COMFORT CREEK NURSING AND REHABILITATION CENTER
For profit - Corporation
98 Beds
BEACON HEALTH MANAGEMENT
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
24/100
#181 of 353 in GA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Comfort Creek Nursing and Rehabilitation Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #181 out of 353 facilities in Georgia, placing it in the bottom half, and is the only option in Jefferson County, meaning families have no local alternatives. The facility's situation appears to be worsening, with reported issues increasing from 2 in 2024 to 8 in 2025. Staffing is somewhat of a strength with a turnover rate of 31%, which is better than the state average, but the facility has concerning RN coverage, which is less than 87% of other Georgia facilities, raising questions about adequate medical oversight. Additionally, the facility has incurred fines totaling $20,910, which is higher than 84% of Georgia facilities, suggesting repeated compliance problems. Specific incidents of concern include failures to properly perform CPR during emergencies, which could have led to serious harm, and insufficient RN coverage for over 60 residents daily, potentially leaving them without necessary clinical care. Overall, while there are some staffing positives, the critical safety issues and overall poor ratings present significant challenges for prospective residents and their families.
- Trust Score
- F
- In Georgia
- #181/353
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 31% turnover. Near Georgia's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $20,910 in fines. Higher than 83% of Georgia facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Georgia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
24/100
Bottom 49%
Review needed
2 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (31%)
17 points below Georgia average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Georgia average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 31%
15pts below Georgia avg (46%)
Typical for the industry
Federal Fines: $20,910
Below median ($33,413)
Minor penalties assessed
Chain: BEACON HEALTH MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
2 life-threatening
Apr 2025
8 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
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, family interview, record review, and review of the facility's policy titled, Change of Condition/Repo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, family interview, record review, and review of the facility's policy titled, Change of Condition/Reporting, the facility failed to provide a timely notification of change in condition for a resident that became unresponsive, breathless, and Cardiopulmonary Resuscitation (CPR) was initiated for one of one resident (Resident (R) 385) reviewed for notification of change in condition of 28 sample residents. This failure had the potential to affect the families' grieving process.
Findings include:
Review of the facility's policy titled, Change of Condition/Reporting, dated [DATE], revealed when a resident exhibits a change in condition, action will be taken to coordinate appropriate care to meet resident needs and communicate condition change to physician . 3. If there is an actual change in condition, the resident's physician is notified promptly and validated as to information. Family/Responsible Party notified promptly.
Review of R385's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R385 was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury (TBI), and she was Full Code status. Resident alert to voices, aphasic in a vegetative state. The resident was bedbound and unable to communicate her needs and wants due to her condition, and was total care. Resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severe cognitive impairment.
Review of the Progress Note located under the Progress Notes tab of the EMR, dated [DATE], revealed on [DATE] at approximately 10:45 pm, Licensed Practical Nurse (LPN) 3 documented being called to R385's room by LPN5 related to no rise and fall of R385's chest and unable to obtain vital signs. (CPR) started by LPN3. At 10:50 pm, emergency medical services (EMS) were called. At 11:01 pm, first responders arrived and continued CPR. EMS stated, unable to get a heart rhythm. LPN3 attempted to notify the Medical Director and received no answer. At 11:07 pm, EMS notified [Name] emergency room (ER) Physician Assistant (PA) and received a stop CPR order. At 11:20 pm, EMS1 notified Deputy Coroner (DC) and refused to come to the facility due to R385 not being pronounced deceased . EMS stated she would not take R385 to [Name] Hospital because she was dead. At 5:19 am, the Director of Nursing was notified. At 5:30 am, R385 was pronounced deceased . At 5:55 am, Mother of R385 was notified. At 6:20 am, the Medical Director was notified. At 8:22 am, Mother and Deputy Coroner (DC) at the Facility. At 9:39 am, R385 out of the Facility with DC.
Review of the Emergency Medical Tech (EMT) report, provided by the facility, indicated EMS was notified on [DATE] at 10:51 pm, arrived at the facility at 11:01 pm, last time known well reported on [DATE] at 9:00 pm, first monitored rhythm indicated asystole (absence of heartbeat).
During a telephone interview on [DATE] at 2:52 pm, LPN3 indicated she was assigned to R385 the night of [DATE] but was not the one who found R385 unresponsive. LPN3 stated she arrived at the facility between 7:00 pm and 8:00 pm on the evening of [DATE], made rounds to check her residents, and at that time, R385 was in her usual state with no concerns. She stated she started passing the evening medications and was unsure if she had given medication to R385, but checked on her during the medication pass. She stated at approximately 10:45 pm, she was notified by LPN5 that R385 was not breathing. LPN3 stated LPN5 began CPR, and she called 911. LPN3 indicated she was not sure when, but the Medical Director (MD) and Director of Nursing (DON) were called with no answer. LPN3 indicated she attempted to contact the DON approximately ten times through the night with no answer and made contact at 5:30 am the morning of [DATE]. When asked if the family was made aware of R385's change in condition, she stated yes after R385 was pronounced deceased at 5:55 am. When asked if a resident was not breathing, calling EMS and beginning CPR was a change in condition, LPN3 stated yes.
During a telephone interview on [DATE] at 8:45 am, LPN5 stated she was working second shift, 7:00 pm to 7:00 am, on the D and E hall, which was at the end of C hall, which gave her a clear view of the C hall. LPN5 indicated she thought she saw someone go into R385's room, and she went in the room, no one was in the room, but she found R385 not breathing. LPN5 stated she notified LPN3 and started CPR. She stated LPN3 made calls and took notes. When asked if the family was made aware of R385's change in condition, she stated, The mother was called after R385 was pronounced deceased . When asked if a resident was not breathing, calling EMS, and beginning CPR was a change in condition, LPN5 stated yes.
During an interview on [DATE] at 10:04 am, the DON confirmed that she was called the night of [DATE], and she did not get the call until she woke up the morning of [DATE]. When asked if she was on call, she indicated they did not have a call rotation. When asked why the family was not notified of R385's change of condition, she stated the mother was notified as soon as R385 was pronounced deceased , and when she signed off that she was pronounced, the event was complete. When asked if a resident was not breathing, EMS called and beginning CPR was a change in condition, she indicated the change of condition was not completed because R385 was not pronounced deceased until 5:30 am and then the family was notified.
During a telephone interview on [DATE] at 11:09 am, the Family Member (FM) 2 confirmed she was not notified of R385's death until [DATE] at 5:55 am. She stated that the last time she saw R385 was on [DATE], and she was fine. She received a phone call on [DATE] from RN1 to notify her that she was being started on an antibiotic for an upper respiratory infection. FM2 stated she asked RN1 if she was okay, and she stated, Yes. FM2 stated she was told that she was found unresponsive at approximately 10:45 pm in the evening of [DATE]. She stated she was just in shock and confused as to why she wasn't informed before the morning. She stated she found out that R385 was not pronounced deceased until the morning of [DATE], when she died on [DATE]. FM2 stated this had been very traumatic and stressful to her and her family, knowing R385 passed on [DATE], and she wasn't called until [DATE], her death certificate stated [DATE] when in fact she knew she passed on [DATE].
During an interview [DATE] at 12:30 pm, the Unit Manager (UM) 2 indicated she was called and notified by LPN3 that R385 was found not breathing and 911 was called. UM2 indicated she went into the facility at approximately 12:00 am to support the staff. When asked if the family was notified and she stated no. When asked if the family should have been notified, she stated, no because they would want to come in and R385 had not been pronounced deceased yet. When asked if a resident was not breathing, EMS called and beginning CPR was a change in condition, she indicated the change of condition was not completed because R385 was not pronounced deceased .
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 record review, interviews, and review of facility policy titled, Freedom from Abuse Standard Addendum, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy titled, Freedom from Abuse Standard Addendum, the facility failed to protect the residents' right to be free from physical abuse by other residents for two of three residents (Resident (R) 65 and R54) reviewed for abuse out of 28 sample residents. The facility's failure to protect residents from abuse placed residents at continued risk of harm.
Findings include:
Review of the facility's policy and procedure titled, Freedom from Abuse Standard Addendum, effective October 24, 2022, revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also included deprivation by an individual, employee, care giver of goods and services that are necessary to maintain the physical, mental, and psychosocial wellbeing .Resident to resident abuse of any type should be reviewed as a potential situation of abuse, and .staff should monitor behaviors that can provoke a reaction by residents or others which include verbally aggressive behaviors such as screaming, cursing, bossing around/demanding, insulting, intimidating.
1. Review of R65's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder.
Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, indicating he had moderate cognitive impairment.
Review of the Care Plan located under the Care Plan tab of the EMR, initiated 2/2025, revealed R65 had impaired cognitive function/dementia or impaired thought processes r/t [related to] dementia. [R65] has a behavior problem related to physical aggression. 3/15/2025-Giver and Receiver of physical aggression.
Review of the Incident Note, dated 3/15/2025 at 12:45 pm, and located in the EMR under the Progress Notes tab, revealed: at [approximately] 12:45 pm, it was reported by CNA [Certified Nurse Aide] that this resident got into a fight with another resident this morning. [This] writer went to speak with resident. [The] resident stated, yeah, I hit him because he talks too much smack all the time. I told him to wait until I got my coffee then I'll move. I hit him, [the] resident stated, he followed me to my room and threw water on me, then we started fighting again. [this] Writer completed [a] skin and pain assessment. [The] resident denies any pain or discomfort at this time. [The] writer noted skin tear on left hand middle finger. [The] writer completed first aide care to resident. [The] wound cleansed with normal saline, pat dry and covered with dry dressing. MD [Medical Director], CHE [mental health provider] DON [Director of Nursing], family member [Name] and . PD [police department] notified. [An] Order to begin Zyprexa 5MG [milligrams] PO [by mouth] Q [every] 12 HR [hour] PRN [as needed] x 14 days and place on 1:1.
2. Review of R54's admission Record located under the Profile tab in the EMR revealed R54 admitted on [DATE] with diagnoses which included muscle weakness and major depressive disorder.
Review of the quarterly MDS with an ARD of 3/17/2025 and located under the MDS tab in the EMR, revealed R54 had a BIMS of 13 of 15, indicating he was cognitively intact.
Review of the Care plan located in the EMR under the Care Plan tab, revealed R54 [revised date] 3/15/2025 receiver and giver of physical abuse with another resident. Interventions included separating the residents, 1:1 supervision, and notifying all appropriate agencies.
Review of the Incident Note located under the Progress Notes tab in the EMR, dated 3/15/2025, revealed R54 stated, yeah, I fought him because he hit me. I told him to move and let me through. Then he just hit me in the head. [The] resident stated, 'I followed him to his room and threw my water on him, then we started fighting again.
Review of the police report, included with the facility's reported investigation and provided by the facility, indicated an officer was dispatched on 3/15/2025 to the nursing facility due to an altercation occurring between two residents. According to the nurse, [R54] stated he was waiting for [R65] to retrieve items from the breakfast cart and commented that [R65] needed to hurry up. According to the nurse, [R54] stated that was when [R65] attacked him, punching him.
During an interview on 4/15/2025 at 12:41 pm, the DON stated that on 3/15/2025, R65 had a verbal altercation with R54. The DON stated R54 went into R65's room and threw water on him. She stated that the two residents then had a physical altercation. She stated R65 sustained a skin tear on his left middle finger. The DON stated after the incident, he was placed on 1:1 and R65 had a mental health evaluation. She stated the in-house psychiatric provider gave an order for medications if needed. She stated he did not require PRN medication and remained on 1:1 supervision for 72 hours.
During an interview on 4/16/2025 at 10:19 am, Licensed Practical Nurse (LPN) 6 stated R65 feeds off of others' energy. She stated he did not like other residents coming into his room. She stated he did not ask for much but when he wanted something he wanted it right then.
During an interview on 4/16/2025 at 12:15 pm, the DON stated she did not believe R65 was a threat to other residents. She stated R65 was provoked by R54 on 3/15/2025. She stated R54 followed R65 into his room after R65 did not get out of R54's way fast enough in the hallway. The DON stated R54 went into R65's room, and they exchanged words, then became physical with one another. She stated the residents were separated, assessed, and placed on 1:1 monitoring. She stated that minor injuries were sustained. The DON stated they were aware of R65's history at another facility of having resident-to-resident altercations. She stated orders for a PRN medication were received, but R65 did not require any medication. She stated no further incidents were reported.
During an interview on 4/16/2025 at 12:20 pm, Unit Manager (UM) 1 stated private rooms were available if needed. Per her recollection, she stated the staff did not feel like R65 needed a private room since the incident did not occur with his roommate. She stated R65 was provoked by R54. She stated the two residents exchanged words and then had a physical altercation. UM1 stated they were separated and placed on 1:1 monitoring. She stated no further incidents have occurred between the two residents.
During an interview on 4/16/2025 at 1:30 pm, the Administrator stated she was not aware of R65's resident-to-resident altercation at another facility. She stated she did not believe he was a threat to others currently. She stated she did not think he needed to be in a private room due to his history of aggression towards others.
During an interview on 4/16/2025 at 3:41 pm, LPN3 stated the event did not happen on her shift, but it was reported to her on her shift. LPN3 stated R65's roommate reported R65 and R54 got in a fight earlier that day. She stated R65 told the nurse he had every right to defend himself. She stated R65 told her R54 wanted to leave his room, and R65 was blocking the way because he was getting something off the dietary cart. LPN3 stated R54 followed R65 to his room. She stated they exchanged words and then became physical with one another. She stated that by the time she came on shift and was notified, the residents were in their own rooms and were calm. She stated that no other incident occurred between the two residents.
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 F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy titled, Bed Hold, the facility failed to provide a writt...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy titled, Bed Hold, the facility failed to provide a written bed hold notice upon transfer to the hospital for one of four residents and/or representative (Resident (R) 25) reviewed for hospitalization out of 28 sample residents. This failure had the potential to cause R25 confusion or distress regarding returning to the same room after hospitalization.
Findings include:
Review of the facility's policy titled, Bed Hold, dated 3/3/2020, revealed All Residents are given the option of reserving their bed when leaving the facility with the intent to return .A Bed Hold Authorization Form should be completed and signed by the resident/ responsible party each time a resident leaves the facility. If the resident does not choose to reserve the bed, they will be offered the first appropriate bed that becomes available.
Review of R25's admission Record located in R25's electronic medical record (EMR) under the Profile tab revealed R25 was admitted to the facility on [DATE] with diagnoses which included diabetes and absence of left leg below knee.
Review of the history listed MDS located in R25's EMR under the MDS tab, documented R25 was discharged Return Anticipated (DRN) and Entry six times as follows: DRN on 5/16/2024, Entry on 5/18/2024. DRN on 8/4/2024, Entry on 8/7/2024. DRN on 8/11/2024, Entry on 8/15/2024. DRN on 9/16/2024, Entry on 9/23/2024. DRN on 10/11/2024, Entry on 10/12/2024. DRN on 1/24/2025, Entry on 1/28/2025.
Review of R25's EMR revealed there was no documentation the facility provided a written bed hold notice to R25 or his representative.
During an interview on 4/17/2025 at 11:25 am, the Director of Nursing (DON) stated R25 was discharged to the hospital for those dates on 5/16/2024, 8/4/2024, 8/11/2024, 9/16/2024, 10/11/2024, and 1/24/2025. The DON stated the facility did not offer an opportunity to hold the bed for R25 for those discharges because R25's payor source was from Veterans Affairs (VA), and the VA did not pay for the bed hold.
