facility failed to have sufficient direct care staff coverage to achieve the highest practicable level of well-being for all residents. The facility census was 189.
Findings included:
A review of the Facility Assessment Tool included a staffing plan to ensure sufficient staff met the needs of the resident at any given time. The positions for the staff needed for the facility census/population included Licensed and Registered Nurses providing direct care, Nurse aides, and other nursing personnel (e.g. those with administrative duties such as staff developer, case manager, Director of nursing, unit managers, PPS, MDS (Minimum Data Set), and Restorative Nursing), staff needed for behavioral healthcare services such as social services and Administrator, Dietician kitchen supervisor, food service director, cooks, and Dietary Aids.
A review of the December 2023 and January 2024 Facility two-week staffing Grid provided by the Staffing Coordinator and reviewed by the Administrator revealed no RN coverage for 1/6/2024, 1/7/2024, and 1/20/2024.
During an interview on 7/1/2024 at 1:43 pm, the Administrator stated that s/he received a call around 7:20 am to 7:35 am that two dietary cooks did not show up on 7/29/2024. The Administrator advised the caller to I told them to call their supervisor, the Former Dietary Manager (FDM) ZZZZ at that time. According to the Administrator, FDM ZZZZ had called around 8:50 am that they overslept. When the Administrator arrived at the facility, the Assistant Administrator had already been at the facility to begin cooking breakfast. They were about two hours behind with meals and FDM ZZZZ never showed up. The Administrator stated that by the time the Assistant Administrator got to the facility, there were some Certified Nursing Assistants (CNAs) downstairs in the kitchen trying to get stuff started. The Administrator stated although s/he appreciated that, they were hired for patient care. The Administrator revealed that there were several instances where CNAs were doing duties outside of their job description. As such, the Administrator had implemented a signup sheet where staff could sign up to work in the dietary, laundry, or housekeeping but not while they are scheduled to work as CNAs.
A review of Resident Council minutes dated 12/27/2023 at 3:00 pm revealed that the topics of discussion included cold food, offensive odors in the facility, food palatability, and staff shortage.
During an interview on on 7/16/2024 at 9:49 am, the Director of Nursing (DON) stated for instance laundry was short-staffed and CNAs volunteered to work extra hours outside of their scheduled CNAs hours to help. The DON stated, I'll come to work and help in the kitchen so just trying to make it work. The DON continued that they were short-staffed in the kitchen like everywhere else in the building but yeah so we just kind of pitched in to help out.
During an interview on 7/16/2024 at 11:17 am, the Former Social Services Director (SSD) revealed that certified nursing assistants and Nursing staff were pulled to Dietary on the following dates Weekend of 4/13/2024, 4/27/2024, the weekend of 5/11/204 and 6/1/2024.
During an interview on 7/16/2024 at 2:58 pm, the Assistant Environmental Services (AEVS) revealed that there were instances where staff in housekeeping and laundry were not getting paid for the hours they had clocked in for. Because of this, staff had walked off the job. The AEVS was not sure if CNAs were working in the laundry or housekeeping during their scheduled working hours where they were expected to be on their respective floors to provide direct patient care. However, AEVS stated it was my understanding that sometimes CNAs would sign up to volunteer to work on the dietary department and laundry for a few days.
During an interview on 7/17/2024 at 10:29 am, the Former Director of Nursing (DON) OOO revealed that s/he had made multiple attempts to reach out to the management company about the lack of staff and RN coverage for multiple shifts. The Former DON OOO stated there were multiple days s/he had to work multiple shifts to ensure weekend RN coverage. The Former DON OOO also added that there were multiple occasions no RN for the day shift.
During an interview on 7/17/2024 at 11:55 am, the Former SSD revealed that There were a couple of times when staff quit because they weren't paid. The third-party vendor provided the staff with both dietary and housekeeping/laundry. In the last three months, they have lost two dietitians and three dietary managers, two of whom were terminated and one who quit. The direct care staff for both departments worked and didn't get paid. There are deficiencies in management and scheduling that are not the fault of the line staff.
A review of a facility document provided by the Administrator titled NCOB cleanup Crew Sing up sheet revealed that as recently as 7/8/2024, the staff is still signing to work additional hours in laundry or housekeeping.
CONCERN
(F)
📢 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
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews, the facility failed to ensure that essential equipment was maintained in a safe and operable manner related to wheelchairs, ice machines, and the...
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Based on observations, interviews, and record reviews, the facility failed to ensure that essential equipment was maintained in a safe and operable manner related to wheelchairs, ice machines, and the walk-in freezer.
Findings included:
A record review of the facility policy titled, Maintenance Service last revised in April 2022, revealed the following:
Maintenance service shall be provided to all areas of the building, grounds, and equipment.
Policy Interpretation and Implementation. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at, all times. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards.
1. During an interview on 7/1/2024 at 11:10 am R49 stated she had been unable to utilize her wheelchair for months due to the brakes not working. She stated that despite her repeated efforts and notifications to the maintenance department, nothing had been done to repair her wheelchair.
During an interview on 7/1/2024 from 12:00 pm, R48 stated that on 6/1/2024, Registered Nurse (RN) SSSS attempted to maneuver her wheelchair and placed the gear in reverse and the wheelchair malfunctioned. She stated that she had been unable to utilize her wheelchair since then and expected that the facility was going to make the necessary repairs. she stated that she declined to use a regular wheelchair when the maintenance department offered her one and explained she was paralyzed on one side and was unable to utilize a manual wheelchair.
During an interview on 7/8/2024 at 10:01 am, Maintenance Director VV revealed part of his job description was to repair wheelchairs and to repair inoperable equipment. He stated residents with wheelchairs that were beyond repair were provided with a new chair and explained that R48's wheelchair was beyond repair.
During an interview on 7/8/2024 at 2:24 am, Social Worker XXX revealed the process regarding inoperable equipment is to notify the maintenance department through a ticket system. She stated she would expect the maintenance department to make the necessary repairs including fixing inoperable wheelchairs for the residents, however, the facility does not assist residents with electrical wheelchair concerns. Social Worker XXX stated R48 reported a grievance regarding her electrical wheelchair which was out of service and that she spoke to R48 regarding her wheelchair. Social Worker XXX stated on 6/1/2024, Certified Nursing Assistant (CNA) RRRR observed RN SSSS in R48's wheelchair and confirmed that the wheelchair was operable until RN SSSS attempted to operate R48's wheelchair.
During an interview on 7/8/2024 at 4:12 pm, Administrator AA stated she explained to R48 facility would provide R48 with a manual wheelchair. She stated that she was unaware that R48's wheelchair malfunctioned while RN SSSS was riding R48's wheelchair. She stated that the facility would be responsible for the specific repairs.
2. During observation and interview on 7/1/2024 at 3:05 pm, Dietary [NAME] PP opened the ice machine which was observed to be inoperable. They stated that it had not been functional for over two weeks.
During an interview on 7/1/2024 at 3:50 pm, Licensed Practical Nurse (LPN) RR revealed that the ice machine located on the Fourth Floor had been inoperable for over a month. LPN RR stated the maintenance department was made aware. They stated that the maintenance department takes several months for equipment to be repaired.
During an interview on 7/1/2024 at 4:07 pm, CNA TT revealed the ice machine on the Fourth Floor was inoperable and explained staff usually have to rely on the ice machine located on the First Floor, but now the First Floor icemaker was down and inoperable as well.
During an interview on 7/1/2024 at 4:01 pm, Maintenance Worker SS stated that they were aware that the ice machines on the Fifth Floor and Second Floors were inoperable.
3. During observations on 7/11/2024 at 3:05 pm, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees Fahrenheit (F).
During observations on 7/13/2024, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F throughout the day.
During observations on 7/15/2024 at 8:49 am, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F.
During observations on 7/16/2024 at 10:45 am, the walk-in freezer in the kitchen revealed an internal temperature of 23 degrees F.
During an interview on 7/31/2024 at 10:52 am, Dietary Manager GGGGG, confirmed that the walk-in freezer had not been able to keep the required holding temperatures.
CONCERN
(F)
📢 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 F0924
(Tag F0924)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were securely affixed to the wall and had end c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that handrails were securely affixed to the wall and had end caps on four of five floors (Second Floor, Third Floor, Fourth Floor, and Fifth Floor).
Findings included:
A review of the facility policy titled, Maintenance Services, dated April 2022, revealed that maintenance services shall be provided to all areas of the building, grounds, and equipment . Maintaining the building in good repair and free from hazards.
During an initial observation on 7/18/2024 at 9:05 am on the Fifth Floor, the following issues were identified:
~The handrail under the sign 510-518 had a loose end cap, and the handrail was unsecured at that point at the wall.
~The handrail under the sign 519-527 was missing an end cap to the handrail and had exposed metal.
~The handrail under the dayroom sign had a missing end cap with exposed metal. The handrail was loose and not secured tightly to the wall.
~The handrail on the left side of the hall, as you enter the day room was loose and not tightly secured to the wall.
During an observation on 7/22/2024 at 8:18 am on the Second Floor, the following issues were identified:
~The handrail to the right of the sign which read, Janitor closet, was loose and not tightly affixed to the wall.
During an observation on 7/22/2024 at 8:25 am, on the Third Floor, the following issues were identified:
~The handrail under the fire extinguisher door in the middle hall was loose and not tightly affixed to the wall.
~The long handrail, on the right going into the dining room, the end cap was missing, and the handrail was not tightly affixed to the wall.
~The handrail under the sign 310-318 was not tightly affixed to the wall.
~The handrail next to room [ROOM NUMBER] was missing and duct tape was covering the opening.
During an observation on 7/22/2024 at 8:35 am, the following issues were identified on the Fourth Floor:
~The handrail to the left of room [ROOM NUMBER] was not tightly affixed to the wall.
~The handrail under the fire extinguisher sign on the north side was not tightly affixed to the wall.
During an interview on 7/22/2024 at 8:48 am, the Maintenance Director and Assistant Maintenance Director both confirmed the loose handrails. They stated that due to low staffing, they have not been able to complete the inspection of the handrails. The Maintenance Director stated, We know there are lots of things that need to be done however, we had not been told about the handrails.
CONCERN
(F)
📢 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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policy titled facility policy, titled Pest Control ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policy titled facility policy, titled Pest Control Policy, the facility failed to have an effective pest control program in place. The census was 189.
Findings included:
A review of the facility policy titled Pest Control Policy last reviewed on 11/15/2022, documented that the policy aims to ensure that, as far as possible, pests (rats, mice, roaches, ants, fruit flies, silverfish, etc.) within the premises are kept to an absolute minimum with the ideal being eradication but due to the resilience and persistence of some species this ideal is impossible to achieve. The Pest Control Contractor shall rid the premises of pests using only approved pesticides and maintain the locations to the required standard for the duration of the contract. The contractor will also respond to unscheduled requests to effectively rid the premises of further pests. The contractor will supply all goods and materials to carry out the service.
A review of the Pest Prevention Service Report (dates 9/26/2023 through 6/24/2024) revealed that the pest control company was present on site on the following dates and treated for the following pests:
On 9/26/2023 pest control treated for crickets.
On 10/13/2023 pest control treated for crickets, ants, and flies around the dumpster.
On 10/16/2023 pest control treated for crickets.
On 11/6/2023 the facility was billed for pest prevention, but no details for treatment were given.
On 12/11/2023 the facility was billed for pest prevention, but no details for treatment were given.
On 1/16/2024 rat traps were placed out and roach gel was put out in the facility.
On 1/22/2024 pest control serviced the kitchen area and physical therapy by applying fly bait to the doors and treated the drains in the kitchen area for fruit flies.