During an interview on 4/17/2025 at 11:35 am, the Revenue Cycle Manager (RCM) stated the facility did not offer any written bed hold notice to R25. The RCM stated all the facility beds were licensed and certified under VA and Medicaid, and there was no VA-specified bed in the facility. The RCM said if a resident's payer source was VA, the facility would discharge that resident when that resident was transferred to the hospital and would get the VA's approval again when the resident was ready to return to the facility. The RCM stated if the VA did not approve, the facility would not take the resident back to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency 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, interviews, and review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Plan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Planning Management, the facility failed to ensure the residents participated in care conferences for one of 28 sample residents (Resident (R) 65) reviewed for care conferences. This failure had the potential for the residents to have unmet care needs.
Findings include:
Review of the facility's document titled, RAI [Resident Assessment Instrument]/Care Planning Management, dated October 2023, indicated Invitations are mailed to the family/responsible party one week prior to the conference date. Invitations are completed by social services department. Social services invites each resident to the care conference personally on the morning of the care conference.
Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, metabolic encephalopathy, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder.
Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date(ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated he had moderate cognitive impairment.
During an interview on 4/16/2025 at 10:11 am, R65 stated he was not invited to a care plan meeting. He stated he did not know what that was.
Review of the Baseline Care Plan Note located under the Documents tab in the EMR, revealed R65's sister was included in the baseline care plan meeting, but the record did not reveal R65 was invited.
During an interview on 4/15/2025 at 12:46 pm, the Director of Nursing (DON) stated the responsible party was invited to the care plan meeting. She was not sure if the residents were invited to attend.
During an interview on 4/16/2025 at 9:31 am, the Administrator stated that all interdisciplinary team (IDT) members should be included in the care plan meetings, and residents should be invited. The Administrator stated meetings could be held in the residents' room if that accommodated their 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
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 staff interview, record review, and review of the facility policy titled, Physician Services, the facility failed to fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility policy titled, Physician Services, the facility failed to follow the physician's orders for one of eight sampled residents (R) (R5).
Findings include:
Review of the facility policy titled, Physician Services, revised [DATE], revealed page six included, Physician's Orders: Procedure 8. No medications, treatments, diet orders, therapy, or procedures of any kind are to be administered to a resident without a physician's order.
Record review revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to type 1 diabetes mellitus, type 1 diabetes mellitus with hyperglycemia, hypertensive heart disease without heart failure, schizoaffective disorder, bipolar type, and non-pressure chronic ulcer of other part of right foot with unspecified severity.
Review of R5's Progress Notes revealed an entry dated [DATE] documented Nurse walked into the residents' room at 7:44 pm to administer medication. No respirations, no blood pressure noted. Cardiopulmonary Resuscitation (CPR) initiated at 7:45 pm. 911 notified at 7:48 pm, fire fighters in at 7:55 pm to assist CPR, advised staff that EMS was in [another location]. Medical Director (MD) notified at 7:58 pm, order received to stop CPR. Regional Nurse Consultant (RNC) stated CPR had to continue until EMS [Emergency Medical Services] arrived. EMS arrived at 8:20 pm, notified doctor at [hospital name] at 8:26 pm order received to stop CPR. RN [Registered Nurse] DD arrived at the facility to pronounce at 8:45 pm. EMS left facility at 9:01 pm.
Review of R5's medical record revealed an order dated [DATE] to stop CPR.
In an interview on [DATE] at 2:00 pm, the Regional Nurse Consultant (RNC) stated that she was not at the facility before, during, or after the code. She stated that the Administrator called her and stated they called the MD, and the MD said to stop CPR. RNC stated that she told them to continue CPR until EMS arrived. She stated that to her knowledge, they never stopped the code.
In an interview on [DATE] at 2:40 pm, Licensed Practical Nurse (LPN) CC stated that she was in the room during the code with three other nurses. LPN CC stated that CPR was stopped after the MD gave the order to stop CPR. She further stated that CPR was resumed after the Administrator instructed them to continue CPR until EMS arrived.
In an interview on [DATE] at 3:00 pm, the Administrator stated that the night the resident expired, Registered Nurse (RN) FF called and informed her R5 had coded, the MD was notified and gave an order to stop CPR. The Administrator further stated she instructed the staff to continue CPR until EMS arrived at the instruction of the RNC.
In an interview on [DATE] at 3:30 pm, LPN BB stated that CPR was initiated on R5, 911 was called, first responders arrived, the MD was called, the MD gave an order to stop CPR, and CPR was stopped. She further stated that when the Administrator was notified, the Administrator instructed staff to continue CPR until EMS arrived, and staff resumed CPR. She further stated that an ambulance arrived, notified their medical director, and stopped CPR.
In an interview on [DATE] at 5:00 pm, LPN AA stated that R5 was found unresponsive, she called for help, and R5 was placed on the floor and CPR was initiated. She stated 911, and the MD were called. She further stated that the MD gave an order to stop CPR, and CPR was stopped. She stated the Administrator instructed staff to continue CPR until EMS arrived, and staff resumed CPR and continued until EMS arrived and took over resident care.
In an interview on [DATE] at 10:03 am, the Director of Nursing (DON) stated that the nurses should have stopped the code on R5 as ordered by the MD. She stated her expectation of nurses was to follow the physician's orders.
In an interview on [DATE] at 10:16 am, the MD stated he was notified by the facility that staff were performing CPR on R5. He stated that he gave an order to stop CPR, and further stated he did not give an order to resume CPR after it had been stopped.
In a follow-up interview on [DATE] at 1:30 pm, the RNC stated that she was aware that the nurses received an order from the MD to stop CPR on R5. She stated that she told the nurses that they had to continue CPR until EMS arrived. The RNC acknowledged that CPR should have been stopped per the physician's 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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to provide tracheostomy care, superv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to provide tracheostomy care, supervision, and supplies for a resident who was care planned to self-care his own tracheostomy site to one of two residents (Resident (R) 13) reviewed for respiratory care of 28 sample residents. This failure had the potential to contribute to respiratory infection for R13.
Findings include:
Review of R13's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R13 was admitted to the facility on [DATE] with diagnoses which included cervical disc disorder and complete traumatic amputation of level between unspecified hip and knee.
Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2025 and located in R13's EMR under the MDS tab, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact. Further review revealed R13 received tracheostomy care in the facility.
Review of R13's Has a tracheostomy care plan, dated 3/12/2025, documented R13 performs his own trach care per his preference. The care plan included the following: For Inner cannula care, when allowed by resident, observe for Changing as he prefers and, on his terms, and schedule. Ensure all supplies are available timely .Trach care performed by resident as he wishes staff to observe for assistance.
Review of R13's physician's order Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025 located in R13's EMR under Orders tab, the report documented R13 received tracheostomy care and monitoring ordered by the physician as follows: Change the inner cannula, size six, daily and as needed, every night shift. Start date, 3/26/2025; Trach care every shift and as needed. Start date, 3/26/2025; Suction tracheostomy as needed for increased secretions. Start date, 3/26/2025; Change tracheostomy tie once weekly on Thursday on every day shift every Thursday. Start date, 3/26/2025.
During an observation and interview on 4/14/2025 at 2:44 pm, R13 stated his tracheostomy size was 6G and he took care of his trach care by himself; the staff did not check on him when he cleaned it. R13 said and pointed to his bedside table and was observed there were no tracheostomy care supplies such as a tracheostomy care kit (contains sterile towel, sterile gauze pads, sterile cotton swabs, sterile small brush, sterile gloves.) or additional supplies (sterile 4x4 drain sponge, hydrogen peroxide, sterile water gauze, tracheostomy securing devise or tapes, ties.) per the facility's policy and the care plan instructed. There was no suction machine in R13's room.
During an observation and interview on 4/15/2025 at 12:24 pm, when asked, R13 stated he used a special brand of toilet paper to clean the surroundings skin of the tracheostomy tube, rolled a napkin, and put it below the tracheostomy tube to support it. R13 pointed to the white rolled napkin on his neck and said he ran out of the toilet paper about a week ago, so he used the same rolled napkin to clean and support it. R13 said if there was blockage in his tracheostomy tube, he would remove the inner cannula, cough out the mucus, and put it back in. R13 then pulled out his inner cannula and coughed to explain how he cleared his mucus in the tracheostomy tube. R13 was observed to have his inner cannula in his hand, and the entire inner cannula tube looked completely brown throughout the whole tube. When asked, R13 said the inner cannula had not been changed or cleaned since he was admitted to the facility more than a month ago, and it had not been changed or cleaned for more than a year. He said if staff could offer him some supplies, such as clean gauze, it would help.
During an interview on 4/15/2025 at 1:05 pm, when the Director of Nursing (DON) was informed about R13's statements and the brownish inner cannula, the DON said she would get some tracheostomy care supplies for R13.
During an observation and interview on 4/15/2025 at 2:24 pm, when R13's care nurse, Licensed Practical Nurse (LPN) 8, was asked why there were no tracheostomy care supplies and spare tracheostomy tube in R13's room ready for him to use, LPN8 stated she would look for it in the supply room. During an observation conducted in the supply room with LPN8, LPN8 did not know where the tracheostomy care supplies were in the supply room, and she said she did not know R13's tracheostomy tube size, she needed to check R13's record. LPN8 found some tracheostomy supplies, which included a tracheostomy kit. However, LPN8 was not sure if the tracheostomy tube and inner cannula would fit R13.
An observation and interview on 4/15/2025 at 2:50 pm, was conducted with LPN8 in R13's room. There was a box of gauze and a new emergency tracheostomy tube size 6DCFN on R13's table. R13 stated they just brought it here not long ago. R13 said he would not use the tube. R13 stated he was size 6G. No suction was observed in R13's room.
During an interview on 4/15/2025 at 3:30 pm, the DON stated tracheostomy care would follow the procedures documented in the policy.
During an interview on 4/15/2025 at 4:48 pm, when asked, LPN8 stated she had not observed or performed tracheostomy care or replaced the inner cannula for R13.
During an interview on 4/16/2025 at 8:43 am, LPN7 said she never provided tracheostomy care to R13. LPN7 stated the treatment nurse did.
During an interview on 4/16/2025 at 9:04 am, the DON stated the facility was in a transition, and currently, there was no treatment nurse, and the nursing staff would provide all treatments to their assigned residents.
During an interview on 4/16/2025 at 9:04 am, LPN2 said she had never provided tracheostomy care for R13 when she was assigned to take care of R13. LPN2 said R13 took care of his own tracheostomy care. LPN2 stated if R13 needed assistance and asked, she would be more than willing to help him. She said the order administration documented as completed with a V sign for tracheostomy care meant that the staff asked R13 and verified with him that he completed the tracheostomy care and cleaning. She said the staff asked R13 to make sure R13 did it, if R13 said yes, he did it, the staff would mark the order as administration completed. LPN2 said she never observed R13 perform tracheostomy care for himself, but she did observe if there were any discharges near the tracheostomy area during the shift.
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
Medication Errors
(Tag F0758)
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 policies titled, Behavior Management Standard, and Depres...
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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 policies titled, Behavior Management Standard, and Depression Management, the facility failed to ensure psychotropic medications' efficacy was monitored, and non-pharmacological interventions were offered and included in the care plan for two of two residents (Resident (R) 13 and R49) reviewed for unnecessary and/or psychotropic medications of 28 sample residents. This failure had the potential to affect a physician's decision to prescribe the lowest possible effective dose of medication.
Findings include:
Review of the facility's policy titled, Behavior Management Standard, dated January 2025, under page three documented Ensuring a thorough and comprehensive assessment of the residents' needs, behaviors .Monitoring the resident's behaviors to establish patterns, determine intensity and behavior frequency, and identifying the specific target behaviors that are distressing to the resident .Planning and implementing appropriate behavior interventions into the resident's plan of care. Evaluating the effectiveness of Pharmacological and non-pharmacological interventions. Monitoring for any adverse side effects of the medications .as per recognized standards of practice.
Review of the facility's policy titled, Depression Management, dated January 2025, documented The interdisciplinary Team (IDT) evaluated the resident with symptoms of depression determine potential cause and developed a plan of care None-pharmacological interventions are attempted as appropriate, prior to initiating pharmacological interventions . Review and address potential causes of depression . Develop goals and interventions on the care plan . Evaluate effectiveness of non-pharmacological interventions prior to/or in addition to initiation of pharmacological interventions .Monitor for efficacy, side effects, and/or adverse consequences of the medication.
1. Review of R13's undated admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 3/5/2025 with diagnoses, which included, major depressive disorder, post-traumatic stress disorder, and insomnia.
Review of R13's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/2025, located in the resident's EMR under the MDS tab, revealed R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact. R13 did not exhibit mood or behavioral symptoms. R13 received antidepressant medication.
Review of R13's Care Plan Report located in the resident's EMR under the Care Plan tab, included a care plan for depression r/t [related/to] Admission, Disease Process Hx [history] of substance abuse (cannabis abuse) Diagnosis of depression, PTSD [post-traumatic stress disorder], initiated on 3/12/2025. The care plan included the interventions as follows:
-Care plan goal: R13 will remain free of signs and symptoms of distress, depression, anxiety, or sad mood by /through review day.
-Administer medications as ordered. Observe/document for side effects and effectiveness.
-Observe, document, and report as needed any risk for harm to self: suicidal plan, past suicide attempt, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, or writing a note), intentionally harmed or tried to harm self, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness.
-Observe, document, and report as needed any signs and symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness.
-Observe, record, and report to the physician as needed for the risk of harming others: increased anger, labile mood, or agitation; feels threatened by others or thoughts of harming someone; possession of weapons or objects that could be used as weapons.
-Pharmacy review monthly or per protocol.
R13's Care Plan Report included a care plan for R13 for antidepressant medication (Remeron, Trazadone) r/t (related to) Depression, initiated on 3/12/2025. The care plan included the interventions as follows:
-Administer antidepressant medications as ordered.
-Observe and document side effects and effectiveness every shift.
-Educate the resident, family, and caregivers about the risks, benefits, side effects, and/or toxic symptoms of antidepressant drugs.
-Observe, document, and report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicide thoughts, withdrawal; decline in activity daily living [ADL] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea and vomiting, dry mouth, and dry eyes.
Review of R13's EMR revealed there was no documentation that the facility was monitoring antidepressant medication's adverse side effects, as the care plan indicated.
R13's care plan did not include what nonpharmacological interventions staff would offer if depression or insomnia symptoms were observed.
Review of R13's Physician's Order Medication Administration Record (MAR) and Treatment Administration Record (TAR) for April 2025, located in R13's EMR under the Orders tab revealed R13 received ordered by the physician as follows:
-Mirtazapine (antidepressant) 30 milligrams (mg). Give one tablet by mouth at bedtime for depression. Start date, 3/26/2025. Review of R13's EMR revealed there was no documentation that the facility was monitoring R13's depression symptoms as the care plan indicated.
-Trazodone (antidepressant) 150 mg, give two tablets by mouth at bedtime for insomnia. Start date, 3/28/2025. Review of R13's EMR revealed there were no hours of sleep monitoring to determine the efficiency of the trazodone used to treat insomnia.
-Antidepressant medication monitor for: DROWSINESS, DIZZINESS, NAUSEA, DIARRHEA, HEADACHES. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/See Nurses Notes' and document findings. every shift for Medication Monitoring. Start date, 3/26/2025.
Review of R13's EMR revealed there was no documentation of whether any nonpharmacological interventions were offered to R13 if depression or insomnia symptoms were presented.
During an interview on 4/16/2025 at 1:30 pm, the Director of Nursing (DON) stated there were no target behaviors for R13's antidepressant medication use; the facility was treating R13 because he had a diagnosis of depression. The DON reviewed R13's record and stated there was no depression monitoring in R13's EMR, and there were no resident-specified nonpharmacological interventions listed to offer. The DON further stated there was no documentation about how many hours of sleep R13 had to monitor for the medication efficiency each day for trazodone use. She said the facility documented by exception, and the nurse would report it if R13 did not sleep well. The DON said there was no intervention in the care plan about what nonpharmacological interventions staff would offer if R13 had trouble sleeping or because of depression.
During an interview on 4/16/2025 at 3:53 pm, the DON stated the policy and regulations should be followed to initiate non-pharmacological interventions and monitoring. The DON stated there was no policy for insomnia care.
2. Review of R49's undated admission Record located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 3/17/2022 with diagnoses which included suicidal ideation, anxiety disorder, unspecified mood disorder, and mental disorder not specified.
Review of R49's annual MDS with an ARD of 1/22/2025, located in the resident's EMR under the MDS tab, revealed R49 had a BIMS score of 14 out of 15, which indicated R49 was cognitively intact. R49 did not exhibit behavioral symptoms, except presenting with Little interest or pleasure in doing things for two to six days. R49 received antipsychotic and antidepressant medication.
Review of R49's Care Plan Report, located in the resident's EMR under the Care Plan tab, included a care plan for has the potential to be Depressed, initiated on 1/19/2023. The care plan included the interventions as follows:
- Administer medications as ordered. Monitor/document for side effects and effectiveness,
- Arrange for psych consultation, follow up as indicated.
-Monitor/document/report PRN [as needed] any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness,
impaired judgment or safety awareness. There was no documentation that the facility was monitoring R49's risk for harm to self as the care plan indicated for quetiapine fumarate use to treat Suicidal Ideations.
-Monitor/document/report PRN any s/sx [signs and symptoms] of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Review of R49's EMR revealed there was no documentation that R49's depression symptoms were being monitored as the care plan indicated.
-Pharmacy review monthly or per protocol.
R49's care plan did not include what nonpharmacological interventions staff would offer if depression symptoms were observed. Review of R49's EMR revealed there was no documentation of what nonpharmacological intervention to be offered to R49 for depression symptoms and insomnia.
Review of R49's Physician's Order MAR and TAR for April 2025, located in R49's EMR under the Orders tab revealed the report documented R49 received orders by the physician as follows:
-Sertraline (antidepressant) 50 mg. Give one tablet by mouth one time a day for mood. Start date, 04/26/24.
-Trazodone (antidepressant) 50 mg, give one tablet by mouth at bedtime for insomnia. Start date, 05/30/24. Review of R49's EMR revealed there were no hours of sleep monitoring to determine the efficiency of the trazodone used to treat insomnia.
-Quetiapine Fumarate (antipsychotic) 25 mg. Give one tablet by mouth two times a day for Suicidal Ideations. Start date, 01/16/23.
-Behavior Interventions:1- Redirect 2- 1:1 3- Ambulate 4- Activity 5- Return to room [ROOM NUMBER]- Toilet 7- Give food 8- Give fluids 9- Change position 10- Encourage to rest 12- Refer to nurses notes every shift. Start date, 01/16/23.
-ANTI-PSYCHOTIC MEDICATION - Monitor for: DRY MOUTH, CONSTIPATION, BLURRED VISION, DISORIENTATION/ CONFUSION, DIFFICULTY URINATING, HYPOTENSION, DARK URINE, YELLOW SKIN, N/V, LETHARGY, DROOLING, EPS SYMPTOMS (TREMORS, DISTURBED GAIT, INCREASED AGITATION, RESTLESSNESS, INVOLUNTARY MOVEMENT OF MOUTH OR TONGUE). Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/ See Nurses Notes' and document findings every shift for Medication Monitoring. Start date, 10/03/23.
-BEHAVIOR(S) - Monitor for: (1- Verbal Aggression, 2- Refusing Care) ITCHING, PICKING AT SKIN, RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, BITING, KICKING, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, STEALING, DELUSIONS, HALLUCINATIONS, PSYCHOSIS, AGGRESSION, REFUSING CARE. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above were observed, select chart code 'Other/ See Nurses Notes' and document specific behavior(s) every shift for Behavior Monitoring Document each behavior observed and number of occurrences. Start Date, 1/16/2023.
During an interview on 4/16/2025 at 3:53 pm, the DON reviewed R49's record and stated there was no documentation the nonpharmacological interventions were offered and what target behavior was monitored for R49's antidepressant medication use. The DON stated there was no documentation that the adverse side effects of antidepressants and depression symptoms, sleep, and suicidal ideation were being monitored. The DON said the facility should follow the policy and regulations to initiate nonpharmacological interventions and monitoring. The DON stated they should also be included in the care plan. She stated there was no policy for insomnia care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of the facility's policy titled, Discharge Plan/Transfers, the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of the facility's policy titled, Discharge Plan/Transfers, the facility failed to ensure a written transfer notice that contained all required information was provided to four of four residents and/or their representative (Resident (R) 65, R72, R68, and R25) reviewed for facility-initiated emergent hospital transfer out of 28 sample residents. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.
Findings include:
Review of the facility's policy titled, Discharge Plan/Transfers, dated October 2023, did not indicate a transfer notice should be provided to the residents and their representative explaining why they were being transferred.
1. Review of R65's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R65 admitted on [DATE] with diagnoses of major depressive disorder, brief psychotic disorder, metabolic encephalopathy, unspecified dementia, bipolar disorder, post-traumatic stress disorder, paranoid schizophrenia, and anxiety disorder.
Review of the admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 2/12/2025 indicated R65 had a Brief Interview for Mental Status (BIMS) of 12 out of 15, which indicated he was moderately cognitively impaired.
Review of the Progress Note located under the Progress Notes tab in the EMR, dated 3/15/2025, revealed R65 was transported to the hospital via 10-13 (signal of immediate help, often due to a dangerous situation) after hitting a staff member in the face.
Review of the EMR did not reveal evidence that a written transfer/discharge notice was provided to R65 or his representative on 3/28/2025.
During an interview on 4/14/25 at 1:54 pm, R65 stated he went to the hospital at the beginning of the month but could not elaborate on why he was sent. He stated he could not recall receiving any paperwork while he was transferred.
During an interview on 4/15/2025 at 12:48 pm, the Director of Nursing (DON) stated R65 did not discharge from the facility. She stated he was gone less than 24 hours and was not gone after midnight. She stated she was not sure if a transfer/discharge notice was provided and would look. She stated she was not aware of the e-interact form not being the same thing as a transfer/discharge notice.
2. Review of R72's admission Record located under the Profile tab in the EMR revealed R72 admitted on [DATE] with diagnoses of monoplegia of lower limb affecting left dominant side, malignant neoplasm of prostate, morbid obesity, major depressive disorder, generalized anxiety disorder, cognitive communication deficit, and peripheral vascular disease.
Review of the quarterly MDS located under the MDS tab of the EMR with an ARD of 3/24/2025 revealed R72 had a BIMS of 13 of 15, indicating he was cognitively intact.
Review of the Progress Notes located under the Progress Notes tab in the EMR, dated 4/11/2025, revealed he was transferred to the hospital on 4/11/2025. R72 complained of abdominal pain at 12:00 am. Upon examination, his abdomen was distended. Resident stated that he has not been able to sleep and that he needs to go to the ER [emergency room] because he feels so bad.
Review of the EMR did not reveal any evidence that R72 received a transfer/discharge notice upon being sent to the emergency room.
During an interview on 4/16/2025 at 9:26 am, the Administrator stated a transfer form should be completed by the nurses and the residents and/or their representatives should receive a copy.
During an interview on 4/16/2025 at 9:48 am, Licensed Practical Nurse (LPN) 6 stated a transfer form should have been completed when residents were sent to the hospital.
During an interview on 4/16/2025 at 9:49 am, Unit Manager (UM) 1 stated the facility had not been sending a transfer discharge notice with the residents, and one was not sent to the responsible party.
During an interview on 4/17/2025 at 2:21 pm, the DON stated R72 did not receive a transfer/ discharge notice when he was sent to the hospital.
3. Review of R68's quarterly MDS tab with an ARD of 2/7/2025 revealed a BIMS score of 13 out of 15, which indicated R68 was cognitively intact. Diagnoses included end-stage renal disease, anemia, coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, and required dialysis.
Review of the EMR located under the Census tab revealed that R68 resident was not in the facility on 7/29/2024, 8/6/2024, 8/28/2024, and 12/30/2024 due to hospitalization.
Review of the EMR located under the Miscellaneous (Misc) tab revealed that the facility issued bed holds for each hospital stay, but did not indicate that the written notification of transfer was completed.
During an interview on 4/16/2025 at 3:15 pm, the DON stated that the facility was not completing the written notification of transfer/discharge. The DON also stated that the facility would be using a transfer/discharge form from now on to ensure that the notices were completed and sent to the resident and resident responsible party.
During an interview on 4/16/2025 at 3:45 pm, the UM1 stated they had not been sending notifications of transfer or discharge to residents' responsible parties and that the facility was educating everyone on how to complete the transfer/discharge form.
4. Review of R25's admission Record located in R25's EMR under the Profile tab revealed R25 was admitted to the facility on [DATE] with diagnoses which included diabetes and absence of left leg below knee.
Review of the history listed MDS located in R25's EMR under the MDS tab, documented R25 was discharged Return Anticipated (DRN) and Entry six times as follows: DRN on 5/16/2024, Entry on 5/18/2024. DRN on 8/4/2024, Entry on 8/7/2024. DRN on 8/11/2024, Entry on 8/15/2024. DRN on 9/16/2024, Entry on 9/23/2024. DRN on 10/11/2024, Entry on 10/12/2024. DRN on 1/24/2025, Entry on 1/28/2025.
Review of R25's EMR revealed there was no documentation that the facility offered a written transfer/ discharge notice to R25 or a representative upon each discharge.
During an interview on 4/17/2025 at 11:25 am, the DON stated R25 was discharged to the hospital for those dates on 5/16/2024, 8/4/2024, 8/11/2024, 9/16/2024, 10/11/2024, and 1/24/2025.
During an interview on 4/17/2025 at 12:45 pm, the DON stated there were no written discharge/ transfer summaries provided to R25 or his representative as to why R25 was discharged or transferred for all the record-requested discharge date s.
Jun 2024
2 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and a review of the facility's policy titled Emergency Response Management Cardiopulm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and a review of the facility's policy titled Emergency Response Management Cardiopulmonary Resuscitation (CPR), the facility failed to activate 911 and continue CPR until more aggressive life-sustaining treatment could be initiated for one resident (R1) of 14 residents reviewed for code status.
On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE].
An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE].
Findings include:
A review of the facility's undated policy, Emergency Response Management Cardiopulmonary Resuscitation (CPR), revealed: Standard: To ventilate and establish circulation on a resident with absence of respirations and pulse. Note: Nurses (required) CNAs (suggested) maintain current CPR certification. Procedure: Determine unresponsiveness by briskly rubbing your knuckles against resident's sternum and deliver two rescue breaths to the unresponsive victim who is not breathing and start chest compressions immediately. If the resident wakes, moan or moves then CPR is not necessary. Call out for help. Delegate a specific individual to check physician orders; CPR order/DNR administrative personnel per facility policy and report back to individual as soon as possible. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR. CPR in three simple steps: 1. Call: Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call for assistance or call 911. 2. Pump: If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Push down the center of the chest 2 inches, 30 times. Pump hard and fast at the rate of 100 compressions per minute. 3. Blow: After 30 chest compressions tilt the head back and lift the chin. Pinch the nose and cover the mouth with yours (may use a mouth guard if available) and blow until you see the chest rise. Give 2 breaths. 4. Continue with 30 pumps and 2 breaths until help arrives.
Record review for R1 revealed the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation.
Record review of the most recent admission Minimum Data Set (MDS) for R1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 08, indicating that he had moderate cognitive impairment.
Record review revealed a physician's order for R1 dated [DATE] to attempt resuscitation in the event R1 had no pulse and was not breathing.
A review of the Nurse's Progress Note dated [DATE] at 4:35 pm revealed that R1 was found not arousable by verbal or physical stimuli and noted to not have any vital signs on [DATE] at 4:35 pm. Licensed Practical Nurse (LPN) AA exited the room, went to the nurse's station, and paged a code. LPN AA returned to the R1 room along with LPN BB and Registered Nurse (RN) CC and initiated CPR. There was no documentation that the facility called 911. LPN BB called the Medical Director (MD) on [DATE] at 4:55 pm. The Medical Director (MD) gave an order to stop CPR. The DON and the Administrator confirmed by DON that the facility staff never called 911. R1 was a full code status and expired in the facility on [DATE].
Interview on [DATE] at 1:32 pm with RN CC revealed the procedure when there is a code is for someone to grab the crash cart, someone calls 911, and someone starts compressions, continuing CPR until EMS arrives. RN CC stated that a nurse was on the phone with the MD, and he gave the order to stop CPR. RN CC stated that they would call EMS back if they did not arrive within 15 minutes. She stated that, as far as she is aware, LPN AA called EMS. RN CC stated that LPN AA called the code, and she and LPN BB took over the code. RN CC verified that there was no documentation that EMS was called.
Interview on [DATE] at 1:53 pm with LPN BB revealed that she assisted LPN AA in the code and did chest compressions. LPN BB stated that she had her cell phone in her pocket, and she called the MD because they had been doing CPR for a long time, approximately 20 minutes; she stated that they were exhausted. LPN BB stated that the MD told them to stop CPR. LPN BB further revealed that after the code was stopped, R1 was pronounced by RN CC. LPN BB verified that there was no documentation that EMS was called.
Interview on [DATE] at 3:09 pm with non-emergency 911 personnel revealed there were no calls from the facility on [DATE] in reference to an [AGE] year-old male.
Interview on [DATE] at 3:20 pm with DON revealed the process for CPR is for everyone to participate. She stated that it is a team effort. The DON stated that one person is responsible for compressions, one person calls EMS, and one person does AMBU (manual breathing). The DON revealed that she was not sure if LPN AA called EMS, but she would call LPN AA and ask if she called EMS. The DON verified that there was no documentation that EMS was called.
Interview on [DATE] at 4:10 pm with the MD revealed typically the nurses call EMS but if EMS was not there or if EMS was taking too long to get there, they sometimes call him. The MD was informed that there was no documentation that EMS was called.
Interview on [DATE] at 11:40 am with the Administrator revealed he was not sure if the facility has an AED or defibrillator. He stated that he had not been at the facility that long, only a week ago in [DATE]. He stated that he was not sure of the policy for CPR, but he would check with the DON and see what their policy on CPR was.
During a phone on [DATE] at 4:50 pm interview with LPN AA revealed she was working the back D and E halls from 7 am -7 pm shift on [DATE]. LPN AA stated that she went to R1's room to give him his medication, and he was not responsive. LPN AA revealed that she left the room, went to the nurse's station, and paged a code. She stated that she went back to the room and started CPR. LPN AA revealed that RN CC and LPN BB responded to the code. She further revealed that RN CC had her cell phone and was supposed to call EMS, but not sure if she contacted EMS. LPN AA further revealed that the normal procedure for a code is that if nobody is around, you yell out for someone to call 911. LPN AA confirmed that she did not yell out for someone to call 911. LPN AA stated that she and LPN BB were switching up doing CPR with compressions and AMBU. LPN AA further revealed that the facility does not have an AED or defibrillator. She stated that no one else came to assist with the code. LPN AA revealed that there are two nurses on the front halls and one nurse on the back halls. She stated that the two front hall nurses were not in the room during the code. She stated that they did not assist with the code. She stated that she had one CNA on D hall and one CNA on E hall. LPN AA stated that to her knowledge, EMS did not come. LPN AA verified that there was no documentation that EMS was called. LPN AA verified that RN CC documented in the chart because she was the RN that pronounced R1.