On 1/29/2024 pest control serviced and cleaned utilities on all floors for roaches.
On 2/5/2024 pest control treated the interior and ground-level hallway in the laundry room and bathrooms with granules and rodent stations. Pest control also serviced the dumpster with fly granules.
On 2/12/2024 pest control serviced all floors with 48-hour rodent traps, it was noted that the facility had recently caught rodents with previously installed 48-hour traps.
On 2/29/2024 pest control treated drains on the third floor in the shower rooms and kitchenettes, the drains in the kitchen and dishwasher area, and the floor drains for fruit flies.
On 2/26/2024 pest control treated the kitchens and utility rooms on all floors.
On 3/4/2024 pest control service the interior and the exterior of the building, dumpster, interior on basement level entryways, common areas around employees, lockers, bathrooms service exterior with granules, max force, and fly baits. It was noted that drains, kitchens, and kitchenette utility rooms on floors were treated where fruit flies had been reported.
On 3/11/2024, pest control serviced, cleaned, and inspected all rodent stations and 48-hour traps on all floors. Pest control also treated drains with chemicals for fruit flies.
On 3/18/2024 pest control treated the kitchen area to include the drains, floor drains and sinks, and bathroom drains for fruit flies.
On 3/25/2024 pest control treated drains on all floors, kitchenettes, and utility rooms for fruit flies.
On 4/5/2024 pest control documented that roaches were reported to have been seen at all nurses' stations and residents' rooms. Pest control was treated for roaches during this visit.
On 4/15/2024 pest control was treated for ants in offices and treated dumpster for flies.
On 4/22/2024 pest control treated the kitchen for siting of rodents and switched our fly glue board and fly light.
On 5/15/2024, pest control serviced the exterior building and dumpster with fly bait and one resident's room for ants.
On 5/13/2024 pest control treated the first-floor conference room for ants (reported by maintenance). This service summary also noted a need for an order for fruit flies.
On 5/24/2024 pest control serviced the center of the building, hallways, service drains and kitchen area for fruit flies and with fly lights. Pest control also treated the office area for ongoing ants.
On 5/29/2024 pest control noted that maintenance reported ongoing issue with fruit flies that was reaching to residents' rooms. Pest control documented that the treatment that was being used was, over and above standard contract treatment, and discussed problems with food being left around the kitchenette, nurses' stations, and other cleaning issues.
On 6/3/2024 pest control treated the exterior building and dumpster for rodents.
On 6/17/2024 pest control was serviced for fruit flies. Pest control noted that after speaking with maintenance it was believed that fruit flies were riding the meal carts from the kitchen area and getting onto the residents' floors.
On 6/24/2024 pest control treated kitchen drains again for fruit flies. It was noted that residents' rooms were found to have issues that could be increasing pests, such as remnants of food and a bowl underneath a table and dishes with food. It was also noted that directives to clean up and maintain cleaning to avoid further fruit fly issues were discussed.
During an observation on 6/26/2024 at 5:10 pm, flies and gnats were observed in room [ROOM NUMBER]B. The resident in that room stated that the flies and gnats had been there for a while. Certified Nursing Assistant (CNA) LL revealed flies were a major concern for two months.
During an observation in the kitchen on 6/26/2024 at 5:20 pm, a live fly was flying around in the kitchen in the food prep area.
During an observation on 6/26/2024 at 5:29 pm, a live gnat flew around in the conference room.
During an interview on 6/26/2024 at 7:05 pm, Licensed Practical Nurse (LPN) KK revealed that flies were a concern and stated that maintenance was made aware. LPN KKK stated several residents had raised concerns regarding flies in their rooms.
During an observation on 6/26/2024 at 8:46 pm, a live fly was observed in the conference room on the table.
During an observation on 6/27/2024 at 8:47 am, the kitchen door that leads to the outside was ajar about seven inches.
During an interview on 6/27/2024 at 9:48 am, the Ombudsman stated there was an issue with rats in the kitchen earlier in the year. She further stated that the facility had rats in the kitchen, but she had always observed that the kitchen's back door was always ajar. She stated that there have also been resident complaints related to the fruit flies in resident rooms.
During an observation on 6/27/2024 at 10:07 am a live fly was observed on a chair in the conference room.
During an observation on 6/27/2024 at 2:24 pm the outside kitchen door was opened.
During an observation on 7/1/2024 at 8:31 am the door to the kitchen that leads to the outside that is located towards the parking lot was propped open. There was a rock used to prop it open.
During an observation on 7/1/2024 at 8:41 am and 9:20 am, the outside kitchen door was observed to be still open.
During an interview on 7/1/2024 at 9:40 am, Maintenance Director VV revealed the facility was infested with fruit flies and flies and that the facility was working on eliminating the spread of fruit flies, with the assistance of a specified pest control company. Maintenance Director VV stated residents and staff voiced concerns related to mice in the kitchen area and flies in resident rooms.
During an interview on 7/1/2024 at 10:01 am, Assistant Maintenance Director XX stated that not too long ago there had been some issues with rats downstairs in the kitchen area. He stated that residents have complained about rats in the hallways and on the second floor. Assistant Maintenance Director XX further stated that gnats have been a huge issue because residents have food and flowers in their rooms.
During an interview on 7/1/2024 at 10:34 am Certified Medical Technician (CMT) NN stated she had seen live mice and flies in the building. She stated that the residents have complained to her about the fly infestation in their rooms.
On 7/1/2024 at 10:39 am, R25 was observed lying in her bed. Her breakfast tray was observed unconsumed on the bedside table with four slices of bacon, bread, and oatmeal. Multiple fruit flies were observed flying around the room and landing on the food. R25 stated that she was unable to enjoy her meal because of the excessive amounts of fruit flies in her room. R25 added that the fruit flies had been a concern for over a month and concluded she had reported her concerns to several staff members.
On 7/1/2024 at 3:10 pm, an observation of the first-floor pantry revealed a plethora of small dark brown particles along the edge of the wall and in the corners. [NAME] PP stated that the small particles were mouse feces. Further observations along the edges of the wall area showed there was evidence of mice infestation in the kitchen area. [NAME] PP confirmed they were aware, and that pest control placed mouse traps around the facility.
During an interview on 7/1/2024 at 3:20 pm, Dietary Aide QQ stated there was evidence of mice in the kitchen. He stated that he observed mouse droppings in the pantry and on the kitchen floors.
During an interview on 7/1/2024 at 3:36 pm the Assistant Maintenance Director XX revealed the small dark droppings in the kitchen pantry showed mouse infestation was a concern.
During an observation on 7/2/2024 at 8:28 am the door to the kitchen leading outside towards the parking lot was propped open. There was a rock used to prop it open.
During an observation on 7/02/2024 at 8:49 am the outside kitchen door was opened with a rock inside to keep it ajar.
During an interview on 7/2/2024 at 9:28 am Maintenance Director VV stated the facility had a pest control program, but he was not confident its ability to eliminate the flies.
During an observation on 7/2/2024 at 3:26 pm a dead fly was observed on the table in the conference room.
During an observation on 7/3/2024 at 12:40 pm a dead fly was observed on the table in the conference room.
During an observation on 7/5/2024 at 8:51 am the kitchen door that leads out to the parking lot was left ajar.
On 7/15/2024 at 9:50 am, a live fly was observed in the conference room.
Sept 2023
13 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean, comfortable, and homelike environment for 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean, comfortable, and homelike environment for 189 of 189 residents who resided at the facility.
Findings include:
During observations from 9/4/2023 - 9/7/2023, the fifth-floor hallway walls and dining room walls were observed to have holes, peeling paint, and scratches. [NAME] splatters were observed on the wall in the dining room closest to the nurses' station.
During an observation on 9/4/2023 at 10:30 AM, the three elevators utilized to access floors one through five were observed to be very odorous of urine.
During an observation in the middle elevator on 9/4/2023 at 10:48 AM, there was a strong pervasive urine odor, and the floor was very sticky.
During an observation on 9/4/2023 at 11:27 AM, a Geri-chair (geriatric chair with lap table), in the hall outside room [ROOM NUMBER], was observed to have a heavy build-up of dirt, grime, and dried food particles on the back and insides of the chair.
During an observation on 9/4/2023 at 12:05 PM, R87's room was observed to be very odorous of urine and the floor had food particles around and under the bed.
During an observation of room [ROOM NUMBER], bed A, on 9/4/2023 at 12:03 PM, the overbed table was observed to have very worn edges and a missing wheel. Although no resident was assigned to bed A at the time of survey, the overbed table was unsightly and unusable.
During an observation on 9/4/2023 at 12:30 PM room [ROOM NUMBER] had ceiling molding that was observed to be pulled away from the ceiling over the door to the room.
During an observation on 9/5/2023 at 9:04 AM room [ROOM NUMBER] had an overbed table which was very worn around all edges. A television base was secured to the overbed table with the television placed face down on the bedside table.
During an interview on 9/7/2023 at 4:20 PM, the Maintenance Director (MD) stated the televisions were secured to the walls now. The overbed table was no longer used, however it had not been removed from room [ROOM NUMBER].
During an observation on 9/5/2023 at 9:04 AM, R87 was asleep across his bed. The floor around and underneath the bed was dirty with food particles.
Throughout the survey, from 9/4/2023 to 9/7/2023, the fifth-floor hallway walls and dining room walls were observed with multiple holes, areas of peeling paint, unpainted patched areas, and many black scratches along the walls.
A Resident Group meeting was held on 9/6/2023 at 11:00 AM in the first-floor dining room. Thirteen residents (R5, R11, R14, R37, R40, R55, R78, R89, R93, R94, R106, R157, and R163), whom the facility deemed cognitively intact to participate in the meeting, attended. When asked about the cleanliness of the facility, the residents said: They could do much better. It's not clean like it used to be. They're not cleaning enough, there's odors. During the meeting, the surveyor's shoes stuck to the carpet in the dining room.
During an interview with the Housekeeping Supervisor (HKS) and the MD on 9/7/2023 at 4:05 PM, the MD said they no longer had a contracted cleaning company as of 8/5/2023. The HKS said he typically worked in the maintenance department and had taken the housekeeping supervisor role temporarily. The MD said the carpet in the dining room was very old and that it was cleaned as needed. The HKS confirmed that the carpet was sticky as his shoes also stuck. The MD said they had just finished painting the fifth floor, three to four months ago and had an ongoing schedule to paint beginning in the day rooms. The MD said there was no formal process to audit for maintenance concerns, We rely on nursing staff to submit a ticket. Both the MD and the HKS said they had a plan to upgrade areas of the facility, however a written plan was not provided as requested.
In an interview on 9/7/2023 at 4:14 PM, the MD stated the fifth floor had just been re-painted about three to four months ago, but the wheelchairs and staff equipment scraped up the walls. He stated there was a plan to begin refinishing all the of the common areas but did not provide this plan prior to the survey exit on 9/7/2023 at 8:45 PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Transfer or Discharge, Emergency, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Transfer or Discharge, Emergency, the facility failed to ensure two (Resident (R) 140 and R179) of six residents reviewed for hospitalization received written notice of transfer to the hospital that included a statement of the resident's appeal rights and the contact information for the office of the Ombudsman. The deficient practice had the potential to cause a lack of understanding of appeal rights and resources should the resident not be permitted to return or disagree with the reason for transfer.
Findings include:
Review of the facility policy titled Transfer or Discharge, Emergency, dated 10/11/2021 and provided on paper, revealed, Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:
a. Notify the resident's Attending Physician.
b. Notify the receiving facility that the transfer is being made.
c. Prepare the resident for transfer.
d. Prepare a transfer form to send with the resident.
e. Notify the representative (sponsor) or other family member.
f. Assist in obtaining transportation; and
g. Others as appropriate or as necessary.