A continued interview on [DATE] at 8:57 am with LPN BB revealed EMS did not arrive at any time during or after the code. LPN BB stated that the facility does not have an AED or defibrillator. She stated that the other two nurses who were in the facility on 3/292024 did not respond to the code. LPN BB stated that she was CPR certified.
A continued interview on [DATE] at 9:15 am with RN CC revealed that she was not aware of EMS arriving at the facility during or after the code. RN CC revealed that she did not call EMS. She stated CPR had been in progress for a while, and LPN BB called the MD. RN CC stated that the MD gave an order to stop CPR because it had been over 15 minutes. She stated that she was the RN and pronounced R1 after she got the stop CPR order from the MD. She further revealed that the facility does not have an AED or defibrillator. RN CC stated that there was only one nurse working on the front halls on [DATE] at 4:35 pm and did not participate in the code. RN CC stated that she was CPR certified.
Interview on [DATE] at 9:25 am with LPN DD revealed she was working on [DATE] at 4:35 pm. She stated that she heard the code being paged. LPN DD stated that she did not respond to the code because they had LPN BB, RN CC, and LPN AA in the room. LPN DD further revealed that she would tell someone to call 911, or she would call herself, call the doctor, and continue CPR until the arrival of the ambulance. She stated that she would call the doctor to let him know what was going on, and if the doctor decided to stop the code, he would give an order to stop. LPN DD stated that the facility does not have an AED or defibrillator. LPN DD stated that she was CPR certified.
Further interview on [DATE] at 9:50 am with LPN AA revealed there was a little mix-up because she thought that RN CC had her cell phone and was making the calls. LPN AA stated that she could not remember who made the calls, but she thought that RN CC called EMS.
Further interview on [DATE] at 4:20 pm with the DON revealed she is responsible for the CPR cards and making sure everyone is active. The DON stated that she had a book with the cards. The DON revealed that the course for CPR was online, with no hands-on check-off, only a test after watching the course. The DON further revealed that successfully passing the test after the course indicates competency in CPR. She stated that after staff passes the test, they are issued a card and that means that they have successfully passed the course without return demonstration of compressions.
The facility implemented the following actions to remove the IJ:
1. Licensed Nurses LPN AA and RN CC failed to continue Cardiopulmonary resuscitation until 911 services were called on [DATE] on R1.
2. On [DATE], Licensed Nurse LPN AA and RN CC received CPR certification to include continuing CPR until 911 services arrive.
3. On [DATE], Senior [NAME] President of Clinical Services reviewed the policy Emergency Response Management policies and procedures and concluded no revisions were made.
4. On [DATE], the Medical Director was educated on the policy and procedure for the Emergency Response Management by the Administrator.
5. On [DATE], The Regional Nurse Consultant educated Director of Nursing and Administrator on Emergency Response Management policy and procedure.
6. On [DATE], Education for the Emergency Response Management policy and procedure was completed by Director of Nursing and/or licensed staff. 3 of 4 RNs, 16 of 17 LPNs, 40 of 44 CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Business office Manager, 1 of 1 Social Service Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff.
7. All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process.
8. On [DATE], an Advance Directive audit was completed by the Social Service Director to include the Physician Orders for Life-Sustaining Treatment (POLST), physician order, and care plan is accurate. 58 Residents elected to receive Cardiopulmonary resuscitation, and 21 residents elected to be a Do Not Resuscitate status for a total of 79, with one resident currently in the hospital. The Administrator and/or Director of Nursing will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays [DATE].
9. On [DATE], 10 of 10 licensed staff received Cardiopulmonary Resuscitation Certification provider whose training includes hands-on practice and in person skills assessment. The additional 11 licensed nurses had CPR Certification prior to compliance date of [DATE]. The total of licensed nurses with CPR certification is 100%.
10. On [DATE], The Regional Nurse Consultant and or Regional MDS Nurse reviewed 79 of 79 resident's records of the Advance Directive audit to ensure orders, POLST, and care plans are completed accurately in the resident record.
11. The Regional Nurse Consultant and Regional [NAME] President of Operation visited the facility on [DATE].
12. On [DATE], the Administrator conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting which consists of the Medical Director, Regional [NAME] President of Operations, Business Office Manager, Social Service Director, MOS nurse, Certified Nurse Assistant, and licensed nurse to review the results of the most recent survey outcomes. The IDT (interdisciplinary Team) will review daily during morning clinical meeting to ensure compliance with following the Clinical Emergency Response Policy to include notifying 911 during CPR, auditing Advance Directives, Physician orders, and Care Plans.
13. All corrective actions were completed by [DATE].
14. All immediacy of the IJ was removed on [DATE].
The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:
1. Review of CPR certifications for LPN AA, and RN CC revealed LPN AA, and RN CC received CPR certification effective [DATE] through expiration date [DATE].
2. Interview with LPN AA on [DATE] at 9:00 am revealed she received CPR certification at the facility on [DATE] provided by a certified CPR instructor to include a CPR course, hands on skills competency check off, and a written test. Interview with RN CC on [DATE] at 9:15 am revealed she received CPR certification at the facility on [DATE] provided by certified CPR instructor to include a CPR course, hands on skills competency check off, and a written test. Observation of CPR training in progress on [DATE] at 3:30 pm.
3. Interview with the Senior [NAME] President (SVP) of Clinical Services on [DATE] at 9:40 am
revealed she reviewed the Emergency Response Management policies and procedures, and no revisions were made. Review of Emergency Response Management policies and procedures reviewed with policies and procedures on Cardiopulmonary Resuscitation (CPR) standards and procedures to include emergency crash cart standards and procedures. Policy review date [DATE] in response to citation of Immediate Jeopardy with SVP of Clinical Services signature.
4. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Administrator provided to the Medical Director. Review of education provided to the Medical Director by the Administrator on the policy and procedure for Emergency Response Management, including, but not limited to, Cardiopulmonary Resuscitation (CPR) and Emergency Crash Carts.
Interview with Director of Nursing on [DATE] at 11:20 am revealed the Medical Director was educated via phone on [DATE]. Phone interview with the Medical Director on [DATE] at 11:50 am revealed he received education from the Administrator on [DATE] on Emergency Response Management including Cardiopulmonary Resuscitation (CPR), Calling 911, and Emergency Crash Cart.
5. Review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional Nurse Consultant provided to the DON and Administrator. Education included handouts on Clinical Emergency Response Management, Cardiopulmonary Resuscitation (CPR) standards and procedures, and Emergency Crash Cart standards and procedures.
Interview with the DON on [DATE] at 8:45 am revealed she received education from the Regional Nurse Consultant on [DATE] on the Emergency Response Management Policy and Procedure.
Interview with the Administrator on [DATE] at 11:30 am revealed he received education provided by the Regional Nurse Consultant on [DATE] on the Emergency Response Management Policy and Procedure.
6. Review of sign in sheet dated [DATE] revealed an in-service conducted by the Director of Nursing provided to 3 of 4 RNs, 16 of 17 LPNs, CNAs, 9 of 9 Dietary Staff, 9 of 14 Therapy staff, 3 of 3 Maintenance Director, 1 of 1 Activities Director, 1 of 1 Director of Nursing, 1 of 1 Administrator, 7 of 11 Housekeeping, 1 of 1 admission Director, and 1 of 1 Human Resource Director 86.20 % of education was completed for all staff. Education included a review of the Clinical Emergency Response Management standard, reviewing the steps to administer CPR with good staff participation. Staff interviews conducted on [DATE] confirming receiving education as previously stated above with LPN AA at 9:00 am, RN CC at 9:15 am, LPN BB at 9:25 am Maintenance Director at 10:00 am, Activity's Director at 10:15 am, Dietary Staff at 10:15 am, Human Resource Director at 10:30 am, CNA GG at 10:45 am, CNA HH at 11:00 am, CNA II at 11:10 am, LPN DD at 11:35 am, Housekeeper LL at11:40 am, Laundry /Housekeeping JJ at 11:50 am.
7. All staff not educated on Emergency Response Management will be in-serviced prior to working their next scheduled shift by the Administrator, Director of Nursing, and or Licensed Nurse. All new hires will be educated during their onboarding process. During validation the facility did not have any new hires.
8. Review of Advance Directive Audit completed by the Social Service Director to include POLST, physician order, and care plan reviewed. The audit form is dated [DATE]. The audit revealed 21 residents with a Do Not Resuscitate order and 58 residents with a full code order to resuscitate. The audit form indicated if the face sheets were correct and the date of correction of [DATE].
9. Review of CPR certifications for 10 of 10 licensed staff revealed licensed staff received CPR certification on [DATE], including a course provided by a certified CPR instructor,
hands-on skills check off, and a written test. Effective date of certification [DATE] through an expiration date of [DATE]. A review of 11 licensed nurses' CPR certifications revealed 11 licensed nurses with current CPR certifications with expiration dates of 10/2024 through 3/2026. Observation of CPR training in progress on [DATE] at 3:30 pm.
10. A review of 20 Advance Directive audits revealed audits with a completion and correction
date of [DATE]. Audits indicated the resident's name, care plan, and code status.
11Confirmed with LPN DD on [DATE] at 11:55 pm revealed she saw the Regional Nurse Consultant and the Regional [NAME] President of Operations at the facility on Wednesday, [DATE] during day shift.
12. An Ad HOC sign form dated [DATE] Emergency Notifications/Emergency Response Management revealed the Administrator, Director of Nursing, Activity Director, Business Office Manager, Dietary Manager, Director of Business Development, Director of Rehab, HR/MR/Payroll, HSKP Supervisor, Maintenance Director, Social Services, and Unit Manager.
A phone interview with the Medical Director on [DATE] at 11:50 am revealed he attended the Ad HOC meeting via phone.
13. All corrective actions were completed by [DATE].
14. All immediacy of the IJ was removed on [DATE].
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 staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the A...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and a review of the Administrator and Director of Nursing (DON) Job Description, the Administration failed to ensure that staff were following appropriate procedure when providing Cardiopulmonary Resuscitation (CPR) for one resident (R1) of 14 residents reviewed for code status.
On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and DON were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:14 a.m. The noncompliance related to the IJ was identified to have existed on [DATE].
An Acceptable Removal Plan was received on [DATE]. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE].
Findings include:
The facility had a Job Description for the job title of Administrator. The description included that the Administrator's primary purpose is to oversee the day-to-day operation of the facility and to review organizational performance. Oversee that residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. Monitor competence of the work force and make necessary adjustments/corrections as required or that may become necessary. Ensure that policies and procedures are developed, implemented, monitored, and evaluated in order to maintain compliance with federal, state, and local rules and regulations.
The facility had a Job Description for the job title of DON. The description included that the Director of Nursing primary purpose is to plan, organize, develop, and direct the overall operation of the Nursing Department to ensure that the highest degree of quality care is maintained at all times. Review nurses' notes to ensure that they are informative, descriptive of the nursing care and consistent with therapy care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Direct the Nurse Educator in the planning, conducting, and scheduling of timely in-service training classes to ensure a well-educated nursing services department. Training would include OSHA, CDC, TB management and blood borne pathogens as well as other in-service training required by state/federal regulations.
The facility failed to provide effective oversight and monitoring of facility procedures related to Full Code residents requiring CPR.
The facility provided an undated policy Emergency Response Management Cardiopulmonary Resuscitation (CPR), revealed: Standard: To ventilate and establish circulation on a resident with absence of respirations and pulse. Note: Nurses (required) CNAs (suggested) maintain current CPR certification.
Procedure: Determine unresponsiveness by briskly rubbing your knuckles against resident's sternum and deliver two rescue breaths to the unresponsive victim who is not breathing and start chest compressions immediately. If the resident wakes, moan or moves then CPR is not necessary. Call out for help. Delegate a specific individual to check physician orders; CPR order/DNR administrative personnel per facility policy and report back to individual as soon as possible. If an AED is immediately available, deliver one shock if instructed by the device, then begin CPR.
CPR in three simple steps: 1. Call: Check the victim for unresponsiveness. If the person is not responsive and not breathing or not breathing normally, call for assistance or call 911. 2. Pump: If the victim is still not breathing normally, coughing, or moving, begin chest compressions. Push down the center of the chest 2 inches, 30 times. Pump hard and fast at the rate of 100 compressions per minute. 3. Blow: After 30 chest compressions tilt the head back and lift the chin. Pinch the nose and cover the mouth with yours (may use a mouth guard if available) and blow until you see the chest rise. Give 2 breaths. 4. Continue with 30 pumps and 2 breaths until help arrives.
R1 had a physician's order dated [DATE] to attempt resuscitation in the event he had no pulse and was not breathing.
Record review of the Nurse's Progress Note dated [DATE] at 4:35 pm revealed that R1 was found not arousable by verbal or physical stimuli and noted not to have any vital signs on [DATE] at 4:35 pm. Licensed Practical Nurse (LPN) AA exited the room, went to the nurse's station, and paged a code. LPN AA returned to R1's room along with LPN BB and Registered Nurse (RN) CC and initiated CPR. LPN BB called the Medical Director (MD) on [DATE] at 4:55 pm. The MD gave the order to stop CPR. RN CC pronounced R1 on [DATE] at 4:55 pm.
There was no documentation that the facility staff contacted Emergency Medical Services (EMS).
Record review revealed on [DATE] at 4:35 p.m., R1 had a change of condition. LPN AA, LPN BB, and RN CC started CPR at 4:40 p.m. and continued until 4:55 p.m. when CPR was stopped, and RN CC pronounced the resident deceased .
Interview on [DATE] at 3:20 pm with the DON revealed that one person is responsible for compressions, one person calls EMS, and one person does AMBU (manual breathing). She stated that she was not sure if LPN AA called EMS. The DON verified that there was no documentation that EMS was called.
Interview on [DATE] at 11:40 am with the Administrator revealed he was not sure if the facility has an AED or defibrillator. He stated that he had not been at the facility that long. The Administrator further revealed that he was not sure of the policy for CPR, but he would check with the DON and see what their CPR policy stated.
Cross refer to F678.
The facility implemented the following actions to remove the IJ:
1. The administration failed to notify emergency management while providing Cardiopulmonary Resuscitation on [DATE]. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR.
2. The Administrator and DON were re-educated on [DATE] by the Regional [NAME] President of Operation on Clinical Emergency Response Policy.
3. On [DATE], the Regional Nurse Consultant re-educated the Administrator and DON on the job description.
4. The Administrator will have daily calls with the Regional [NAME] President of Operations regarding process of the plan, identified concerns and non-compliance identified items beginning on [DATE]. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR) including weekends and holidays.
5. The Regional Nurse Consultant and Regional [NAME] President of Operations will visit the facility daily beginning [DATE] to ensure compliance and identify any areas of concern with not notifying emergency management (9I I) during CPR, beginning on [DATE]. A review of the findings will be placed in a weekly trip report by the Regional Nurse Consultant and Regional [NAME] President of Operations.
6. All corrective action was completed on [DATE].
7. The immediacy of the IJ was removed on [DATE].
The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:
1. The Administration failed to notify emergency management while providing Cardiopulmonary Resuscitation on [DATE]. The licensed nurse failed to notify 911 during CPR. It was identified the facility failed to implement all components of the Clinical Emergency Response Policy that included notifying 911 during CPR.
2. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional [NAME] President of Operation provided to the Administrator and DON. Education included handouts on Clinical Emergency Response Management, Cardiopulmonary Resuscitation (CPR) standards and procedures, and Emergency Crash Cart standards and procedures. Confirmed education with DON on [DATE] at 8:45 am, and Administrator on [DATE] at 11:30 am.
3. A review of the sign-in sheet dated [DATE] revealed an in-service conducted by the Regional Nurse Consultant provided to the Administrator and DON. Confirmed education with the DON on [DATE] at 11:00 am.
4. Beginning on [DATE], the Administrator will have daily calls with the Regional [NAME] President of Operations regarding the plan's process, identified concerns, and non-compliance items. The Administrator and/or DON will update daily the Advance Directive Audit tool and the Event Monitoring tool (to include residents who receive CPR), including weekends and holidays.
Interview on [DATE] at 8:30 am with the DON revealed there was a change in leadership. The DON stated that the Administrator who was there is no longer there, and she has stepped into the role of the Administrator, and her Administrator license was verified.
5. Regional Nurse Consultant and Regional [NAME] President of Operations were observed at the
facility on [DATE], [DATE], and [DATE]. Confirmed with LPN DD on [DATE] at 11:55 am revealed she saw the Regional Nurse Consultant and the Regional [NAME] President of Operations at the facility.
6. All corrective action was completed on [DATE].
7. The immediacy of the IJ was removed on [DATE].
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, staff and resident interviews the facility failed to document administered bathing for two of three sampled residents (R) (5 and R10) and failed to provide setup a...
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Based on observation, record review, staff and resident interviews the facility failed to document administered bathing for two of three sampled residents (R) (5 and R10) and failed to provide setup and clean up after a meal for one resident (R) (10). This failure had the potential to negatively impact residents quality of life and decrease functional status.
Findings include:
1. Record review of the Electronic Medical Record (EMR) revealed R5 had a diagnosis that included contracture of the right and left hands, pressure ulcer of left hip stage four, and muscle weakness.
Record review of the most recent Annual Minimum Data Set (MDS) assessment for R5 dated 9/15/2023 revealed the resident required total assistance for toileting, personal hygiene, and bathing with two staff for bathing and toileting.
Record review of the care plan for R5 dated 5/11/2018 revealed . [named R5] has an ADL [activity of daily living] Self Care Performance Deficit r/t [related to] Severe Traumatic Brain Injury, Unable to do anything for herself, totally dependent for ALL ADL's and Mobility .
Record review of the EMR revealed no bathing documented for R5 for September and October 2023.
A review of the shower sheets for September 2023 and October 2023 revealed R5 received five showers for September 2023 and six showers for October 2023.
Observation of R5's room on 11/21/2023 at 9:03 am revealed a stop sign on the outside of the door. R5 was not in the facility but was discharged to the hospital.
During a telephone interview on 11/22/2023 at 5:53 pm, the Resident Representative (RP) of R5 stated she smelled awful because she was not bathed. The RP further revealed her hands were contracted, and her nails grew long and became dirty.
Interview on 11/29/2023 at 12:15 pm, Licensed Practical Nurse (LPN) CC stated R5 was aware of her surroundings, but she was mostly in a vegetative state. R5 was repositioned every two hours with a wedge and the Certified Nurse Aides (CNA) checked and changed R5.
Interview on 11/29/2023 at 12:17 pm, CNA DD (Shower CNA) stated the C, D, and E halls residents received showers on Tuesdays and Thursdays. The A and B halls received showers on Monday and Wednesday. CNA DD revealed that Fridays were the makeup days for any resident who missed or just wanted a shower. The CNAs used shower sheets to chart which resident they administered a shower to. CNA DD further revealed R5 was getting a daily bed bath. If a resident refuses CNA DD would speak with the resident and then report it to the nurse. CNA DD did not know where the information of refusals was documented, but the assigned CNA will bring the resident to the shower room or report they already had a bed bath.
2. Record review of the EMR revealed R10 had a diagnosis that included neuroleptic-induced parkinsonism, muscle weakness, and lack of coordination.
Record review of the most recent Annual MDS assessment for R10 dated 11/3/2023 revealed the resident had a BIMS score of 14, indicating no cognitive impairment. Continued review revealed R10 required substantial assistance for showering and setup and clean up assistance before and following a meal.
Record review of the care plan for R10 dated 11/25/2021 revealed . [named R10] requires assistance with ADL's r/t confusion, Dementia, Impaired balance .The resident is able to assist with actual bathing once in shower .
Record review of the EMR revealed no bathing documented for R10 for September, October, and November of 2023.
A review of the shower sheets for September 2023, October 2023, and November 2023 revealed R10 received two showers for September 2023, one shower for October 2023, and one shower for November 2023.
Observation in R10's room on 11/21/2023 at 3:12 pm revealed the resident lying on his back. The bed was in a low position. The resident mouth was full of dark orange debris on his mouth and the sides of his mouth.
Observation in R10's room on 11/22/2023 at 8:04 am revealed a plate of breakfast food on the bedside table near the bed. The feet of the bed were up, and the head of the bed was down. R10 was lying on the bed. A piece of bread was eaten and was hanging off the plate. The plate had bacon, grits, eggs, milk, and juice.
Observation and interview in the dining room on 11/22/2023 at 2:08 pm revealed R10 seated at a table during lunch. He was wearing a clothing protector. R10 revealed he fed himself meals. R10 stated he ate mostly in his room, and was supposed to be raised up while eating.
Interview on 11/22/2023 at 2:12 pm, Certified Nurse Aide (CNA) AA stated she did not normally care for R10 but had done so in the prior. CNA AA revealed R10 could eat by himself, and that she sat him up this morning. CNA AA further stated that staff said he could move himself in the bed and can walk. CNA AA said that she remembered asking him if he wanted jelly or butter and he declined. It was 20 minutes prior when she had brought his breakfast tray.
Interview on 11/22/2023 at 2:16 pm, Registered Nurse (RN) BB stated R10 would eat his food partly and then lay flat. RN BB revealed that R10 sometimes wants assistance when he eats his meals, and he does have behaviors. What we saw this morning was a behavior. He will get in and out of bed. RN BB stated that R10 will pull the call light out of the wall, throw things and throw his food tray. He normally does not need assistance.
Interview on 11/29/2023 at 12:24 pm, the Restorative CNA EE stated R10 was assigned to be setup for meals. His abilities to perform his ADLs and movement varied from day to day.
Interview on 11/29/2023 at 1:01 pm, the Director of Nursing (DON) stated the CNAs were required to document their completed ADLs performed for the residents in the EMR. The residents can receive showers whenever they want a shower. The DON revealed that the protocol was to inform the nurse or unit manager if a resident refused a shower and to make a nurse's note.
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
Based on observation, staff interviews, record review, and review of the facility's policies titled, Administration of Enteral Feedings: Continuous and Diet Ordering the facility failed to have start ...
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Based on observation, staff interviews, record review, and review of the facility's policies titled, Administration of Enteral Feedings: Continuous and Diet Ordering the facility failed to have start and stop times for a continuous enteral feeding for two of two residents (R) (5 and 11) and failed to have a complete diet order for one of one resident (R) (11).
Findings include:
A review of the facility's policy titled, Administration of Enteral Feedings: Continuous dated October 2023 revealed .Per facilities protocol and after reviewing physician orders from the resident's medical record, confirm the following information prior to initiating enteral therapy: Right time for therapy and/or medication .
1. Record review of the most recent Annual Minimum Data Set (MDS) assessment for R5 dated 9/15/2023 revealed the resident required a feeding tube while in the facility.
Record review of the care plan for R5 dated 5/11/2018 revealed . [named R5] at risk for and has a HX [history] of unplanned/unexpected weight loss r/t [related to] dependent for nutrition and hydration .administer nutrition/hydration via gastrostomy tube as indicated .
Record review of the physician orders for R5 dated 3/28/2022 revealed .___1.5 at 55 ml/hr [milliliters/hour] x 22 hours/Day every shift feeding pump .
Record review of the Medication Administration Record (MAR) for R5 dated October 2023 revealed: .Enteral Feed Order every shift for Supplement ___ 1.5 ml/hr x 22 hrs/day . Continued review revealed there was a place for the nurses to check during the day and night when it was administered.
Record review of the MAR for R5 dated October 2023 revealed .Hold ____ 1.5 x 2 hours daily one time a day for tube feeding . Continued review revealed there was a place for the nurses to check during the day when it was administered.
Record review of the MAR for R5 dated October 2023 revealed: .Resume ____ 1.5 one time a day for tube feeding . Continued review revealed there was a place for the nurses to check during the day when it was administered.
Observation on 11/21/2023 at 9:03 am of R5's room revealed a stop sign on the outside of the door. R5 was not in the facility but was discharged to the hospital.
During a telephone interview on 11/22/2023 at 5:53 pm, the Resident Representative (RP) of R5 observed the facility staff would turn off R5's continuous enteral feedings and forget to attach her back to the enteral feedings. The RP of R5 knew about the continuous feedings and that R5 needed to be turned off for two hours. The RP of R5 felt the nurses were not following the physician's orders.
2. A review of the facility's policy titled, Diet Ordering dated August 2021 revealed .All residents' diets shall be served according to the attending physician's written order .Special nourishments/supplements shall be provided for any resident for which they are deemed necessary and have a physician's order. Special consideration is given to residents who are underweight and residents who have pressure injuries .
Record review of the most recent quarterly MDS assessment for R11 dated 10/20/2023 revealed the resident had a BIMS score of 99 indicating the resident was unable to participate in the cognitive assessment. Continued review revealed that R11 required a feeding tube and had swallowing difficulties such as coughing and choking during meals.
Record review of the care plan for R11 dated 1/12/2023 revealed . [named R11] has unplanned/unexpected weight loss r/t Dependent for Nutrition and hydration via Gastrostomy tube .10/24/2023-Enteral feeding changed to ____ 1.5 as indicated. Administer feedings via gastrostomy tube as indicated .
Record review of physician orders for R11 dated 9/19/2023 revealed .Regular diet, Pureed texture, NPO (noting by mouth) consistency .
Record review of the physician orders for R11 dated 10/24/2023 revealed .Enteral Feed Order every shift for G tube/feeding pump ____ 1.5 at 75 ml/hr for 22 hrs a day. Continued review revealed there was a place for the nurses to check during the day and night when it was administered .
Observation on 11/27/2023 at 2:50 pm, in the hallway by the A & B nurses' station revealed R11 seated in a chair with a blanket over her hands. Continued observation revealed the resident was not connected to an enteral feeding pump for continuous feeding.
Observation and interview in R11's room on 11/28/2023 at 10:35 am revealed R11 in bed the feeding pump was on hold. The Speech Therapist (ST) was in the room with R11. The ST stated that R11 was scheduled for puree pleasure feedings four to five times a week. It is either a pudding or apple sauce. At 10:37 am the ST turned the pump back on.
Interview on 11/27/2023 at 2:59 pm with Licensed Practical Nurse (LPN) FF stated the enteral feeding order for R11 did not have a time of when to start the feeding and when to take her off for the two-hour rest. LPN FF stated that R11 was taken off around lunchtime. R11 is put back to bed towards the end of the day shift. The shift starts at 3:00 pm and she was one of the ones that would go back to her bed before the other shift came to work.
Interview on 11/28/2023 at 4:00 pm, the Director of Rehabilitation stated she did not see a complete order for pleasure food for R11.
Interview on 11/28/2023 at 4:06 pm, with ST stated she had spoken with the nursing department regarding the recommendation for pleasure food for R11. The ST revealed the nursing department recommends frequency or amount of pleasure food and not the speech therapy department. This deficient practice had the potential to place residents at risk for inadequate nutritional intake.
Interview on 11/28/2023 at 4:32 pm, the DON and Unit Manager (UM) stated any recommendations that are made by the Therapy department are discussed with the Medical Director (MD). If the MD agrees then it is put on the MAR. The DON further revealed that some of the nurses are nervous about giving R11 her pleasure snack. Continued interview revealed the order was to be as tolerated. The DON expected the nurses to try the pleasure snack after medication administration and at different times.
Interview on 11/29/2023 at 1:01 pm, the Director of Nursing (DON) stated there was never a specific time for continuous enteral feeding. It was only specified to have the residents on the enteral feeding for 22 hours a day. R11 would not be in the hallway receiving enteral feeding because her RP would not allow it. The DON stated she would not expect the nurses to document when they take a resident off their continuous feeding because the night shift does not turn off the enteral feedings. The continued interview revealed that R11's order had just been clarified, and she was to get a snack BID (twice a day).
Oct 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure that a safe, clean, and home like environment was maint...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to ensure that a safe, clean, and home like environment was maintained for six of 10 room on the E hall, and three of eight rooms on the D hall. This failure had the potential to place residents at risk for the use of unsanitary and unsafe environments and a potential for diminished quality of life.
During the initial tour of the facility on 10/6/2023 at 8:40 am the following environmental concerns were observed: Observation on D and E halls revealed floors scuffed up with dark black streaks down hallway and in residents' rooms. D hall had three of eight rooms observed floors and room doors with dark streaks. E hall had six of 10 rooms observed floors and room doors with dark streaks.
D hall room [ROOM NUMBER] observed a high back chair with the cushion torn and exposed, room [ROOM NUMBER] walls observed with black scuff marks, bathroom door and floor dirty with black scuff marks. Right side entry way floor of room [ROOM NUMBER] observed the tile dirty and cracked. Six of ten rooms on E hall Observed floors in six of 10 room doors with dark streaks. Wall by B bed observed with chipped paint, wall by window scuffed up. E hall room [ROOM NUMBER] floors scuffed up with dark black streaks. Wall by B bed observed with chipped paint, wall by window observed with chipped paint. E hall room [ROOM NUMBER] wall by left side of sink observed the cold base peeling, bathroom door scuffed and dirty.
Pictures of all environmental issues observed in the nine resident rooms were verified by the Administrator on 10/7/2023 at 1:00 pm during walking room rounds.
Interview with the administrator on 10/07/2023 at 1:53 pm, the administrator stated that they have identified environmental issues and started a PIP in August 2023. Administrator stated that she adds to the PIP so it's ongoing. Administrator provided a copy of a PIP dated 3/25/2021. Administrator stated that she would get the maintenance director to stop what he was doing and start to work on those rooms identified by the surveyor.
10/7/2023 at 10:00 am the following environmental concerns were observed: Observation on D and E halls revealed floors scuffed up with dark black streaks down hallway and in residents' rooms. D hall three of eight rooms observed floors and room door with dark streaks.
D hall room [ROOM NUMBER] observed a high back chair with the cushion torn and exposed, room [ROOM NUMBER] walls observed with black scuff marks, bathroom door and floor dirty with black scuff marks. Right side entry way floor of room [ROOM NUMBER] observed the tile dirty and cracked. Six of ten rooms on E hall Observed floors in six of 10 room doors with dark streaks. Wall by B bed observed with chipped paint, wall by window scuffed up. E hall room [ROOM NUMBER] floors scuffed up with dark black streaks. The wall by B bed observed with chipped paint, wall by window observed with chipped paint. E hall room [ROOM NUMBER] wall by left side of sink observed the cold base peeling, bathroom door scuffed and dirty.
Interview on 10/8/2023 at 10:17 am with the Maintenance Director (MD) revealed he has been in the position for two years. He stated that he works on the floor continuously. He stated that they try and have a plan but sometimes you can't go by the plan. He stated that he does not have an assistant. The MD stated that they had an outside contractor that did the wallpaper but not the rooms. He stated that he goes into rooms and visually checks for repairs. He stated that nurses and staff do guardian rounds, and they make out a work order. He stated that sometimes when they see him in the hall, they just verbally tell him. He stated that he painted the outside of D and E hall but not the rooms. The MD stated that he painted most of the rooms but has not completed all the rooms. He stated that he thinks that they have enough work for them to get a full-time painter. He stated that he has not expressed this to the administrator. The MD stated that he does the best he can, and he tries to make the residents happy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R46 was admitted on [DATE] and re-admitted on [DATE] with diagnoses of chronic post-traumatic stress disorder dated 1/7/2021 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R46 was admitted on [DATE] and re-admitted on [DATE] with diagnoses of chronic post-traumatic stress disorder dated 1/7/2021 and major depressive disorder dated 1/11/2023.
Review of the Admissions Minimum Data Set (MDS) dated [DATE] revealed section A1500 the resident currently not considered to have serious and/or intellectual disability or related conditions.
Review of the physicians' orders revealed an order dated 2/24/2023 for Sertraline Hydrochloride (a medication used to treat major depressive disorder and post-traumatic stress disorder) 12.5 milligrams (mg) by mouth one time a day.
Review of the care plan initiated on 1/11/2023 included (not all inclusive) a focus area of resident is at risk for insomnia related to PTSD and depression.
Review of the electronic medical record (EMR) revealed the PASRR Level I dated 12/14/2020 did not document R46 had diagnoses of PTSD and major depressive disorder.
There was not a PASRR Level II in the EMR.
Interview on 10/7/2023 at 1:55 pm with the Director of Nursing (DON) revealed the admission Director reviewed the diagnoses of newly admitted or readmitted residents. She stated if the Admissions Director was unsure about a diagnosis, she notified the DON, and the clinical staff would review the diagnoses and determine if a submission for a PASRR Level II should be submitted.
Interview on 10/7/2023 at 2:05 pm with the Admissions Director revealed she had worked as the Admissions Director for two weeks. She stated she had not had formal training on the process of PASRR and she trusted the PASRR Level I for R46 was accurate since the hospital had completed and submitted it prior to admission to the facility.
Interview on 10/7/2023 at 2:10 pm with the Administrator revealed the admission Director should review the diagnoses of a newly admitted resident to determine if a submission for a PASRR Level II should be submitted. She stated there was not a system in place for clinical staff to review diagnoses of newly admitted residents. She stated she trusted the hospital completed and submitted the PASRR Level I correctly prior to a residents' admission to the facility.
4. R90 was admitted on [DATE] with primary diagnosis of paranoid schizophrenia.
Review of the Admissions Minimum Data Set (MDS) dated [DATE] revealed section A1500 the resident currently not considered to have serious and/or intellectual disability or related conditions.
Review of the physicians' orders revealed an order dated 8/2/2023 for olanzapine 2.5mg (a medication used to treat schizophrenia and bipolar disorder) tablet by mouth two times a day for schizophrenia.
Review of the care plan initiated on 8/4/2023 included (but not all inclusive) a focus area of resident is resistive to care related to paranoid schizophrenia.
Review of the electronic medical record (EMR) revealed the PASRR Level I dated 8/2/2023 did not document R46 had diagnoses of PTSD and major depressive disorder.
There was not a PASRR Level II in the EMR.
Interview on 10/7/2023 at 1:55 pm with the Director of Nursing (DON) revealed the admission Director reviewed the diagnoses of newly admitted or readmitted residents. She stated if the Admissions Director was unsure about a diagnosis, she notified the DON, and the clinical staff would review the diagnoses and determine if a submission for a PASRR Level II should be submitted.
Interview on 10/7/2023 at 2:05 pm with the Admissions Director revealed she had worked as the Admissions Director for two weeks. She stated she had not had formal training on the process of PASRR and she trusted the PASRR Level I for R90 was accurate since the hospital had completed and submitted it prior to admission to the facility.
Interview on 10/7/2023 at 2:10 pm with the Administrator revealed the admission Director should review the diagnoses of a newly admitted resident to determine if a submission for a PASRR Level II should be submitted. She stated there was not a system in place for clinical staff to review diagnoses of newly admitted residents. She stated she trusted the hospital completed and submitted the PASRR Level I correctly prior to a residents' admission to the facility.
2. R16 was admitted to the facility on [DATE] with diagnoses that included but not limited to bipolar disorder, and schizoaffective disorder.
Review of R16's annual Minimum Data Set (MDS) dated [DATE] revealed:
Section C-Cognition: Brief interview of mental status (BIMS) score of nine (9) indicating moderate cognitive deficit.
Section N-Medications: Antipsychotic and antidepressant use for seven (7) days during review period.
Review of R16's Physician orders revealed but not limited to:
Abilify Tablet 5 mg (Aripiprazole) give 1 tablet by mouth in the morning for schizoaffective d/o.
Mirtazapine 7.5 mg tablet give 1 tablet by mouth at bedtime for schizoaffective d/o.
Review of a Social Services Progress note dated 9/15/2023 revealed:
R16 is a [AGE] year-old white female resident. Resident has not had any changes in adaptive devices and uses a manual wheelchair to propel the facility. Resident takes medications for a primary dx of schizoaffective disorder. Resident is observed and psych services are as indicated. Resident does not have any behaviors this assessment period and responded no to all mood assessment questions with none noted by staff.
5/6/2023 05:02 Behavior Note Text: this resident has repeatedly told her roommate to get out, this is not your room and you do not belong here, I have assisted resident to room X6, put her in the bed, explained to her that this resident does belong in this room, but she continues to disagree and the roommate leaves the room X6 and sleeps/sits in chair in front of nurses station.
Interview with the administrator on 10/07/23 at 12:47 pm, the administrator stated that the facility does not do a level II after a resident is admitted to the facility. She stated R16's primary diagnosis on admission was respiratory distress. Continued interview with the administrator on 10/7/2023 at 2:10 pm revealed the admission Director should review the diagnoses of a newly admitted resident to determine if a submission for a PASARR Level II should be submitted. She stated there was not a system in place for clinical staff to review diagnoses of newly admitted residents. She stated she trusted the hospital completed and submitted the PASARR Level I correctly prior to a residents' admission to the facility.
Interview with the DON on 10/07/23 01:00 pm revealed R16 does not have any behaviors that she is aware of such as screaming, yelling, or being disruptive. Continued interview with the DON on 10/7/2023 at 1:55 pm revealed the admission Director reviewed the diagnoses of newly admitted or readmitted residents. She stated if the Admissions Director was unsure about a diagnosis, she notifies the DON, and the clinical staff would review the diagnoses and determine if a submission for a PASARR Level II should be submitted.
Interview on 10/7/2023 at 2:05 pm with the Admissions Director revealed she had worked as the Admissions Director for two weeks. She stated she did not have formal training on PASARRs and trusted the PASARR Level I was accurate since the hospital had completed and submitted it.
Interview with LPN HH on 10/08/23 at 7:40 am revealed R16 does not have any behaviors.
Interview with CNA GG on 10/08/23 at 07:55 am revealed R16 does not have any behaviors.
Based on record review, staff interviews, and review of the facility policy titled Pre-admission Screening and Resident Review, the facility failed to complete a new Pre-admission Screening and Review (PASRR) level II after admission to the facility to include resident (R) R46, R90, R43 and R16. This had the potential to affect four of six residents reviewed with a qualifying psychological diagnosis.
Findings include:
Review of the facility policy titled Pre-admission Screening and Resident Review effective August 2022, revealed:
All applications to a Medicaid certified Nursing Facility are to receive a level I preliminary assessment to determine whether they might have a mental illness, intellectual disability, or related condition. If one of the above conditions is identified, the Social Worker (SW) will make a referral for a level II assessment.
Readmissions may have a new diagnosis that will need to be added to the resident's assessment and will trigger a new PASRR to be completed. The SW is responsible to review and ensure new PASRR is completed.
1. R43 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury (TBI), moderate intellectual disability, bi-polar disorder, and schizoaffective disorder.
Review of R43's quarterly Minimum Data Set (MDS) dated [DATE] revealed:
Section C-Cognition: Brief interview of mental status (BIMS) score of nine indicating moderate cognitive deficit.
Section G-Function Status: Supervision with bed mobility, walking, toileting, and personal hygiene; Independent with transfers and eating; Extensive assistance with dressing; Total dependent with bathing.
Section N-Medications: Antipsychotic and antidepressant use for seven days during review period.
Review of R43's care plans include but not limited to:
R43 has impaired cognitive function related to mental retardation (MR), TBI, psychosis and hitting other residents.
At risk for fluctuations in mood and behavior related to MR and TBI.
At risk for behaviors related to injury to self, related to schizophrenia disorder, has inappropriate behaviors problem of lying on the floor anywhere in the building, running in hallways, leaves wheelchair in hallway and runs, refuses to wear footwear.
Review of R43's Physician orders revealed but not limited to:
Seroquel extended release (ER) tablet give 200 milligrams (MG) by mouth (PO) at bedtime (HS) for psychosis.
Trazodone 50 MG give 1.5 tablest PO HS for insomnia.
Depakote ER tablet give 250 mg PO two times a day (BID) for mania related to bipolar disorder, schizoaffective disorder, and psychosis.
Ziprasidone HCl capsule 80 MG give 1 capsule PO BID for TBI with Psychosis.
Oxcarbazepine tablet 150 MG give 1 tablet PO three times a day (TID) for mood stabilization/manic related to bipolar disorder, schizoaffective disorder, and psychosis.
Review of a Social Services Progress note dated 9/13/2023 revealed:
R43 is a [AGE] year-old white male resident. Resident is alert with confusion and forgetfulness .Resident recently returned to the facility on 9/6/2023 after a psychiatric stay at the hospital. Resident takes medications for bipolar, mania/mood, psychosis, and insomnia. Resident is observed and psychiatric services are as indicated. Resident responded no to all mood assessment .
Review of a behavioral health note dated 9/12/2023 revealed:
.Monitoring psychotic behavior, aggression, medication, and readmission.
Resident was admitted to an in house psychiatric unit 8/29/2023 through 9/6/2023 for increased behaviors towards staff that escalated.
Observation on 10/06/2023 at 10:02 am of R43 revealed the resident in the dining room with other residents drinking coffee. Resident then got up and walked down the hall with his cup of coffee, in covered cup, staff attempted to intervene and have him sit and drink coffee and resident dropped the cup of coffee on the floor. Staff had resident sit and he calmed down.
Interview on 10/7/2023 at 1:55 pm with the Director of Nursing (DON) revealed the admission Director reviewed the diagnoses of newly admitted or readmitted residents. She stated if the Admissions Director was unsure about a diagnosis, she notifies the DON, and the clinical staff would review the diagnoses and determine if a submission for a PASRR Level II should be submitted.
Interview on 10/7/2023 at 2:05 pm with the Admissions Director revealed she had worked as the Admissions Director for two weeks. She stated she did not have formal training on PASRR and trusted the PASRR Level I was accurate since the hospital had completed and submitted it.
Interview on 10/7/2023 at 2:10 pm with the Administrator revealed the admission Director should review the diagnoses of a newly admitted resident to determine if a submission for a PASRR Level II should be submitted. She stated there was not a system in place for clinical staff to review diagnoses of newly admitted residents. She stated she trusted the hospital completed and submitted the PASRR Level I correctly prior to a residents' admission to the facility
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interviews and record review, the facility failed to provided treatment and care in accordance with professional standards for one of 32 sampled residents (R) (R244) related to (...
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Based on observation, interviews and record review, the facility failed to provided treatment and care in accordance with professional standards for one of 32 sampled residents (R) (R244) related to (1) failed to assess and monitor bruises to bilateral arms and failed to follow physician orders related to weekly skin audits.
Findings included:
A review of the facility's undated policy titled Skin Management Standards revealed all residents will be checked for skin condition changes and/or alterations daily during routine care by the certified nursing assistant. Any changes in skin condition will be reported to the licensed nurse. All residents will receive a head-to-toe body audit by a licensed nurse on admission, transfer, re-admission, weekly, and upon change in condition. Any change in resident's skin condition will be documented and immediately reported to the supervising nurse. The supervising nurse is responsible for notifying the Wound Care Nurse and/or the Director of Nursing of changes in a resident's skin condition. The Wound Care Nurse is responsible for reviewing Body Audits at least on a weekly basis and PRN on all residents and for implementing appropriate treatment interventions, per physician order. The resident's physician and responsible party shall be notified of a change in the resident's skin condition. Quarterly skin audits are coordinated by the Director of Nursing to ensure all resident skin data is accurate.
On 10/6/2023 at 12:26 p.m. R244 was observed in bed. Resident had multiple red- and purple-colored bruises to the left forearm and hand and multiple red bruises to the right forearm. In addition, resident had two open areas to left forearm and hand with dried blood. R244 was alert but confused.
Review of the Electronic Medical Record (EMR) revealed that R244 had a diagnoses of, but was not limited to neuroleptic induced parkinsonism, schizoaffective disorder, depressive type, age-related cognitive decline, cognitive communication deficit, and generalized muscle weakness.
Review of the current physician orders in the EMR revealed resident was not receiving any medications that would potentially put resident at increased risk for bleeding. Further review of the current orders revealed an order for skin audit every day shift every Friday with a start dated of 8/4/2023.
Review of a Long-Term Care Evaluation in the EMR dated 9/15/2023 on page 19 and 20 under the skin section SI was documented as no skin issues.
Review of the Treatment Administration Record (TAR) revealed skin audits were documented as being complete on 9/1/2023, 9/8/2023, 9/15/2023, 9/22/2023 and 9/29/2023. Review of October 2023 TAR revealed residents skin audit was documented as complete on10/6/2023.
Record review revealed a progress note dated 10/3/2023 that reads: called to dining room by Certified Nursing Assistant (CNA). Resident noted getting on floor underneath table, no injuries noted. Will continue to observe. Further review of progress notes revealed five entries in the progress notes dated 9/27/2023 which indicated R244 was repeatedly getting onto the floor, no injuries noted.
Observations on 10/7/2023 at 8:31 a.m. and at 2:28 p.m. revealed R244 was wearing a short sleeve shirt and the bruises to residents arms were easily visible.
During an interview 10/7/2023 at 2:12 p.m. with CNA GG revealed that R244 is combative therefore rendering care to resident is a hit and miss due to his behaviors. CNA GG further stated R244 had not been combative today. CNA GG looked at the bruises on residents arms and stated that she did see the bruises but did not report it to the nurse because that is not abnormal for him. CAN GG stated normally she would report new bruises, but this was not out of the ordinary for R#244 because he has really tender skin.
During an interview 10/7/2023 at 2:18 p.m. with CNA BB revealed R244 did not have the bruises or scabbed areas on his arms when she last worked with him, and the areas are new. CNA BB further stated that she is required to report bruises and open skin areas to the charge nurse and treatment nurse as soon as she sees the areas.
During an interview 10/7/2023 at 2:24 p.m. with Licensed Practical Nurse (LPN) FF revealed that the treatment nurses are responsible for completing and documenting the weekly skin audits in the electronic record. LPN FF further stated that she was aware R#244 had red bruises on his left arm Wednesday 10/3/2023 and she reported her observations to the LPN Treatment Nurse EE at that time.
During an interview 10/7/2023 at 2:33 p.m. with Treatment Nurse EE and Treatment Nurse DD, TN DD confirmed that there were no skin assessments for R#244 since 9/8/2023. TN DD further confirmed that she documented the skin audits as completed on the TAR on 10/06/2023 but she did not have the opportunity to actually complete the assessment. TN EE and TN DD confirmed they are responsible for performing and documenting the weekly skin assessments in residents electronic record. Both treatment nurses looked at the bruises on R#244's arms and stated that they were not aware of resident having these areas on his arms.