1. Review of R140's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. Review of the Census tab of the EMR revealed R140 was transferred to the hospital on 5/11/2023.
Review of R140's quarterly Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR, with an assessment reference date (ARD) of 5/10/2023, revealed she scored three out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. She was rarely/never able to make herself understood or understand others.
Review of the Notes tab of R140's EMR revealed she was transferred via ambulance to the hospital on 5/11/2023 following a fall with suspected fracture. R140 returned to the facility on 5/23/2023.
Review of R140's E-Interact Transfer Form, located in the Assessments tab of the EMR, revealed the form contained information regarding the reason for transfer, the location of the transfer, and the date of the transfer, as well as notice of the facility's bed hold policy. The form did not include information regarding the resident's appeal rights and information to file an appeal or the name, address, and phone number for the state Long-Term Care Ombudsman.
2. Review of R179's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE]. Review of the Census tab of the EMR revealed she was transferred to the hospital on 8/12/2023.
Review of R179's significant change MDS assessment, located in the MDS tab, with an ARD of 6/22/2023, revealed she scored 12 out of 15 on the BIMS, indicating moderate cognitive impairment. She was usually able to make herself understood and understand others.
Review of R179's E-Interact Transfer Form, located in the Assessments tab of the EMR, revealed she was sent to hospital via ambulance on 8/12/2023 at 4:00 AM for nausea and vomiting that did not respond to treatment in the facility. The form contained information regarding the reason for transfer, the location of the transfer, and the date of the transfer, as well as notice of the facility's bed hold policy. The form did not include information regarding the resident's appeal rights and information to file an appeal or the name, address, and phone number for the state Long-Term Care Ombudsman.
In an interview on 9/7/2023 at 1:08 PM, Licensed Practical Nurse (LPN) 1 stated when a resident was sent to the hospital, the responsible party was notified via telephone of the transfer if the resident was not alert and oriented. She stated the E-Interact Transfer Form was also completed and provided to the responsible party as well as emergency medical services and the receiving hospital. LPN1 stated she did not provide information regarding appeal rights or Ombudsman contact information.
In an interview on 9/7/2023 at 2:19 PM, the Administrator stated the facility provided a copy of the E-Interact Transfer Form to the resident's responsible party if a resident was not alert and oriented. She stated information regarding filing an appeal or contacting the Ombudsman was not included on this form and was not provided to a resident or their responsible party upon transfer to the hospital. The Administrator stated the facility only provided written notice of ombudsman contact and appeal rights upon 30-day notice for involuntary discharges but not for hospital transfers.
In an interview on 9/7/2023 at 3:30 PM, the Director of Nursing (DON) stated the facility provided the E-Interact Transfer Form upon transfer to the hospital but did not provide any additional information related to appeals or contacting the Ombudsman.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, and review of the facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) assessment for one (R...
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Based on record review, staff interviews, and review of the facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) assessment for one (Resident (R) 164) of 46 sample residents accurately reflected R164's nutritional status. This failure had the potential to lead to ineffective or inaccurate care planning for R164.
Findings include:
Review of the facility policy titled Resident Assessment Instrument (RAI) Policy, dated 10/7/2021, revealed, The MDS Coordinator and interdisciplinary team members complete the MDs using the data collected with medical record documentation, assessments, direct observation, and communication with staff and resident and/or resident's representative . The interdisciplinary team composes or reviews and revises a comprehensive person-centered care plan using information from the Minimum Data Set (MDS), Care Area Assessment (CAA) and other information gathered during the assessment process. This information helps the
interdisciplinary team to plan care that allows the resident to reach his/her highest level of practicable level of functioning . If an error is discovered in the Minimum Data Set (MDS) or Care Area Assessments (CAAs), the Assessment Coordinator and/or the interdisciplinary assessment team will follow the established processes for making corrections to the MDS in accordance with the Resident Assessment Instrument (RAI).
Review of R164's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility with diagnoses including protein-calorie malnutrition, gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of a feeding tube) status, and anemia.
Review of R164's quarterly MDS assessment, with an assessment reference date (ARD) of 6/27/2023, revealed she used a feeding tube for 26 percent (%) to 50% of her daily calorie intake.
Review of R164's Care Plan, located in the Care Plan tab of the EMR, revealed, [R164] is at an increased risk of altered nutritional status r/t [related to] dx [diagnoses] of malnutrition, dysphagia, anemia, wounds, swallowing/chewing difficulty, hx [history] of significant weight loss, and tube feeding providing a sole source of nutrition/hydration needs. Tube feeding provides 100% nutrition and hydration needs daily via PEG [feeding tube]. At risk for aspiration, dehydration and/or fluctuation in nutrition and weight.
Review of R164's 5/17/2023 Healthcare Registered Dietician Nutritional Assessment, located in the Assessments tab of the EMR, revealed the resident's tube feeding provided 2,340 calories per day, and she required 1,680 to 1,960 calories per day.
Review of R164's 6/20/2023 Dietary Note, located in the Notes tab of the EMR, revealed, Jevity 1.5 [an enteral feeding] @ [at] 65cc/hr [cubic centimeters per hour] x 24 hrs [hours] via PEG [percutaneous endoscopic gastrostomy]. Will change to Jevity 1.5 @ 65cc/hr x 20 hrs to prevent over [sic].
Review of R164's EMR under the Orders tab revealed an order, which originated on 6/24/2023, for tube feeding, Jevity 1.5 formula at 65 cc/hr for 20 hours each day. The Orders tab indicated a diet order for nothing by mouth (NPO).
In an interview with the registered dietician (RD) on 9/7/2023 at 10:27 AM, the RD stated R164 had an order for NPO, and she received all her nutrition via feeding tube. She stated she had not completed the nutrition section of the most recent MDS.
In an interview on 9/7/2023 at 12:00 PM, the MDS Coordinator (MDSC) stated R164's MDS was inaccurate, she did receive 100% of her nutrition via feeding tube. The MDSC stated the staff member who had completed the section was no longer employed at the facility, and a correction would be made immediately.
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
Based on observations, interviews, record review, and review of the facility policy titled, Activity of Daily Living Policy, the facility failed to ensure staff provided the necessary level of assista...
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Based on observations, interviews, record review, and review of the facility policy titled, Activity of Daily Living Policy, the facility failed to ensure staff provided the necessary level of assistance with positioning and food tray set-up to meet the needs of one (Resident (R) 173) of one resident reviewed for Activities of Daily Living (ADLs). Specifically, care plan interventions were not implemented to assist with positioning in bed and food tray set-up in accordance with accepted standards of practice, the care plan, and the resident's choices and needs and/or preferences.
Findings include:
Review of the facility's Activity of Daily Living Policy, dated May 2021 and last reviewed November 2022, revealed, . each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan .
Review of the electronic medical record (EMR) Diagnosis tab revealed diagnoses for R173 that included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, fracture of one rib, left side, severe protein calorie malnutrition, muscle weakness, abnormalities of gait and mobility.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/31/2023, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating R173 had intact cognition. Further review of the MDS revealed R173 required extensive assistance for bed mobility and setup or clean-up.
Review of R173's Care Plan dated 7/31/2023 revealed the resident required extensive assistance with two-person physical assist for transfer and eating required supervision with one-person physical assist.
Observation and interview of R173 on 9/6/2023 9:15 AM revealed resident was positioned in bed with the head of bed elevated. His feet extended past the bottom end of the bed. The bedside table was positioned on the left side of his bed. A breakfast tray was sitting on the bedside table but was out of reach for R173 to eat. R173 was extending his right arm and hand to reach his breakfast tray to eat breakfast. He said, I was asleep when the staff brought my breakfast tray, and it is my own fault that I have to reach to eat my cold breakfast.
Interview with Certified Nursing Assistant (CNA)4 on 9/6/2023 10:15 AM revealed that R173 chooses to sleep later than the scheduled breakfast delivery to his room. She stated that he did not call for help to assist him to reposition himself in bed and to access his breakfast tray.
Interview with Unit Manager (UM)2 9/6/2023 at 9:20 AM revealed that R173 required repositioning in bed and assistance with food tray set-up. He stated that he would request kitchen staff to send R173 a hot breakfast. He also stated that he tries to monitor staff to ensure they are implementing care-planned interventions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, and review of the manufacturer's guidelines, the facility staff failed to follow the proper administration process for a medication, Advair Diskus (used for tre...
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Based on observation, staff interviews, and review of the manufacturer's guidelines, the facility staff failed to follow the proper administration process for a medication, Advair Diskus (used for treating the symptoms of chronic obstructive pulmonary disease) for one of four residents (Resident (R) 339) during the medication administration pass. Specifically, R339 was not instructed to rinse his mouth out with water then split it out into a cup after Advair Diskus administration. The deficient practice had the potential to cause a fungal infection in the mouth for R339.
Findings include:
Review of the instructions for Advair Diskus from the pharmaceutical company, GlaxoSmithKline (GSK) that manufactures this medication located on the website for GSK at https://gskpro.com, revealed .Rinse your mouth with water without swallowing after each dose of Advair Diskus .
Review of R339's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab indicated R339 was admitted to the facility with diagnosis including but not limited to chronic obstructive pulmonary disease.
Review of R339's admission Minimum Data Set (MDS) located in R339's EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/31/2023, revealed a score for the Brief Interview for Mental Status (BIMS) 12 out of 15 which indicated R339 had moderately impaired cognition.
An observation was conducted on 9/5/2023 at 9:50 AM, during the medication administration pass in which Licensed Practical Nurse (LPN)2 administrated Advair Diskus one puff by mouth to R339. LPN2 did not instruct the resident to rinse his mouth out with water then spit it out into a cup to prevent a fungal infection in the resident's mouth.
During an interview on 9/5/2023 at 10:00 AM LPN2 stated, I didn't know that. LPN2 confirmed she did not know she should have instructed the resident to rinse his mouth out with water and then spit it out.
During an interview on 9/5/2023 at 10:10 AM Unit Manager (UM)4 stated, You are to have the resident take some water in their mouth and spit it out in a cup after they take Advair.
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, record review, resident and staff interview, and the review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure one (Resident (R) 104) of f...
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Based on observations, record review, resident and staff interview, and the review of the facility policy titled, Restorative Nursing Program, the facility failed to ensure one (Resident (R) 104) of four residents reviewed for range of motion (ROM) received a palm guard/orthotic as needed to address his limited range of motion in his right hand. The deficient practice had the potential for further reduction of ROM and/or mobility for R104.
Findings include:
Review of the facility policy titled, Restorative Nursing Program dated 11/15/2022 and provided on paper, revealed, Restorative Nursing Documentation Guidelines: Splint or Brace Assistance:
Describe interventions and effectiveness of teaching interventions used to improve or maintain resident's self-performance in applying, manipulating, and caring for the brace or splint (e.g., Resident applied left leg brace with verbal cues and task segmentation). Document physician's orders that specify the type of brace, location for application, frequency, and duration. Describe activities used to maintain resident's performance in putting on and removing the prosthesis Document presence or absence of complications: Pain or discomfort; Skin status issues, redness, warm to touch, swelling, necrosis or pressure ulcer. Describe the effectiveness of the brace or splint use. Compare the current level with the baseline to demonstrate progress towards established goals.
Review of R104's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side.
Review of R104's annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/23/2023 and located in the MDS tab of the EMR, revealed he scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. He was usually able to make himself understood and understand others. R104 did not exhibit any behavioral symptoms, including rejection of care. He required extensive assistance with dressing and had impaired functional range of motion on one side in both the upper and lower extremities.