During an interview 10/7/2023 at 2:37 p.m. with Director of Nursing (DON) revealed that she was aware that there was an issue with the treatment nurses completing the weekly skin audits. DON stated that the treatment nurses were documenting the weekly skin audits on the TARs but were not documenting the weekly skin audits/assessments in an assessment in the electronic record. DON stated both are required for compliance. DON stated that the treatment nurses were educated on the skin audit process. DON further stated that she and the Unit Managers had not had the opportunity to follow up for compliance.
Feb 2023
17 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, resident and staff interviews, record reviews, and a review of the facility policy titled, Freedom of Abu...
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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 policy titled, Freedom of Abuse, Neglect, and Exploitation: Abuse Prevention, the facility failed to ensure that two of 33 sampled residents (R) (#47 and #88) were free from physical abuse by another resident. The failure to assure residents were free from resident-to-resident abuse had the potential to cause either physical or psychosocial harm to R#47 and R#88.
Findings include:
Review of the facility's undated policy titled Freedom of Abuse, Neglect, and Exploitation: Abuse Prevention stated, The purpose of this standard is to provide the preventative steps taken by the facility staff to reduce the potential for mistreatment, neglect, misappropriation, exploitation and unreasonable confinement of residents residing in nursing facilities .Definitions- Abuse .willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Most Common Forms of Abuse .Physical: infliction of pain, injury which includes but is not limited to slapping, hitting, pinching, licking, shoving.
1. Review of the admission Record for R#47 provided by the facility, revealed that the resident was admitted with a primary diagnosis of quadriplegia.
Review of the Care Plan for R#47 located in the electronic medical record (EMR), indicated the resident was able to feed himself but required full assistance with all other activities of daily living (ADL's) due to quadriplegia status.
Review of a grievance submitted on 11/01/2021 by R#47, revealed he had expressed a concern to the Veterans Affairs Social Worker that other residents were wandering the halls and entering his room all day and night, Additionally R#47 told the Veterans Affair Social Worker he was assaulted by another resident within the last several months.
In response to this grievance, the facility performed an internal investigation and confirmed that physical abuse occurred on 06/14/2021. The allegation of physical abuse was submitted to the state agency as a facility reported incident on 06/14/2021. The investigation stated that on 06/14/2021, R#47 alleged that R#387 hit him in the mouth and twisted his arm. A nurse heard screaming coming from R#47's room. Both residents were immediately separated, and R#387 was placed on one-on-one observation. A full body assessment was completed, and the facility noted no injuries to R#47. An abuse in-services were completed with all staff during the investigation. Interventions put in place included placing a mesh STOP sign on his doorway to deter wandering residents from entering his room and moving R#47 to another hallway.
Review of a police report document titled, Incident Report- Narrative dated 6/14/2021, revealed R#387 then walked over to him and stated that he would take that from him R#47's Cellphone and back scratcher. R#47 advised that he pulled his items close to him and that, at that point, R#387 began twisting his arm, trying to get the items from him. R#47 advised that R#387 struck him in the mouth (no injuries were noted). R#47 advised that a nurse and the Physical Therapist came in and stopped R#387.
Review of the admission Record for R#387 provided by the facility stated the resident was admitted to the facility on [DATE] and discharged on 10/8/2021, with a diagnosis including dementia with behaviors.
Review of the Care Plan for R#387 dated 05/21/2021, The resident is an elopement risk/wanderer r/t [related to] resident wanders aimlessly walks up and down the hallway going in and out of others room .Distract resident from wandering by offering pleasant diversion activities, food, conversation, television, and books.
Observation on 01/31/2023 at 10:29 a.m. revealed a STOP sign on R#47's doorway, and the resident was resting in his bed with his eyes closed.
Interview on 02/02/2023 at 1:39 p.m. with a Licensed Practical Nurse (LPN) 4, she confirmed R#47 was struck by R#387 on 06/14/2021. LPN4 stated that R#387 had a history of wandering but would only become aggressive if someone approached him wrong.
2. Review of the admission Record for R#88 provided by the facility revealed the resident was admitted with a primary diagnosis of cerebral infarction and was discharged from the facility on 01/17/2022.
Review of the Care Plan for R#88, created on 07/26/2021, stated R#88 required assistance with activities of daily living (ADL's) related to hemiplegia, limited mobility, limited range of motion, and stroke.
Review of the admission Record for R#90 provided by the facility revealed that the resident was admitted to the facility with a primary diagnosis of dementia with behavioral disturbance. The resident was discharged from the facility on 09/11/2022.
Review of the Care Plan for R#90 indicated that R#90 required assistance with ADLs related to aggressive behavior, confusion, and impaired balance. Additionally, on 12/28/2021, the care plan added that R#90 had the potential to be physically aggressive related to poor impulse control and post-traumatic stress syndrome.
Review of the Progress Note for R#88 dated 01/02/2022 at 10:25 p.m. by LPN 10, revealed that R#90 became angry at the writer when he was told his volume on tv had to be turned down because of the time, and it was at 99. R#90 went over to the roommate's bedside after the writer left the room. The writer heard him yelling cry baby, profanity's and returned to the room to see him strike the roommate in the face on the left upper jaw area.
Review of the Progress Note for R#88 dated 01/02/2022 at 10:25 p.m. by LPN10 stated, R#88 was struck in the face by his roommate. Injury location: face, resident alert, and had pain of 6/10. Resident's left side of the face and jaw area are red, bottom lip slightly swollen.
Review of a Facility Reported Incident, dated 01/03/2022, revealed that Staff entered the room and witnessed
R#90 hitting R#88. Staff immediately removed R#90 to another room. Full skin assessment completed on R#88 with no negative findings. Education provided to staff on Freedom of Abuse. Pain assessment completed. Physician and both families notified of altercation. R#88 was placed 1:1. R#88's family member at facility rubbing residents face causing redness. R#88's family member requested for him to be sent to the hospital for evaluation .No findings of injury noted by the doctor at the hospital. Behavioral Health services to evaluate R#90. The residents were separated. R#88 was transferred to a different room. Although the incident was witnessed, it is not possible to determine why the incident occurred. This was the first incident R#88 has been involved. Staff will attempt to keep some distance between the two residents. R#88 will have increased supervision. Care plans for both residents updated.
Interview on 02/02/2023 at 1:21 p.m. with a Licensed Practical Nurse (LPN)9, she confirmed R#88 was assaulted by R#90. LPN9 stated that R#88 had previously sustained a stroke, was nonverbal, was able to make noises, would gesture, and required full assistance with ADL's. LPN9 further revealed that the staff heard R#88 yelling. R#90 was removed from their room when staff witnessed R#90 grab R#88's television remote and then hit R#88 on the face.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on resident and staff interviews, record review, and review of facility policy, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a...
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Based on resident and staff interviews, record review, and review of facility policy, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime (staff to resident verbal abuse) in accordance with section 1150B of the Act and failed to report the allegation of verbal abuse to the State Survey Agency for one of 11 residents (R#238) reviewed for abuse. These failures had the potential to contribute to further verbal abuse and possible psychosocial harm for R#238.
Findings include:
Review of the facility's policy dated 06/2017, Freedom of Abuse, Neglect, and Exploitation; Abuse/Incident Standard revealed, All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law . Ensure that all alleged violations involving abuse. neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is mode, if the events that cause the allegation involve abuse or result in serious bodily injury.
Review of the 2022 Grievance Log, provided on paper by the Social Services Director (SSD), revealed a Resident Grievance/Concern/Complaint Report, filed on 04/08/2022 on behalf of R#238. The report documented, Resident states he does not want Certified Nursing Assistant (CNA) 9 to be his CNA anymore he doesn't like how she works [sic], she is rude, rough, and she is very disrespectful. CNA stated she was not rude or disrespectful to the resident.
Interview on 02/01/2023 at 3:27 p.m. with the Regional [NAME] President of Operations (RVPO), she stated the allegation had yet to be reported to the State Survey Agency or to law enforcement. She added that she would submit a late report to the state, as well as institute a performance improvement plan to address reporting of all allegations of abuse.
In an additional interview on 02/01/2023 at 4:49 p.m. with the RVPO, she stated the typical protocol when an allegation of staff to resident abuse is received was to notify law enforcement and the State Survey agency within two hours.
Cross Reference F610
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on resident and staff interviews, record reviews, and review of the facility policy titled, Freedom of Abuse, Neglect, and Exploitation; Abuse/Incident Standard, the facility failed to implement...
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Based on resident and staff interviews, record reviews, and review of the facility policy titled, Freedom of Abuse, Neglect, and Exploitation; Abuse/Incident Standard, the facility failed to implement this policy for one of 11 residents (R#238) reviewed for abuse. Specifically, the facility failed to suspend a staff member pending an investigation into an allegation of verbal abuse towards R238. Allowing this staff to work, pending investigation, created the potential for continued verbal abuse towards the resident.
Findings include:
Review of the facility policy dated, 06/2017 Freedom of Abuse, Neglect, and Exploitation; Abuse/Incident Standard revealed, An immediate investigation into the alleged incident, during the shift it occurred on, is initiated as follows:
1. Complete incident report in PCC [Point Click Care - the facility's EMR (Electronic Medical Record) system] .
2. Interview the resident or other resident witnesses (e.g., roommate, if appropriate). The interview is to be dated, documented, and signed by the nursing supervisor .
3. Interview the staff member implicated. The interviewer is to document the staff member's knowledge and/or version of the incident in a written narrative that is dated and signed .
4. Interview all staff on that unit, as well as other staff or other available witnesses. The interviewer is to document the staff's knowledge of the incident in a written narrative .
Any employee suspected (alleged) of abuse will be suspended as the incident is reported; pending outcome of the investigation.
Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#238's, located in the MDS tab of the EMR, with an assessment reference date (ARD) of 01/01/2023, revealed R#238 scored 14 out of 15 points on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. He exhibited symptoms of depression, such as feeling down, feeling bad about yourself, and trouble sleeping but no behavioral symptoms. R#238 was able to make himself understood and understand others.
Interview on 01/30/2023 at 10:25 a.m. with R#238 in his room, R#238 stated he had been verbally abused by a female certified nurse aide (CNA). He added, She's mean as a snake . She refused to help me. R#238 stated he reported his allegation of verbal abuse to Licensed Practical Nurse (LPN) 4, who served as the unit manager. He added, I don't know if anything was done because she still works here on a different hall.
Review of the 2022 Grievance Log, provided on paper by the Social Services Director (SSD, revealed a Resident Grievance/Concern/Complaint Report, filed on 04/08/2022 on behalf of R#238. The report revealed, under the section on the form titled, Investigation Report, signed as completed by Licensed Practical Nurse (LPN) 4 on 04/08/2022, was documented, as CNA assigned to different hall. Informed CNA to just monitor tone. There was no additional documentation provided to indicate that a thorough investigation, which included interviews with staff and other residents, was completed. In addition, there was no evidence that the facility took steps to protect residents from the potential for further abuse by suspending the alleged perpetrator during the investigation, in accordance with facility policy.
Interview on 02/01/2023 at 3:27 p.m., with the Regional [NAME] President of Operations (RVPO), she stated the allegation had not been investigated. She added that she would immediately institute an investigation and a performance improvement plan to address investigating allegations of abuse.
Interview on 02/01/2023 at 4:49 p.m., with the RVPO, she stated the typical protocol when an allegation of staff to resident abuse is received, the employee is suspended, and an investigation is conducted. She further revealed that the investigation would include staff interviews and interviews with all cognitively aware residents who may have received care from the staff member or witnessed the event.
Cross Reference F609
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one Resident (R) (R#237) of one resident reviewed for baseline care plans. This deficient practice had the potential to increase the risk for R#237 to not receive services that met the immediate care needs present upon admission.
Findings include:
Review of the policy titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2019, revealed, Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care (42 CFR §483.21(a)).
Review of R#237's admission Record, revealed the resident was admitted on [DATE] with a primary diagnosis of type two diabetes mellitus.
Review of R#237's undated Baseline Care Plan, located under the Assessments tab in the electronic medical record (EMR), revealed the baseline care plan was incomplete and only included the resident's primary language, daily preferences, and medication allergies.
Interview on 02/02/2023 at 4:19 p.m., with the Minimum Data Set Coordinator (MDSC) revealed that she did not work at the facility at the time that R#237 was a resident and did not know why the baseline care plan was not completed. The MDSC confirmed that R#237 did not have a completed baseline care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on staff interviews, record review, and a review of the facility policy titled, RAI (Resident Assessment Instrument) Care Planning Management, the facility failed to ensure care plan interventio...
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Based on staff interviews, record review, and a review of the facility policy titled, RAI (Resident Assessment Instrument) Care Planning Management, the facility failed to ensure care plan interventions related to emergency tracheostomy care were developed for two of 33 sampled residents (R) (#7 and #63) reviewed for tracheostomy (a surgical opening into the windpipe for breathing) care. This failure increased the resident's risk for compromised airway/respiratory distress.
Findings include:
Review of a facility policy titled, RAI (Resident Assessment Instrument) Care Planning Management, revised 07/2022, revealed that Process for Completing the MDS (Minimum Data Set0, CAAs (Care Area Assessments) and Care Plans Standard: It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Objective: 1. To identify residents' individual needs and care requirements. 2. To assure that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. 3. To assure that all residents are reviewed and reassessed based on their individual needs and OBRA guidelines/
1. Review of the comprehensive Care Plan for R#7 dated 05/11/2018, under the Care Plan tab located in the EMR, revealed the resident has a Tracheostomy r/t [related to] Severe Traumatic Brain Injury. Further review of the care plan revealed the interventions did not include the tracheostomy brand, size, or cuff or uncuffed. The care plan further revealed Tube Out Procedures: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB [head of bed] 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. However, the care plan did not address maintaining an emergency trach kit at the bedside and did not address tracheostomy information (style, size, or cuffed or uncuffed).
Interview on 02/01/2023 at 12:03 p.m. with the MDS Coordinator (MDSC) revealed she had worked at the facility for three months and was in the process of reviewing and revising all the care plans. The MDSC stated that the former MDSC and unit managers developed the residents' care plans. The MDSC also stated that the resident's care plans should reflect the physician's orders. The MDSC confirmed that R#7's care plan should include specific orders for maintaining an emergency trach kit at the bedside, tracheostomy information, and emergency trach management. The MDSC verified that the emergency management of the trach intervention on the care plan was not accurate, and the nursing staff should call 911 if the trach dislodged.
2. Review of the comprehensive Care Plan for R#63 dated 11/25/2022 and located in the Care Plan tab of the EMR, revealed, R#63 has a tracheostomy r/t impaired breathing mechanics. The approaches included: Ensure that trach ties are secured at all times . Monitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia . Monitor/document level of consciousness, mental status, and lethargy PRN [as needed] . Monitor/document respiratory rate, depth, and quality . Check and document q [every] shift/as ordered . Provide good oral care daily and PRN . Suction as necessary . Use universal precautions as appropriate . Administer oxygen as indicated via trach . Give medications as ordered by physician . Keep head of bed elevated 30-90 degrees . Observe for s/sx [signs/symptoms] of respiratory distress and report to [physician] PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color .Position resident to facilitate ventilation/perfusion matching: use upright, high Fowlers position whenever possible to allow for optimal diaphragm, when on side, the good side should be down (e.g., damaged lung should be up). Review of the Care Plan revealed there were no interventions addressing emergency management of the tracheostomy, including maintaining an emergency trach kit and interventions in the event the trach dislodged.