In an interview with R104 in the dining room on 9/4/2023 at 12:58 PM, R104 stated he was unable to move the fingers of his right hand. He stated he had a brace for the hand at night, but he lost it two days ago. R104's right hand was observed in a tight fist without any orthotic device to protect the palm of his hand or aid in positioning of the right hand.
Review of R104's Orders tab of the EMR revealed there was no order for use of hand splint/palm protector at night. An order for occupational therapy was initiated on 7/23/2023, to continue through 9/30/2023.
Review of R104's 9/1/2023 Occupational Therapy Treatment Encounter Note, located in the Therapy tab of the EMR, revealed, Patient continues to wear orthotic device without any signs of swelling, skin breakdown, bruising, or pain.
Review of R104's 6/7/2021 Care Plan revealed,[R014] receiving restorative program. [R104] has hx [history] of refusing to wear splint (AFO [ankle foot orthosis] to the R [right] lower extremity). The approaches included assisting the resident with ambulation and sit to stand exercise and referring the resident to therapy as needed. The Care Plan also documented, The resident has R sided hemiplegia/hemiparesis r/t [related to] stroke but did not include use of an orthotic device for the hand.
During subsequent observations, R104 was again observed without any orthotic device on his right hand, which remained contracted into a fist:
-On 9/4/2023 at 3:31 PM, R104 was observed asleep in bed without any device on his right hand.
-On 9/5/2023 at 9:13 AM, R104 was observed seated in his wheelchair in the dining room without any device on his right hand.
-On 9/6/2023 at 2:50 PM, R104 was observed seated in his wheelchair in the dining room without any device on his right hand.
-On 9/7/2023 at 11:36 AM, R104 was observed seated in his wheelchair in the dining room without any device on his right hand.
In an interview on 9/7/2023 at 11:20 AM with Certified Nurse Aide (CNA) 12, she stated she thought R104 had a hand splint that he was to wear while up in his chair during the day. She stated the CNAs were responsible for putting the splint on and she did not know why he was not wearing a hand splint. She stated it may be missing, as the resident could misplace it at times if he removed it himself. CNA12 stated there was no documentation related to use of a splint for R104. When asked how CNAs would know he needed the splint, she stated, I just know because I've seen him with it before.
In an interview on 9/7/2023 at 11:30 AM, the Restorative Nurse Aide (RNA) stated R104 was not on a restorative program, and she did not know whether he used a hand orthotic or not.
In an interview on 9/7/2023 at 1:10 PM, Licensed Practical Nurse (LPN) 1 stated R104 had a hand splint but often refused to wear it. She stated she thought this information was on his Care Plan.
In an interview on 9/7/2023 at 1:42 PM, the Occupational Therapist (OT) stated R104 refused to wear his hand splint, so he was referred to therapy for follow-up. She stated R104 agreed to wear a palm guard at night, because he thought it was too restrictive to wear during the day. She stated the resident had not refused to wear the palm guard at night, per her knowledge. The OT stated there should be a physician's order for the use of the palm guard, so the nursing staff was aware of the need to put on the palm guard at night and document its use and any refusals. The OT stated she was not aware of the resident's claim the palm guard had been lost, and stated, it's usually in his top drawer. She stated she was unaware there was no physician's order for the use of the palm guard and did not know whether the intervention had been communicated to the CNAs or if the CNAs documented the palm guard's use.
In an interview on 9/7/2023 at 3:34 PM, the Director of Nursing (DON) stated if there was a physician's order for the palm guard, it would show up on the CNAs' documentation and they would chart its use. She stated she was unaware there was no order for or documentation of the palm guard.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to lock the medication cart when the nurse was n...
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Based on observations, interviews, record review, and review of the facility policy titled, Storage of Medications and Biologicals, the facility failed to lock the medication cart when the nurse was not in attendance for one of eight carts; and failed to store medications in a locked medication cart for one Resident (R) 340 of four residents in the medication administration pass observation. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.
Findings include:
Review of the facility policy titled, Storage of Medications and Biologicals with a revision date of September 2017, revealed All Medication, Treatment carts must be secured/locked when not attended by licensed staff.Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.
1. During the medication administration pass observation on 9/5/2023 at 9:30 AM, Licensed Practical Nurse (LPN)2 was asked by a resident for a cup of ice. LPN2 went up the hallway and obtained a cup of ice at the pantry located behind the nurses' station desk. When LPN2 passed back by the medication cart going to the resident's room, LPN2 stopped and locked the medication cart.
During an interview on 9/5/2023 at 9:59 AM, LPN2 stated, It was unlocked, and I locked it back when I came back. She stated, I knew it had to be locked.
2. Review of the undated R340's Face Sheet located in the electronic medical record (EMR) under the Profile tab, indicated R340 was admitted to the facility with diagnoses including but not limited to fracture of the collapsed vertebra in the thoracic region, congestive heart failure and severe protein-calorie malnutrition.
Review of the admission Minimum Data Set (MDS) under the MDS Tab in the EMR, with the Assessment Reference Date (ARD) of 9/1/2023 coded the resident as having a Brief Interview Mental Status (BIMS) of 11 out of 15 which indicated R340 was moderately cognitively impaired.
During an observation on the medication administration pass on 9/5/2023 at 9:20 AM, LPN2 sat the medication in a medicine cup down on R340's overbed table and left the room to get gloves off her medication cart. The medicine cup with the pills were left where they could not be seen when LPN2 left (R)340's room.
During an interview on 9/5/2023 at 9:57 AM LPN2 stated she could not see the pills when she left the resident's room. She stated, I should have taken them with me.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, and record review, the facility failed to ensure one (Resident (R) 21) of three residents reviewed for dental services received assistance to obtai...
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Based on observation, resident and staff interviews, and record review, the facility failed to ensure one (Resident (R) 21) of three residents reviewed for dental services received assistance to obtain dentures. This failure had the potential to contribute to weight loss and nutritional problems due to a dislike of a mechanically altered diet, decreased self-esteem, and increased discomfort for R21.
Findings include:
Review of R21's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility with diagnoses including adult failure to thrive, dysphagia, and diabetes.
Review of R21's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 6/12/2023, revealed he scored three of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. He was usually able to make himself understood and understand others. R21 had no mouth or dental problems.
In an observation and interview with R21 in his room on 9/4/2023 at 11:08 AM, the resident stated he did not have any natural teeth and had been waiting to find out what happened with a plan to get dentures. He stated he had been waiting for months to hear about beginning the process to obtain dentures and stated he was unable to chew regular foods. R21 stated he received a soft diet, but wanted to receive a regular diet and did not like soft foods. R21 was observed without any teeth.
Review of R21's 8/2/2022 Dental Exam and Treatment/Exam note, located in the Miscellaneous tab of the EMR, documented he did not have any natural teeth and documented, Pt [patient] is edentulous (lacking teeth) - desires dentures. Review of the EMR revealed no follow up records regarding R21's desire for dentures.
In an interview 907/2023 at 12:51 PM, Social Services Worker (SS) 1 stated R21 received a courtesy dental consult on 8/2/2022 because he did not have a source of payment for dental services. She stated dentures were not pursued at that time because he did not have a source of payment. SS1 stated R21 recently switched insurance, and she would be contacting the insurance company to begin the process for dentures; however, she was unable to state any attempts since 8/2/2022 to find alternative sources of dentures for R21. SS1 added R21 received a mechanical soft diet because he did not have teeth and could not chew regular foods.
In an interview on 9/7/2023 at 3:31 PM, the Director of Nursing (DON) stated she would expect social services to follow up on a resident's desire for dentures and seek out options in the case of insufficient funding.
In an interview on 9/7/2023 at 5:55 PM, the Social Services Director (SSD) stated R21 did not have a payor source until he signed up with a new insurance provider, and dental services should now be covered for him. She stated R21 never reported any acute issues related to pain of problems eating or filed any grievances related to acquiring dentures; however, had he complained of any issues, he would have been sent to a free clinic or investigated other available community resources for follow-up.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and review of the facility policy titled, Documentation Policy, the facility failed to ensure the medical record for one (Resident (R) 286) of 46 sample reside...
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Based on record review, staff interview, and review of the facility policy titled, Documentation Policy, the facility failed to ensure the medical record for one (Resident (R) 286) of 46 sample residents accurately reflected the resident's condition. This failure had the potential to lead to care needs not being met for R286.
Findings include:
Review of the Documentation Policy, initiated October 2018 and reviewed 11/3/2022, revealed, The resident's medical record is a legal document and may be used as evidence in a court of law. Therefore, the record must be accurate, legible, and complete . Copy and Paste practices are discouraged to ensure accuracy of information.
Review of R286's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility with diagnoses including multiple sclerosis, seizures, encephalopathy, and rhabdomyolysis (a serious medical condition that occurs when damaged muscle tissue releases its proteins and electrolytes into the blood).
Review of R286's Orders tab of the EMR revealed an order for an antibiotic, ciprofloxacin, 500 milligrams (MG), two times a day for urinary tract infection, which originated on 7/23/2022. The order was discontinued on 7/26/2022.
Review of R286's July 2022 Medication Administration Record (MAR), found under the Orders tab of the EMR, revealed the ciprofloxacin was administered twice a day on 7/23/2022, 7/24/2022, and 7/25/2022. The record indicated the order was discontinued on 7/26/2022.
Review of R286's 7/26/2022 Pacleaders Soap Note, located in the Notes tab of the EMR, documented, Patient seen today. Recent ordered urine culture shows < [less than] 10,000 Staphylococcus. On assessment he denies dysuria (pain or discomfort when urinating). He denies any subpubic discomfort. He is currently on Cipro [ciprofloxacin] prophylactically for UTI [urinary tract infection] which is resistance [sic] to organism. He denies any concerns this visit. He is in no acute distress . Assessment and Plan: Patient taking medication that is resistant to organism. Organism is < 10,000. No need for treatment. D/C [discontinue] ciprofloxacin.
Review of R286's EMR under the Notes tab revealed inaccurate documentation regarding administration of ciprofloxacin after the medication was discontinued:
-On 7/27/2022, a Skilled Evaluation note Patient continue on PO [oral] ABT [antibiotic] ciprofloxacin 500 MG 1 tablet by mouth two times a day for UTI for 7 days. No averse [sic] reaction noted.
-On 7/28/2022, a Skilled Evaluation note documented, Patient continue on PO ABT ciprofloxacin 500 MG 1 tablet by mouth two times a day for UTI for 7 Days. No averse [sic] reaction noted.
-On 7/30/2022, a Skilled Evaluation note documented, Patient continue on PO ABT ciprofloxacin 500 MG 1 tablet by mouth two times a day for UTI for 7 Days. No averse [sic] reaction noted.
-On 7/31/2022, a Skilled Evaluation note documented, Patient continue on PO ABT ciprofloxacin 500 MG 1 tablet by mouth two times a day for UTI for 7 Days. No averse [sic] reaction noted.
The author of the above notes was no longer employed at the facility as of 8/31/2022 and was unavailable for interview.
In an interview on 9/7/2023 at 8:30 PM, the Director of Nursing (DON) stated the documentation on 7/27/2023 through 7/31/2022 regarding antibiotic use was not accurate, as the resident's antibiotic had been discontinued on 7/26/2023 and another one had not been started.
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observations, resident and staff interviews, and review of the facility policy titled, Call System/Light, the facility failed to ensure the call system for one (Resident (R) 7) of 47 sampled ...
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Based on observations, resident and staff interviews, and review of the facility policy titled, Call System/Light, the facility failed to ensure the call system for one (Resident (R) 7) of 47 sampled residents was functioning. This failure created the potential for R7's needs to go unmet or an inability to summon staff in an emergency.
Findings include:
Review of the Call System/Light policy, dated 10/20/2022, revealed, The purpose of the Resident Call System shall allow residents to call for staff assistance through a
communication system that relays the call directly to a staff member or to a centralized staff work area . Equipment: 1. Bedside call light in functioning order 2. Emergency call light in working order . Report any defective call lights to charge nurse and the maintenance department immediately.
Review of R7's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility with diagnoses including hypertensive heart disease, peripheral neuropathy, dementia, anemia, depression, insomnia, muscle weakness, lack of coordination, and abnormal gait.
Review of R7's quarterly MDS assessment, with an assessment reference date (ARD) of 8/2/2023, revealed she scored three of 15 on the Brief Interview for Mental Status (BIMS) indicating R7 was severely cognitively impaired. R7 required limited assistance with bed mobility and extensive assistance with transfers, walking in her room, and toilet use. She was able to ambulate independently but had unsteady balance. R7 experienced one fall with no injury in the previous three months.
Review of R7's 4/12/2023 Care Plan, located in the Care Plan tab of the EMR, revealed, [R7] is moderate risk for falls r/t [related to] gait/balance problems, incontinence, and psychotropic medication use. The approaches included, Be sure [R7's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
In an interview with R7 in her room on 9/4/2023 at 10:56 AM, the resident stated her call light was not working. She stated she did not know how long it had not been working, and added, it just lays on the bed but don't [sic] do nothing. A concurrent observation revealed the call system at the resident's bedside and in the bathroom did not activate when pressed and did not alert the staff of a call either visually or audibly.
During a subsequent observation in R7's room on 9/6/2023 at 11:45 AM, both the call lights in the bathroom and at the bedside were still not functioning.
In an interview on 9/6/2023 at 11:44 AM, Certified Nurse Aide (CNA) 12 stated R7 used the call light at times when she needed help in the bathroom, but she often would come out to the nurses' station independently to request assistance in her room when needed. The CNA stated she was not aware the call system in R7's room was not working.
In an interview on 9/6/2023 at 12:01 PM, Licensed Practical Nurse (LPN) 1 stated R7 sometimes used her call light, but usually would walk out to the nurses' station to ask for assistance when needed. She stated she was not aware the resident's call system was not working. LPN1 tested the call system in R7's room and bathroom and stated they were not functioning and did not alert the staff to a call either via the light above the door or the alert system at the nurses' station. LPN1 then called the maintenance department to report the issue.
In an interview on 9/6/2023 at 12:06 PM, the Certified Medication Aide/Technician (CMAT) stated R7 used her call light at times but also came out to the nurses' station to request assistance. The CMAT stated she was not aware R7's call light was not working.
In an interview on 9/7/2023 at 4:14 PM with the Maintenance Director (MD), he stated the call system in R7's room was fixed on 9/6/2023. He added the maintenance department did not have a process to audit the call system for proper functioning, and he relied on the nursing staff to identify and report any issues. The MD stated the staff had not reported R7's call system was not working prior to 9/06/2023.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on resident and staff interviews, record review, and review of the facility policies titled, Call System/Light and Food Preferences, the facility failed to ensure the facility made prompt effort...
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Based on resident and staff interviews, record review, and review of the facility policies titled, Call System/Light and Food Preferences, the facility failed to ensure the facility made prompt efforts to resolve continued resident grievances regarding food choices and call light response time. This failure affected the resident council and six residents who voiced concerns (Resident (R) 433, R14, R435, R434, R20, and R21) of 47 sampled residents. The deficient practice created the potential for care needs to go unmet or a lack of staff response in case of emergency.
Findings include:
A. Call Light Response Grievances
1. Resident Council Grievances
Review of the Resident Council Minutes from February 2023 to August 2023, provided on paper, revealed continued grievances regarding call light wait times:
-The 7/26/2023 minutes documented, Lights not being answer [sic] in a timely manner.
-The 5/31/2023 minutes documented, Call light is staying on for a long period of time.
-The 2/22/2023 minutes documented a resident stated she laid without some assistant [sic] from staff.
The Resident Council Minutes did not document any resolution or corrective actions taken for the above concerns.
A Resident Group meeting was held on 9/6/2023 at 11:00 AM in the first-floor dining room. Thirteen residents (R5, R11, R14, R37, R40, R55, R78, R89, R93, R94, R106, R157, and R163), whom the facility deemed cognitively intact to participate in the meeting, attended. The residents were asked if they had to wait for staff to take them to the bathroom. The following statements were made: Yes, it's worse at shift change. Yes, we have waited up to two hours or not assisted at all. At times we're told to wait for the next shift. Sometimes they turn off the light and don't come back. We've complained about this. It doesn't change.
2. Individual Grievances
Review of the May 2023 to September 2023 Grievance forms, provided on paper, revealed continued concerns regarding call light wait times with no documented resolution:
a. Review of R433's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility with diagnoses including prostate cancer, history of falls, chronic kidney disease, hypertension, Guillain-Barre syndrome, and dysphagia.
Review of R433's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/21/2023, revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. He was able to make himself understood and understand others. R433 required extensive assistance with bed mobility, transfers, personal hygiene, and toilet use.
Review of R433's 8/28/2023 Care Plan, located in the Care Plan tab of the EMR, revealed, [R433] is at risk for falls r/t [related to] Guillain-Barre, decreased safety awareness, history of falls in the community. The approaches included, Be sure [R433's] call light is within reach and encourage [R433] to use it for assistance as needed. [R433] needs prompt response to all requests for assistance.
Review of R433's 8/29/2023 Grievance/Complaint Form documented, It is alleged that the member potentially experienced inadequate treatment while inpatient since 8/15/2023 as the call button is not responded to in a timely manner while it takes an hour or longer. The facility's response was completing staff education on call lights and a call light audit. The attached Random Call Light Audit forms documented nine lights were audited on 8/21/2023, 8/22/2023, and 8/23/2023 and an additional seven lights were audited on 8/25/2023, 8/26/2023, 8/28/2023, and 8/29/2023. The audits documented the following wait times over 15 minutes:
-8/21/2023, 3:00 PM to 3:27 PM (27 minutes);
-8/22/2023, 9:37 AM to 10:00 AM (23 minutes);
-8/22/2023, 3:55 PM to 4:13 PM (18 minutes);
-8/23/2023, 2:30 PM to 2:53 PM (23 minutes); and
-8/26/2023, 7:30 PM to 7:50 PM (20 minutes).
Though the form documented the instruction, Please provide education where needed, there were no comments to indicate education was provided or who the responsible staff were.
b. Review of R14's admission Record revealed she was admitted to the facility with diagnoses including paraplegia, hypertension, muscle weakness, and chronic pain.
Review of R14's quarterly MDS assessment, with an ARD of 8/10/2023, revealed she scored 15 out of 15 on the BIMS, indicating intact cognition. She was able to make herself understood and understand others. R14 required extensive assistance with bed mobility and toilet use, and total assistance with transfers.
Review of R14's 5/8/2018 Care Plan revealed, [R14] is risk [sic] r/t impaired mobility, incontinence. She has weakness of lower extremities with a dx [diagnosis] of [history of] polio, spinal tumor.
Review of R14's 7/26/2023 Grievance/Complaint Form documented, Stated her light was on for a long period of time and she call [sic] the desk and was told that the CNA [certified nurse aide] could not come and she is still [in another room]. The facility's response was completing staff education on call lights and a call light audit. The attached Random Call Light Audit documented four lights were audited from 7/26/2023 to 7/28/2023. The audit documented the following wait times over 15 minutes:
-7/2/2023, 3:45 PM to 4:05 PM (20 minutes) and
-7/28/2023, 4:14 PM to 4:30 PM (16 minutes).
Though the form documented the instruction, Please provide education where needed, there were no comments to indicate education was provided or who the responsible staff were.
c. Review of R435's admission Record revealed he was admitted to the facility with diagnoses including Parkinson's disease, diabetes, stroke, seizures, and dementia.
Review of R435's admission MDS assessment, with an ARD of 6/26/2023, revealed he scored 11 out of 15 on the BIMS, indicating moderately impaired cognition. He was able to make himself understood and understand others. He required extensive assistance with bed mobility, transfers, and personal hygiene and total assistance with toilet use.
Review of R435's 5/9/2023 Care Plan revealed, [R435] is a high risk for falls r/t gait/balance problems. The approaches included: Be sure [R435's] call light is within reach and encourage the resident to use it for assistance as needed. [R435] needs prompt response to all requests for assistance.
Review of R435's 6/24/2023 Grievance/Complaint Form documented, [Family member] is concerned with call light response time and call light working. [Family member] states that [R435] has called her several times a day since admission stating he is not getting a response to his call light. [Family member] states she had to call the facility to get response from staff. The facility's response was to complete a call light audit. The attached Random Call Light Audit documented eight lights were audited on 6/27/2023 from 4:25 PM to 5:49 PM. The audit documented a wait time from 4:48 PM to 5:10 PM (22 minutes). Though the form documented the instruction, Please provide education where needed, there were no comments to indicate education was provided.
d. Review of R434's admission Record revealed she was admitted to the facility with diagnoses including congestive heart failure, dysphagia, muscle weakness, and bipolar disorder.
Review of R434's admission MDS assessment, with an ARD of 6/29/2023, revealed she scored 14 out of 15 on the BIMS, indicating intact cognition. She was able to make herself understood and understand others. R434 required extensive assistance with bed mobility and toilet use and limited assistance with transfers and personal hygiene.
Review of the Care Plan tab of R434's EMR revealed no care plan addressing call light usage.
Review of R434's 6/27/2023 Grievance/Complaint Form documented, Concerns for call light response. The facility's response was completing staff education on call lights and a call light audit. The attached Random Call Light Audit documented audits were completed on 6/30/2023 from 1:29 PM to 2:37 PM. The audit documented two of the three audited lights had a wait time over 15 minutes, from 1:29 PM to 2:00 PM (31 minutes) and from 2:09 PM to 2:37 PM (28 minutes). Though the form documented the instruction, Please provide education where needed, there were no comments to indicate education was provided or who the responsible staff were.
e. Review of R20's admission Record revealed he was admitted to the facility with diagnoses including diabetes, congestive heart failure, Bell's palsy, and history of falls.
Review of R20's quarterly MDS assessment, with an ARD of 8/25/2023, revealed he scored 15 out of 15 on the BIMS, indicating intact cognition. He was able to make himself understood and understand others. R20 required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene.
Review of R20's 6/10/2023 Care Plan revealed, [R20] is low risk for falls r/t impaired physical mobility. The approaches included, [R20] needs a safe environment with free from clutter; adequate, glare-free light; a working and reachable call light, and the bed in low position at night.
Review of R20's 5/25/2023 Grievance/Complaint Form documented, Resident reports his call light is not answered promptly. The facility's response was completing staff education on call lights and a call light audit. The attached Random Call Light Audit documented four lights were audited on 5/25/2023 and 5/26/2023. The audit documented a wait time on 5/25/2023 from 10:50 PM to 11:12 PM (22 minutes). Though the form documented the instruction, Please provide education where needed, there were no comments to indicate education was provided or who the responsible staff were.
3. Resident Interviews
a. Review of R21's admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility with diagnoses including adult failure to thrive, dysphagia, diabetes, muscle weakness, glaucoma, and blindness in one eye.
Review of R21's quarterly MDS assessment, with an ARD of 6/12/2023, revealed he scored three of 15 on the BIMS, indicating severely impaired cognition. He was usually able to make himself understood and understand others. He required extensive assistance with bed mobility, transfers, personal hygiene, and toilet use.
In an interview in his room on 9/4/2023 at 11:08 AM, R21 stated, They take a while to answer the call light; sometimes they don't come for hours. I have to start hollering to get someone to come in.
4. Staff Interviews
In a concurrent interview on 9/7/2023 at 12:01 PM with the Certified Medication Aide/Technician (CMAT) and CNA9, the CMAT stated she had heard many residents' complaints regarding call light wait times. She stated the staff tried to answer them as quickly as possible, but there were times when they were busy assisting another resident and could not answer right away.
In an interview on 9/7/2023 at 3:35 PM, the Director of Nursing (DON) stated a timely call light response was subjective and could be different for each individual and each situation. She stated, however, she felt a wait time of five to seven minutes was reasonable and would be concerned about any times over seven minutes. The DON stated in response to continued resident grievances regarding call light wait times, the facility conducted audits and staff education on answering call lights. The DON stated the unit managers also conducted random call light audits. The DON stated no additional actions had been taken to address the repeated concerns. The DON was asked to provide follow-up to the long wait times identified in the call light audits (above) and to provide the unit managers' random call light audit logs. This information was not provided by the survey exit on 9/7/2023 at 8:45 PM.
5. Policy Review
Review of the Call System/Light policy, dated 10/20/2022, revealed, Answer all call lights in a prompt, calm, courteous manner for assurance of resident's safety, aiding and to promote a home-like environment by reducing noise levels.
B. Resident Food Grievances
1. Resident Council Grievances
In the Resident Group Meeting, on 9/6/2023 at 11:00 AM, the thirteen residents in attendance had the following responses to questions about their meals:
We do not always get our food served like it's supposed to be, they miss items.
We do not always get enough food, especially when they serve cold sandwiches at night, that's not a meal.
Breakfast is cold, they don't deliver the trays very fast.
They don't send up enough bedtime snacks for everyone.
Some residents do not get help to eat because the CNA's have to pass trays or help, others don't help.
We do not want our meals 14 hours apart; we would get too hungry.
We tell them about the food, but nothing changes.
2. Resident Food Grievance Logs
The following concerns were noted in the facility Food Committee Meeting minutes:
On 7/11/2023, it was noted that Tickets don't match the tray.
On 6/13/2023, Long waits for food, was identified.
On 5/9/2023, it was stated that Food is cold, speed up the delivery.
On 2/7/2023, Late food coming to rooms on the weekend, was noted.
There was no follow-up to the resident food grievances documented.
3. Individual Grievances
Review of R96's electronic medical record (EMR) revealed a quarterly MDS with an ARD of 8/14/2023 located under the RAI (Resident Assessment Instrument) tab. The assessment recorded a BIMS score of 15 of 15 for R96, which indicated the resident was cognitively intact.
During an interview on 9/5/2023 at 9:45 AM, R96 stated the food served at meals was not hot. R96 specified the food served at breakfast had soggy bread and the food was terrible.
Review of R173's EMR revealed a quarterly MDS with an ARD of 7/18/2023 located under the RAI tab. The assessment recorded a BIMS score of 13 of 15 for R173, which indicated the resident was cognitively intact. During an interview on 9/4/2023 at 1:09 PM, R173 stated the food was served cold when he received meals in his room.
Review of R173's Diagnosis Report, dated 9/6/2023, revealed that R173 had a diagnosis of severe protein calorie deficiency. Review of the Physician's Order Summary Report revealed an order for consistent carbohydrate diet pureed texture with additional nutrients added.
During an interview on 9/4/2023 at 12:03 PM, R50 said They never get my food right, I said I don't like oatmeal, don't send it, I won't eat it, I want grits when they have them. R50 said the kitchen usually sends oatmeal and he doesn't eat it. R50 said, I'm 6 foot 6 inches and I'm hungry, you can't feed a man my size a tiny little bit of food.
During an interview on 9/5/2023 at 8:55 AM, with R50, he said he was Very disappointed in breakfast, there's minimal food, no meat, it's terrible.
4. Staff Interviews
In an interview with the Registered Dietician (RD), on 9/7/2023 at 10:15 AM, she said she would have to talk to the residents and review their preferences again. She said she has heard some complaints. We are transitioning. We got a new food vendor around 8/4/2023 and will be getting new menus soon. We are holding a monthly food meeting to review the menus and all residents are invited to attend the meeting. She said they do have a meal of the month. She stated they did have steam table issues and got a new steam table on 7/27/2023. She said some electrical issues with the steam table had to be resolved. When asked why only sandwiches were served for dinner, she said it was decided to have the heavier meal during lunch and a lighter meal for dinner.
5. Policy Review
Review of the facility's policy titled Food Preferences, dated 10/2/2017, line 11 revealed that the facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. Periodic reviews were not documented.
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 F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on record review, interviews, and review of the facility policy titled, Dialysis Care and Services, the facility failed to ensure ongoing communication between the facility and the dialysis unit...
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Based on record review, interviews, and review of the facility policy titled, Dialysis Care and Services, the facility failed to ensure ongoing communication between the facility and the dialysis unit following a residents hemodialysis treatment for two of three residents (Resident (R) 65 and R39) reviewed for dialysis services. The sample size was 47.
Findings include:
Review of the facility's policy titled, Dialysis Care and Services dated 10/20/2022, indicated the policy did not address ongoing communication between the facility and the dialysis unit regarding the resident's care.
Review of the dialysis contract dated November 14, 2014, revealed . Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD (End Stage Renal Dialysis) Dialysis Unit .
1. Review of R65's admission Record from the electronic medical record (EMR) under the Profile tab showed R65 was admitted to the facility with the diagnoses of malignant neoplasm of left kidney, end stage renal disease (ESRD), anxiety disorder, and major depression disorder.
Review of R65's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 8/18/2023 under the Resident Assessment Instrument (RAI) tab indicated R65 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R65 was cognitively intact.
Review of R65's EMR under the Assessments tab indicated numerous forms titled, COMS Pre/Post Dialysis Evaluation. A review was completed for a month's worth of the dialysis evaluation forms. It was noted the forms did not contain the post dialysis information that would have been completed by the dialysis unit on 9/1/2023,08/28/2023, 8/21/2023, 8/16/2023, 8/11/2023, 8/9/2023, 8/7/2023, and 8/2/2023.
During an interview on 9/7/2023 at 11:35 AM, regarding communication with dialysis, the Unit Manager (UM) 2 stated the facility staff completed an evaluation sheet which was sent with the resident to dialysis. UM2 explained the expectation was for the dialysis unit to return the evaluation form with the post dialysis medical information recorded on the sheet. UM2 said there were times when the information sheet was not returned or if returned it was blank. UM2 stated when no information was returned, they could have called the dialysis unit and obtained an update regarding the resident's current medical condition.
During an interview on 9/7/2023 at 3:50 PM regarding communication with dialysis, the Director of Nursing (DON) confirmed receiving post dialysis information from a dialysis unit can be a challenge. The DON confirmed the facility staff sent the pre dialysis information, but they did not always receive the post dialysis information from the dialysis unit. The DON stated when a resident returned from dialysis the facility nurses completed a clinical assessment on the resident. The DON said the facility staff should have called the dialysis unit if they did not receive documentation from the dialysis unit, in order to obtain a report. The DON confirmed when the facility nurses contacted the dialysis unit for a report, they did not document the communication in the resident's EMR.
2. Review of R39's undated Face Sheet under the Profile Tab in the EMR revealed R39 was originally admitted to the facility with diagnosis including but not limited to Stage 4 chronic kidney disease.
Review of the annual MDS under the MDS Tab in the EMR, with an ARD of 7/15/2023 coded the resident as having a BIMS of 14 out of 15 which indicated R39 was cognitively intact.
Review of R39's Pre/Post Dialysis Evaluation documentation under the Miscellaneous (MISC) tab in the EMR revealed forms dated 8/14/2023, 8/16/2023 and 8/28/2023. The Pre/Post Dialysis Evaluation forms were received back from the dialysis center, but they did not contain any documentation from the dialysis center back to the facility. There were no further notes in this section of the EMR for R39.
During an interview on 9/6/2023 at 2:30 PM, UM4 was asked about the communication that the dialysis center sent back to the facility when a resident returned from dialysis. UM4 stated, We rarely get anything back from dialysis.
During an interview on 9/7/2023 at 3:45 PM, the DON stated, The process to follow is for the pre-evaluation once completed by the nurse, is to be copied and sent to the dialysis center. The dialysis center is to return it back to us when they come back with any notations from them on the visit on these forms. It rarely comes back, but the nurses are to call the center if we do not receive the paperwork.
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 F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observations, resident and staff interviews, record review, the facility failed to maintain an effective pest control program regarding flies which affected all five floors of the facility, s...
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Based on observations, resident and staff interviews, record review, the facility failed to maintain an effective pest control program regarding flies which affected all five floors of the facility, specifically for ten (Residents (R) 21, R23, R50, R57, R87, R92, R105, R123, R153, and R167) of 47 sampled residents.
Findings include:
Observations of the facility from 9/4/2023-9/7/2023 revealed an excessive number of flies. The flies were throughout the facility including dining rooms, resident rooms, offices, and the conference room. Observations were made from 9:00 AM to 4:15 PM on 9/4/2023; from 8:30 AM to 4:15 PM on 9/5/2023; from 6:30 AM to 5:00 PM on 9/6/2023; and from 8:15 AM to 8:30 PM on 9/7/2023.
During an observation of the fourth floor on 9/4/2023 from 10:40 AM through 12:45 PM, flies were observed throughout the fourth floor, in resident rooms, in hallways, dead on windowsills, in the dining room, and in the elevator.
During an observation on 9/4/2023 at 11:12 AM, R153 and R123 were in their room. When asked, each resident said they did not like the flies in the facility, They get on our food. Review of the Brief Interview for Mental Status (BIMS), located in the electronic medical record (EMR) under the MDS tab revealed R153 had a score of 11 out of 15 indicating moderately impaired cognition. R123 had a BIMS score of 13 out of 15 indicating intact cognition.
During an observation on 9/4/2023 at 11:37 AM, R167 was in his bed in his room. R167's breakfast tray was at his bedside. When the resident was asked if he had eaten his breakfast, he lifted the insulated dome to show that he had not, stating he was not hungry. R167 said he ate all his meals in his room. During the interview, flies were observed throughout the room and four were dead on the windowsill. Review of the BIMS, located in the EMR under the MDS tab revealed R167 had a BIMS score of 12 out of 15 indication moderately impaired cognition.
During an observation on 9/4/2023 at 12:03 PM, R50 was in bed in his room. During the interview with R50, two flies were observed in the room. The resident said he ate all his meals in his room and did not like the flies in the facility. Review of the BIMS, located in the EMR under the MDS tab revealed R50 had a BIMS score of 12 out of 15 indicating moderately impaired cognition.
During an observation on 9/4/2023 at 12:05 PM, R87 was noted to be out of the facility. Several flies were observed in his room.
During an observation of the fifth floor on 9/4/2023 from 11:00 AM through 1:35 PM, flies were observed throughout the fifth floor, in resident rooms, in hallways, and in the dining room.
During an observation and interview on 9/4/2023 at 11:08 AM in R21's room, there were two flies in the room, and both had landed on the straw of the drink on the resident's bedside table. R21 stated that there were a lot of flies in the facility and was observed to have constantly swatted them away from his drink during the interview.
During an observation on 9/4/2023 at 12:54 PM flies were in R92's room and in the hallway outside the room. The resident said she ate all her meals in her room and would just shoo the flies away. Review of the BIMS, located in the EMR under the MDS tab revealed R92 had a BIMS score of 14 out of 15 indicating intact cognition.
During an observation on 9/4/2023 at 1:17 PM, R57 was seated on the side of his bed eating lunch. Two flies were observed on the resident's pureed food. The resident did not verbally respond when asked about his lunch or the flies. Review of the BIMS, located in the EMR under the MDS tab revealed R57 had a score of 6 out of 15, indicating severely impaired cognition.
During an observation on 9/4/2023 at 1:24 PM, R23 was in the dining room seated at a table. The resident was eating a cup of sherbet. While eating, numerous flies were observed in the dining room, landing on the tables and on R23. The resident did not comment on the flies, when asked, instead asked 'Do I have a room? Review of the BIMS, located in the EMR under the MDS tab revealed R23 had a BIMS score of 6 out of 15 indicating severely impaired cognition.
During an observation on 9/5/2023 at 8:50 AM, R167 was asleep in bed. Numerous flies were observed in the room as well as four flies dead on the windowsill.
A Resident Group meeting was held on 9/6/2023 at 11:00 AM in the first-floor dining room. Thirteen residents (R5, R11, R14, R37, R40, R55, R78, R89, R93, R94, R106, R157, and R163), whom the facility deemed cognitively intact to participate in the meeting, attended. When asked about the flies in the building, the residents were very adamant that they did not like the flies especially when they land on our food!
On 9/6/2023 at 8:02 AM, a Certified Nursing Assistant (CNA) 5 was observed delivering the residents' breakfast trays. CNA5 delivered R105's tray to her room, raised the resident up in bed, prepared her meal, offered her a bite, and encouraged the resident to eat. At 8:06 AM, R105 was observed in bed, not eating, and had three flies on her food. R105 did not verbally respond when asked about the flies. Review of the BIMS, located in the EMR under the MDS tab revealed R105 had a BIMS score of 1 out of 15 indicating severely impaired cognition.
Review of facility's pest control contract revealed pest control visits were completed once a week with rotations of each floor being serviced, therefore, each floor would be treated one time a month. The last service was on 8/28/2023. A specific floor was not identified on the invoice. Treatment of flies was noted on the last two invoices.
During an interview on 9/7/2023 at 4:05 PM, the Maintenance Director (MD), said the pest control serviced the building every week. The pest control was provided for each floor and the kitchen drains as a preventative measure. The MD said he had no clue why all of the sudden why we have a mass problem with flies. When asked about the bug lights on the wall, he said they installed them on the second floor when the flies were a problem on that floor, We'll have to look to put them up on the other floors too.
Dec 2021
3 deficiencies
CONCERN
(D)
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 record review, policy review and staff interviews, the facility failed to ensure one of four sampled residents (R) #58 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interviews, the facility failed to ensure one of four sampled residents (R) #58 with a mental illness, had a Level I Pre-admission Screening and Record Review (PASARR) accurately completed prior to admission to determine the need for specialized services.
Findings included:
Review of facility policy titled Preadmission Screening & Annual Resident Review (PASARR) Policy revised 11/20/2020, revealed The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The policy defined Mental Disorder/Serious Mental Disorder-An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: Diagnosis: The individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised in 1987. 1. A schizophrenic, mood, paranoid, panic, or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability.
Review of the clinical record for R #58 revealed she was admitted to the facility on [DATE] with diagnoses of but not limited to bipolar disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.
The resident's most recent Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment.
Review of the care plan dated 7/8/2021, revealed that R#58 had PTSD and bipolar disorder. Interventions to care include make psychotherapy counseling referral.
Review of the electronic medical record (EMR) for R#58 revealed there was no evidence of Level I PASARR on file.
Review of the Level I PASARR for R#58 provided by the Administrator revealed it was not accurately completed. Missing information on the Level 1 PASRR included on page one the patient had not been admitted to the Nursing Facility; page two question two asked if the patient had a severe physical illness was unanswered; page three question three asked if the individual had a terminal illness was unanswered, question four asked if the individual had primary diagnoses of serious mental illness, developmental disability, or related condition and was unanswered. The remainder of question four pertaining to treatment history was unanswered. Question five on page five pertaining to associated diagnoses, age of onset of diagnoses, for intellectual disability (ID) or developmental disability (DD) or undiagnosed conditions, including treatment history was unanswered. Since the Level I PASARR was incomplete, it did not trigger a Level II PASARR assessment to determine if specialized services were needed for.
Interview on 12/29/2021 at 11:00 a.m. with the Administrator confirmed R#58 Level I PASARR was not accurately completed. She stated if the Level I had noted the diagnoses of bipolar disorder, PTSD, and major depression, it would have triggered a Level II PASARR assessment to be completed. During further interview, she confirmed a Level II PASARR had not been completed since the Level I PASARR was incomplete. The Administrator stated the facility should have caught the incomplete Level I PASARR for R#58 when she was admitted .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, policy review and staff interviews, the facility failed to use or discard emergency food supply prior to the expiration date and failed to discard molded food items in dry stora...
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Based on observations, policy review and staff interviews, the facility failed to use or discard emergency food supply prior to the expiration date and failed to discard molded food items in dry storage. In addition, the facility failed to maintain sanitary conditions of the kitchen equipment and failed to demonstrate proper use of the three-compartment sink; failed to maintain the holding temperatures of hot foods on the steam table above 135 degrees. The census was 172 and the sample size was 50.
The findings included:
1. Review of the facility policy titled Dietary Considerations for Residents (Food and Water Emergency Supplies) revised June 2021, revealed the facility would maintain a minimum of food and water to last for three days in a specific location.
Observation during initial tour on 12/27/2021 at 9:56 a.m. with the Dietary Manager (DM) revealed 17 cans of 71 ounces Campbell's Chicken Noodle Soup with a use by date of 1/10/2021, 12 cans of 50 ounces Campbell's Tomato Soup with a use by date of 5/30/2021, and four 5-pound cans of eggplant with a use by date of 7/30/2020.
Observation during initial tour on 12/27/2021 at 9:56 a.m. with the DM, revealed in the dry storage pantry, a container of peanut butter with a dried green substance on the outside rim of the container. The container had an open date of 7/29/2021 with no expiration date identified.
2. Review of the undated facility policy titled Healthcare Services Group Sanitation revealed cleaning is defined as removal of dirt and debris and all staff are responsible for making sure the kitchen remains clean and sanitary.
During initial tour on 12/27/2021 at 9:56 a.m. with the DM revealed grease build up on the range hood. The cleaning sticker indicated the hood was last cleaned in September 2021. The main stove and range had a buildup of grease and a white substance that resembled flour. The convection ovens and warmers had a visibly thick buildup of grease and oil.
Observation during initial tour on 12/27/2021 at 9:56 a.m. with the DM, of the walk-in freezer revealed approximately three-inch ice buildup along the inside top of the door.
Interview on 12/27/2021 at 9:56 a.m. with DM stated that expired items should be discarded. DM stated that the hood range is scheduled to be cleaned every three months or as needed. She stated the ovens and ranges in the kitchen are scheduled to be cleaned weekly, and confirmed all items were cleaned last week. During further interview, the DM stated that the peanut butter had a shelf life of three months after being opened and the substance on the outside of the peanut butter container looked like mold. The DM stated the door to the walk-in freezer accumulates ice due to staff not securely closing the door after opening. There was no evidence of any in-services related to the identified concerns.
3. Review of the facility policy titled Healthcare Services Group, Inc. Policy 016 Food Preparation revised 9/2017, revealed all utensil, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use.
Observation on 12/28/2021 at 11:14 a.m. with Chef CC during use of three-compartment sink, revealed he placed the lid of the food processor on dirty end of the three-compartment sink and did not properly rewash it prior to continuing the puree process for surveyor observation.
Interview on 12/28/2021 at 11:25 a.m. with Regional District Manager (RDM) BB stated the proper use of the three-compartment sink is to wash the dishes in the first compartment, rinse the washed dishes in the second compartment, and sanitize the dishes in the third compartment. After going through the sanitizing, dishes should be placed on the side shelf to air dry.
Interview on 12/28/2021 at 11:31 a.m. with Chef CC stated that after he initially washed, rinsed, and sanitized the lid to the food processor, he placed it on top of dirty end of the sink. Chef CC stated that the proper way to utilize the three-compartment sink is to not place clean dishes back with dirty dishes.
4. Review of the facility policy titled Healthcare Services Group, Inc. Policy 016 Food Preparation revised 9/2017, revealed the Dining Services Director/Cooks will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit (F) and/or less than 135 degrees F. All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding, and less than 41 degrees F for cold holding. Temperature for foods will be recorded at the time of service and monitored periodically during meal service periods.
During observations of steam table temperature on 12/28/2021 at 11:35 a.m., temperature was below 135 degrees F for turkey patties, which was 125 degrees F.
Review of facility documentation of food temperatures was provided for the first set of temperatures after food was cooked and placed on steam table. There was no documentation provided for the second set of temperatures taken prior to service/plating. The temperatures were documented on the menu and showing only one temperature recorded.
Interview on 12/28/2021 11:44 a.m. with RDM BB stated the steam table temperatures are to be taken twice, after being placed on the steam table and again before being plated. RDM BB stated that it is the responsibility of the staff who is starting the serving line to take the second temperatures.
Interview on 12/29/21 at 11:47 a.m. with Registered Dietitian (RD) RR stated that her role was primarily clinical, and the dietary manager oversees the daily operations of the kitchen. During further interview, she stated that she completes a monthly Sanitation Audit that provided some oversight to the operations of the kitchen.
A review of the monthly Sanitation Audit Report for the months of October 2021, November 2021, and December 2021 showed that the RD RR checked that kitchen appliances were clean and sanitized and emergency food supplies followed state and federal regulations.
Interview on 12/30/2021 at 12:17 p.m. with the Administrator stated that it was her expectation that the DM and the RD ensure the cleanliness of the kitchen, foods were discarded after expiration and the kitchen appliances were clean.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. The facility census was 172.
Findings include:
On 12...
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Based on observations and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner. The facility census was 172.
Findings include:
On 12/27/2021 at 10:15 a.m., an observation was made with the facility's Dietary Manager (DM), on a walk through to the garbage dumpster area, revealed wet debris including masks, bottle tops, and decomposing paper on the ground around the dumpster area.
A review of the facility's monthly Sanitation Audit Report for the months of October 2021, November 2021, and December 2021 revealed no evidence that dietary personnel were responsible for ensuring that the dumpster area was clean and free of debris.
Interview on 12/27/2021 at 10:15 a.m. with the DM, stated that she did not know who was responsible for keeping the area around the dumpster clean.
Interview on 12/30/2021 at 12:17 p.m. with Administrator stated that everyone taking out trash is responsible for cleaning around the dumpster area. During further interview, she stated it is ultimately the responsibility of the dietary department to ensure that the dumpster area is kept clean.
Oct 2018
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policy it was determined that the facility failed to ensure the compre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policy it was determined that the facility failed to ensure the comprehensive care plan was implemented to maintain the nutritional status for one Resident (R) R#192 out of 35 sampled residents.
The findings included:
Review of the medical records for R#192 revealed he was admitted to the facility on [DATE] with diagnoses that include: deep venous thrombosis, hypertension, muscle weakness and adult failure to thrive.
Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 9/21/18 revealed R#192 had a Brief Interview Mental Status (BIMS) with a score of 15, which indicates cognitively intact for decision making. The assessment identified the resident's functional status for bed mobility and transfers - requires extensive assistance with resident involved in activity and staff provide weight bearing support with one - person physical assist. Eating- needs supervision with set up help only. Nutrition - coded as Therapeutic Diet. The Care Area Assessment (CAA) Summary triggered for nutritional status and a care plan was developed to maintain R#192 nutritional status.
Review of R#192 care plan (9/7/18) revealed the Focus- Resident at potential for altered nutrition and or fluctuations in weight related to receiving therapeutic diet related to diagnosis of hypertension, sepsis, adult failure to thrive, recent fall with fracture. BMI (body mass index) indicates normal weight. Labs show depleted protein, will recommend nutritional protein will recommend nutritional supplements to provide additional kcals (units of calories) and pro (protein). Will continue to monitor resident until stable and make adjustment as needed.
Interventions include:
Administer medication as ordered. Monitor/ Document for side effects and effectiveness.
Monitor/ record/ report to medical doctor (MD) as needed, signs and symptoms of malnutrition: Emaciation (Cachexia) muscle wasting, significant weight loss: 3 pounds (lbs). in 1 week, greater than 5% in 1 month, greater than 7.5 % in 3 months.
Registered Dietician (RD) to evaluate and make diet change recommendations as needed.
In an interview with R#192 on 10/15/18 at 12:15 p.m. in the resident room, the resident revealed he was not eating the food and he was losing weight. He revealed his dislike of the food. R#192 said he did not have to tell the kitchen he was not eating they could see on his tray that he was not eating the food.
A review of the weight record for resident #192 revealed:
9/18/18
138.9 lbs.
10/11/18
120.4 lbs.
An 18.5 lbs./ 13.32% weight difference.
No reweigh was noted.C
The RD was not notified.
The MD was not notified.
An interview was conducted on 10/17/18 at 3:01 p.m. with RD KK in her office. RD KK revealed the restorative aide who had weighed R#192 had not notified her of the weight discrepancy. There was a miscommunication over when and how to notify her of a weight discrepancy. The MD had not been notified of the weight loss.
A phone interview was conducted with MD RR on 10/18/18 at 3:46 p.m., revealed he had not been informed of the weight loss. MD RR said he had expectations for the facility to inform him of weight loss.
Review of the facility policy titled Weight Assessment and Intervention Policy dated November 28, 2017, revised on October 2, 2017 revealed policy statement- The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents.
The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.
Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the dietitian.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and policy reviews, it was determined that the facility failed to provide care...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and policy reviews, it was determined that the facility failed to provide care and services to maintain an acceptable parameter for the nutritional status for one Resident (R) R#192 of the 35 sampled residents.
The findings include:
R#192 was admitted to the facility on [DATE] with diagnoses including: deep venous thrombosis, hypertension, renal insufficiency, urinary tract infection, muscle weakness and adult failure to thrive.
Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date of 9/21/18, revealed R#192 had a Brief Interview Mental Status (BIMS) with a score of 15, which indicates cognitively intact for decision making. The assessment identified the resident's functional status for bed mobility and transfers to require extensive assistance with resident involved in activity and staff provide weight bearing support- one-person physical assist. Eating - coded as needing supervision with set up help. Nutrition - Therapeutic Diet. The Care Area Assessment (CAA) Summary revealed the resident trigger in the care area for Nutritional Status.
In an interview on 10/15/18 at 12:15 p.m. in the resident room, R#192 revealed he was not eating the food. R#192 said he does not eat pork and sausages, but the kitchen keeps sending him the same thing over and over. R#192 said he had spoken with the dietitian but it had not changed anything. R#192 revealed that he was losing weight and his pants were not fitting. R#192 said he did not have to tell the kitchen he was not eating, they could see on his tray that he was not eating the food.
A review of the R#192 medical records for weights revealed:
9/18/18
138.9 lbs.
10/11/18
120.4 lbs.
An 18.5 pounds (lbs). / 13.32% difference.
No reweigh was noted on the next day.
No notification to the dietitian
No notification to the physician.
An interview was conducted on 10/17/18 at 3:01 p.m. with Registered Dietitian (RD) KK in her office. RD KK revealed the restorative aide gets the resident's weights for their assigned units. The restorative aide puts the weight into the facility system. The restorative aide compares the weights of the resident from one week to the next and is supposed to inform the dietitian of any weight discrepancy. RD KK said there was a miscommunication on how and when to inform the dietitian of a weight discrepancy. RD KK revealed any weight discrepancy would have been discussed at the weight meeting for Patients at Risk Meetings and the physician would be notified. RD KK said she had not been notified and the physician had not been notified of the weight discrepancy for R#192.
An interview was conducted on 10/17/18 at 3:01 p.m. in the dietitian office with Restorative Aide (RA) OO. RA OO said she does take the weight of the residents assigned to her on the unit. RA OO said she enters the weights into the facility computer system, but she had not been told to do a comparison of the weights. RA OO stated she was told to just enter the weights and the dietitian would see the problem and tell her to weigh the resident again.
An interview was conducted on the phone with medical doctor (MD) RR on 10/18/18 at 3:46 p.m. MD RR said he had not been informed of the weight loss for R#192, and no action had been taken. He said, his expectations were for the facility to follow the policy and that they usually left a note in the book or they would call the office or speak with his assistants.
An interview was conducted on the phone with physician assistant (PA) SS on 10/18/18 at 5:01 p.m. PA SS revealed he would expect the facility to call when they see a weight loss. He said weight loss is a big issue.
Review of the facility policy titled Weight Assessment and Intervention Policy dated November 28th, 2017, revised on October 2, 2017 revealed policy statement - The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents.
1.
The nursing staff will measure resident's weights on admission, the next day and weekly to two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter.
2.
Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing we notify the Dietitian.
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** Based on observation, interviews, record reviews and facility policy reviews, it was determined that the facility failed to prov...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews and facility policy reviews, it was determined that the facility failed to provide professional services for dialysis care to one Resident (R) R#312 out of 35 sample residents.
The findings include:
Review of the medical records for R#312 revealed she was admitted to the facility on [DATE] with diagnoses including [NAME]-[NAME] Syndrome, cellulitis of other sites, end stage renal disease, hypotension, and unspecified anemia in chronic kidney disease
.
Review of R#312's Nursing admission Evaluation and 48 Hour Initial Care Plan dated 10/12/18 revealed the resident needs dialysis (hemodialysis) related to renal failure. The outcome - the resident will have no signs or symptoms of complications from dialysis through the next review date. Interventions included; Check bruit and thrill every shift and as needed. Monitor labs and report to doctor as needed. Monitor/document/ report to MD (medical doctor) as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung. No lab or blood pressure in arm with dialysis shunt or lymphedema dominant arm.
In an interview on 10/15/18 at 4:17p.m. in the resident's room, R#312 said she had not had dialysis for four days. She stated she came in late on Friday and was told she would receive her scheduled dialysis on Saturday at 11: 00 a.m. by the staff. R#312 said the dialysis did not happen on Saturday. R#312 said she was told later, she would go on Tuesday, her next scheduled date. The resident said she was having body urges she usually did not have and was very concerned about her fluid retention. R#312 said she was already a scheduled client with the dialysis center the facility used and had scheduled chair times to be dialyzed on Tuesday, Thursday and Saturday. R#312 said, the facility should have let her stay at her prior location until they got the arrangement straight for her appointment.
An interview was conducted on 10/15/18 at 10:40 a.m. with License Practical Nurse (LPN) BB at the nursing station. LPN BB revealed that if a resident comes into the facility and needs dialysis, the admissions coordinator will let the charge nurse know to inform the staff of their needs. LPN BB said the transportation person is informed by admissions. The information comes by e-mail and they give a copy to the resident. LPN BB said that R#312 was listed as going to the same dialysis center she was already scheduled for prior to coming to the facility.
In an interview conducted on 10/17/18 at 10:15 a.m. with Unit Manager (UM) AA at the nursing station, it was revealed that R#312 was admitted late to the facility on Friday 10/12/18. The UM AA said she received an e-mail (communication sheet) from admission with the resident location and chair time for dialysis.
An interview was conducted on 10/17/18 at 11:35 a.m. with the admission Coordinator (AC) PP in the employee breakroom. AC PP indicated that she did all the coordination and had put all the clinical paperwork together for R#312. AC PP said an e-mail was sent to the transportation company the facility uses for dialysis transport with the resident's information, location and chair times. The required information was e-mailed to the transporting agency when the referral for admission was confirmed. The communication sheet emailed by admissions to the transportation agency had R#312 schedule for dialysis on Tuesday, Thursday and Saturday at 11:00 a.m. The correct information was sent timely. AC PP said she was informed on Monday (10/15/18) that R#312 did not make her scheduled dialysis appointment on Saturday 10/13/18.
An interview was conducted on 10/17/18 at 2:01p.m. with the Administrator in her office. The Administrator said that Admissions sets up the transportation for the residents admitted to the facility needing dialysis. The Administrator said that the admission Director had informed her that the transportation for R#312 to go to dialysis had not occurred. The Administrator and admission Director had contacted the transporting agency to inquire why the transportation did not occur. The transport agency Director response was the agency was not aware of the resident needing transportation to dialysis. The Administrator said, the facility dropped the ball.
A phone interview was conduct on 10/17/18 at 4:49 p.m. with MD CC. MD CC said when he came to the facility on Monday, he assessed R#312 and she was stable. The facility had informed him that a problem had occurred with transportation and that R#312 did not go to dialysis on Saturday
.
The communication sheet emailed by admissions to the transportation agency had R#312 schedule for dialysis on Tuesday, Thursday and Saturday at 11:00 a.m. Review of Policy titled Dialysis, Care of the Resident Receiving Dialysis Treatment date of issue November 2016, revised November 2, 2017 - Policy Statement - To prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage in residents receiving dialysis.
#8. Arrange for dialysis as ordered.
#9. Resident that is diagnosed with renal disease and requires dialysis will receive appropriate treatment and services to attain and maintain his or her highest practicable physical, mental, and psychosocial well-being.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 77 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $14,842 in fines. Above average for Georgia. Some compliance problems on record.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Nurse Care Of Buckhead's CMS Rating?
CMS assigns NURSE CARE OF BUCKHEAD an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Georgia, 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 Nurse Care Of Buckhead Staffed?
CMS rates NURSE CARE OF BUCKHEAD's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 66%, which is 20 percentage points above the Georgia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 92%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Nurse Care Of Buckhead?
State health inspectors documented 77 deficiencies at NURSE CARE OF BUCKHEAD during 2018 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 71 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Nurse Care Of Buckhead?
NURSE CARE OF BUCKHEAD 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 WELLINGTON HEALTH CARE SERVICES, a chain that manages multiple nursing homes. With 220 certified beds and approximately 208 residents (about 95% occupancy), it is a large facility located in ATLANTA, Georgia.
How Does Nurse Care Of Buckhead Compare to Other Georgia Nursing Homes?
Compared to the 100 nursing homes in Georgia, NURSE CARE OF BUCKHEAD's overall rating (1 stars) is below the state average of 2.6, staff turnover (66%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Nurse Care Of Buckhead?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Nurse Care Of Buckhead Safe?
Based on CMS inspection data, NURSE CARE OF BUCKHEAD has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Georgia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Nurse Care Of Buckhead Stick Around?
Staff turnover at NURSE CARE OF BUCKHEAD is high. At 66%, the facility is 20 percentage points above the Georgia average of 46%. Registered Nurse turnover is particularly concerning at 92%. 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 Nurse Care Of Buckhead Ever Fined?
NURSE CARE OF BUCKHEAD has been fined $14,842 across 4 penalty actions. This is below the Georgia average of $33,227. 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 Nurse Care Of Buckhead on Any Federal Watch List?
NURSE CARE OF BUCKHEAD is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.