Interview on 02/01/2023 at 12:03 p.m., the MDSC confirmed that R#63's Care Plan should include specific orders for maintaining an emergency trach kit at the bedside, tracheostomy information, and emergency trach management. The MDSC verified that there was no information in the care plan addressing emergency management if the trach dislodged.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and review of the facility policy titled, Elopement Management, the facility failed to ensure that one of eight sampled residents (R) (#62) review...
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Based on observation, staff interview, record review, and review of the facility policy titled, Elopement Management, the facility failed to ensure that one of eight sampled residents (R) (#62) reviewed for accidents received supervision needed to prevent accidents. R#62, who was at risk for elopement, was able to exit the facility without staff supervision. This failure created the potential for risk of injury while unsupervised.
Findings include:
Review of the facility policy titled, Elopement Management, dated 2021, revealed, Definition: Elopement occurs when a resident leaves the facility or a safe area without authorization. lf a resident is off facility property, then an elopement has occurred. lf a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. Authorization means a physician order for discharge, leave of absence, or leave with
appropriate supervision to do so.
Review of admission Record for R#62 revealed he was originally admitted to the facility with a primary diagnosis of traumatic brain injury.
Review of Care Plan, for R#62, initiated 04/29/2021, revealed the resident was at risk for elopement related to a history of attempting to leave the facility unattended, and the resident would often state, I need to get out of here. Multiple interventions were listed for diversion from wandering. In addition, for security measures, outside doors were to be securely closed when staff or visitors entered and exited the building.
Review of the most recent quarterly Minimum Data Set (MDS), for R#62 dated 11/0/2022, revealed that the resident was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 9/15. The MDS revealed, the resident was independent in ambulation/locomotion, and had no wandering behaviors during the assessment period.
Observation during initial tour on 01/30/2023 revealed that all facility doors to the outside were secured and required a code to exit.
Interview on 01/31/2023 at 6:00 p.m. with R#62 revealed that he did not remember exiting the building unsupervised on 07/17/2021 or on any other occasion.
Review of Wander Data Collection Tool, for R#62, dated 03/30/21 and 07/05/21, revealed that R#62 had wandered before at home/previous living settings, and the family had voiced concerns, according to the tool, the resident had attempted to elope in the present facility.
Review of R62's Elopement Investigation, dated 07/17/21, revealed the Resident noted to be standing at the end of corridor [outside of the facility] by writer and another staff member. Staff opened doorway and asked resident to return inside, he denied and stated, 'I will get back in the same way I got out.' Resident was then observed to go to the end of E hall and enter the access code to open the door, he then returned inside. Per the report, predisposing situation factors included the resident being an active exit seeker. No injuries were noted, and all appropriate parties were notified.
Review of Progress Notes for R#62 in the Electronic Medical Record (EMR), dated 07/19/2021 at 9:53 a.m., revealed that in response to the resident exiting the facility, We will need to include an education to staff to block the door code when entering it if residents are nearby and can see the code. This education was provided, and per the resident's record, no further elopements had occurred.
Interview on 02/02/2023 at 11:51 a.m., Licensed Practical Nurse (LPN) 4 confirmed R#62 exited the building on 07/17/2021. LPN4 stated that the facility investigated and determined that R#62 saw one of the staff enter the code to get out of the secured door, then entered the code himself to exit the door. LPN 4 stated that no staff witnessed R#62 leave the building; however, a staff member was walking by and saw R#62 sitting on the front porch of the facility. Staff approached him, and he agreed to return to the building. Staff was not aware of how long he had been outside the building.
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, interview, record review, and review of facility standards, the facility failed to make arrangements for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility standards, the facility failed to make arrangements for the provision of meals for one (Resident (R) 84) of one residents reviewed for dialysis, when the resident was out of the facility to receive dialysis treatment.
Findings include:
Review of the Facility's Renal Dialysis Management standard, dated 08/2021, revealed, Arrangements should be made for an appropriate meal to accompany the resident to dialysis.
Review of R84's admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile tab, revealed R84 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease and type II diabetes mellitus.
Review of R84's Physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated 01/03/23 for the resident to receive dialysis on Monday, Wednesday, and Friday.
Review of R84's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/23, located in the resident's EMR under the MDS tab, specified the resident received dialysis. The resident had a Brief Interview for Mental Status (BIMS) score of 8/15, which indicated the resident had moderate cognitive impairment.
Review of R84's care plan located in the resident's EMR under the Care Plan tab revealed a Focus area initiated on 01/16/23 that specified R84 required hemodialysis related to renal failure. A goal specified that R84 will have no signs or symptoms of complications from dialysis through the review date. The care plan did not address how the facility was going to make arrangements for an appropriate meal to accompany R84 to his dialysis treatments three times per week.
During an interview on 01/30/23 at 5:16 PM, R84 stated he was hungry because he had not eaten since breakfast. R84 explained that on 01/30/23, he left the facility to go to dialysis at around 10:00 AM and he did not eat lunch because he did not return to the facility until around 4:30 PM. R84 stated he does not each lunch when he goes to dialysis three times per week because the facility does not provide him with any food to take to the dialysis center. R84 stated that he does get hungry on the days that he receives dialysis.
During an additional interview on 02/01/23 at 9:40 AM, R84 stated he was sitting in the facility's front lobby waiting for the van to pick him up and take him to dialysis. R84 stated the facility did not provide him with any food to take to dialysis this morning.
Observations on 02/01/23 at 10:17 AM revealed R84 was being assisted onto the transport van by the van driver. R28 was observed not to have any food provided by the facility to take with him to the dialysis center.
During an interview on 02/01/23 at 10:24 AM, the Dietary Manager (DM) stated the dietary department did not provide R84 with any food to take to his dialysis treatments, which are scheduled three days a week. The DM stated she did not recall the care plan team having any discussions with the dialysis center regarding how to coordinate R84 bringing food from the facility to his dialysis treatments.
During an interview on 02/01/23 at 10:33 AM, the MDS Coordinator stated the facility's Interdisciplinary care plan team did not have any discussions with the resident or the dialysis center regarding how to coordinate R84 bringing food from the facility to his dialysis treatments.
During an interview on 02/02/23 at 11:45 AM, the facility's Registered Dietitian (RD) stated the dietary department should provide R84 with a meal to take to his dialysis treatments on Monday, Wednesday, and Friday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was secured...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was secured. One of four medication carts was not locked at all times. Medication was kept openly at the bedside and not secured under lock for one (Resident (R) 80) of 33 sampled residents. These failures placed residents at risk of having their unsecured medications diverted.
Findings include:
1. Record review of the facility policy titled Medication Administration Guidelines dated 06/2022, revealed that, Medication carts are to be kept locked at all times when not under visual supervision.
Observation on 02/02/23 at 4:27 AM revealed the C-hall medication cart was unlocked and unattended while parked at the nurse's station between hall D and hall E. Ongoing observation revealed the medication cart remained unlocked and unattended until Licensed Practical Nurse (LPN) 5 returned to the nurse's station area at 4:35am. During the time that the unlocked cart was not under the nurse's visual supervision, one resident, R2, walked near the cart. In addition, Certified Nursing Aide (CNA) 4 was within 10 feet of the cart for approximately two minutes while it was unattended and unlocked.
Interview with LPN5 on 02/02/23 at 4:38 AM revealed the cart should be locked and, at this time, LPN5 then locked the cart. LPN5 stated, What happened is that I was standing there a while ago, and I didn't kick the bottom drawer, so it didn't lock completely. I have a habit of always locking it, even when I am standing in front of it still. I will put a work order in and tell them to fix it.
Interview on 02/02/23 at 11:06 AM with the Director of Nursing (DON) revealed that the expectation and policy was that the medications carts should be locked when not attended.
2. Review of R80's electronic medical record (EMR) revealed an undated admission Record located under the Profile tab which showed the resident was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (Absence of oxygen in the tissues), and chronic obstructive pulmonary disease (COPD).
Review of the EMR under the Orders tab revealed physician orders dated 12/19/22 Ipratropium- Albuterol Solution 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] - 1 vial inhale orally every 4 hours as needed for SOB [shortness of breath].
Interview on 01/30/23 at 10:57 AM with R80 revealed the resident takes the breathing treatments (in which the ordered medication vials are added to a nebulizer machine) every four hours. During an observation on 01/30/23 at 4:19 PM, R80 was sitting in his wheelchair next to his bed near the window, holding a nebulizer mask and inhaling the mist coming out of the mask.
During an observation on 02/01/23 at 9:31 AM, there were three unopened medication vials, containing a clear substance, next to the nebulizer machine.
During an interview on 02/01/23 at 09:44 AM, R80 confirmed that he usually does the treatment by himself. Observation revealed three empty medication vials and two unopened medication vials next to the machine.
During an interview on 02/01/23 at 10:14 AM, LPN7 was asked about the resident having the unsecured medication vials at bedside. LPN7 stated the resident was very independent but there should not be any vials in his room, adding, The nurse should put the medication in the nebulizer cup.
During an interview on 02/01/23 at 10:23 AM, the DON was shown the vials at the side of the machine on the nightstand. The DON stated, These should not be here at the bed side.
During an interview on 02/01/23 at 11:25 AM, the Medical Director stated, Medication should not be necessarily at the bedside.
Based on observation, resident and staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure medication was secured. One of four medication carts was not locked at all times. Medication was kept openly at the bedside and not secured under lock for one of 33 sampled residents (R) (#80). These failures placed residents at risk of having their unsecured medications diverted.
Findings include:
1. Record review of the facility policy titled, Medication Administration Guidelines, dated 06/2022, revealed that, Medication carts are to be kept locked at all times when not under visual supervision.
Observation on 02/02/2023 at 4:27 a.m. revealed the C-hall medication cart was unlocked and unattended while parked at the nurse's station between hall D and hall E. Ongoing observation revealed the medication cart remained unlocked and unattended until Licensed Practical Nurse (LPN) 5 returned to the nurse's station area at 4:35 a.m. During the time that the unlocked cart was not under the nurse's visual supervision, one resident, R#2, walked near the cart. In addition, Certified Nursing Aide (CNA) 4 was within 10 feet of the cart for approximately two minutes while it was unattended and unlocked.
Interview with LPN5 on 02/02/2023 at 4:38 a.m. revealed the cart should be locked and, at this time, LPN5 then locked the cart. LPN5 stated, What happened is that I was standing there a while ago, and I didn't kick the bottom drawer, so it didn't lock completely. I have a habit of always locking it, even when I am standing in front of it still. I will put a work order in and tell them to fix it.
Interview on 02/02/2023 at 11:06 a.m. with the Director of Nursing (DON) revealed that the expectation and policy were that the medications carts should be locked when not attended.
2. Review of the electronic medical record (EMR) for R#80 revealed an undated admission Record located under the Profile, tab which showed the resident was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (Absence of oxygen in the tissues), and chronic obstructive pulmonary disease (COPD).
Review of the EMR under the Orders tab revealed physician orders dated 12/19/2022 Ipratropium- Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) - 1 vial inhale orally every four hours as needed for SOB (shortness of breath).
Interview on 01/30/2023 at 10:57 a.m. with R#80 revealed that the resident takes the breathing treatments (in which the ordered medication vials are added to a nebulizer machine) every four hours. During an observation on 01/30/2023 at 4:19 p.m., R#80 was sitting in his wheelchair next to his bed near the window, holding a nebulizer mask and inhaling the mist coming out of the mask.
Observation on 02/01/2023 at 9:31 a.m., there were three unopened medication vials, containing a clear substance, next to the nebulizer machine.
Interview on 02/01/2023 at 09:44 a.m., R#80 confirmed that he usually does the treatment by himself. Observation revealed three empty medication vials and two unopened medication vials next to the machine.
Interview on 02/01/2023 at 10:14 a.m., LPN7 was asked about the resident having unsecured medication vials at the bedside. LPN7 stated the resident was very independent, but there should not be any vials in his room, adding, The nurse should put the medication in the nebulizer cup.
Interview on 02/01/2023 at 10:23 a.m., the DON was shown the vials at the side of the machine on the nightstand. The DON stated, These should not be here at the bedside.
Interview on 02/01/2023 at 11:25 a.m., the Medical Director stated, Medication should not be necessarily at the bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of facility policy titled, Maintenance Work Request, the facility failed to ensure the bathroom sink was functioning properly for one of 33 sampled resident...
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Based on observation, interview, and review of facility policy titled, Maintenance Work Request, the facility failed to ensure the bathroom sink was functioning properly for one of 33 sampled residents (R) (#47).
Findings include:
Review of the facility's undated policy, titled Maintenance Work Request, revealed its purpose is to, ensure the facility is well-maintained for the safety of residents, staff and visitors. Each facility may use the TELS (building management platform to submit work orders) system as a means of scheduling of preventive maintenance drills. Procedure: .4. All maintenance work requests will be completed within five days of receipt, unless the work needed is of an urgent nature, in which case it will be done immediately.
Observation on 01/31/2023 at 5:00 p.m., R#47's bathroom sink was stopped up and halfway full of stagnant water.
During an observation on 02/02/2023 at 10:00 a.m., R#47's bathroom sink was stopped up and halfway full of stagnant water.
Interview on 01/31/2023 at 5:00 p.m., R#47 stated that his bathroom sink had been stopped up for about four months. The resident stated he cannot get hot water for his face because the sink overflows. R#47 stated that the maintenance director came in over two months ago. However, the could not get it unstopped, and the sink is still stopped up with old water in it.
Interview on 02/01/2023 at 10:25 a.m., the Maintenance Director (MD) confirmed that R#47's sink was stopped up, adding that it had been draining slowly for about two or three months. In the past, he had unclogged the sink by snaking it. However, the MD continued, the sink would not drain a few weeks ago and he was unable to unclog it by using a cleaning agent in the sink or cleaning the vent pipe. The MD said the expectation was for a work order to be resolved within 48 hours; however, he could not find a completed work order for the stopped up sink. The MD stated that R#47 told him he was upset about the sink because he could not use the sink to shave and that the water was warm in the sink.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of the facility policy titled, Restorative Nursing Standard, the facility failed to provide range-of-motion and/or splinting services to addr...
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Based on observation, interview, record review, and review of the facility policy titled, Restorative Nursing Standard, the facility failed to provide range-of-motion and/or splinting services to address range of motion loss and/or contractures for four of six residents (R) (#63, #6, #4, and #7) reviewed for a limited range of motion. These failures had the potential to cause worsening contractures and/or complications for four residents.
Findings include:
Review of the facility policy titled Restorative Nursing Standard, dated 08/2021, revealed that The nursing staff is responsible to assure that the resident receives the necessary
restorative nursing care. In rehabilitation nursing, it is the nurse and the therapist who do
most of the teaching of the resident to help him regain the highest level of independence
possible.
1. Review of R#63's undated admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R#63 was admitted with diagnoses of contracture of the right hand, contracture of the left hand, contracture of the right elbow, contracture of the left elbow, and quadriplegia.
Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#63, with an Assessment Reference Date (ARD) of 11/09/2022, located in the MDS tab of the EMR, revealed that R#63 was rarely/never able to make herself understood and was unable to complete the Brief Interview for Mental Status (BIMS). R#63 was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. R#63 had an impaired range of motion in both the upper and lower extremities.
Review of the comprehensive Care Plan, for R#63 dated 08/12/2022 and located in the Care Plan tab of the EMR, revealed, R#63 has an alteration in musculoskeletal status r/t (related to) contracture of the right and left hands. The interventions included: See MD orders and/or PT (physical therapy) treatment plan . ROM (range-of-motion) during care as tolerated . Splints as recommended.
Review of the Occupational Therapy Discharge Summary, for R#63, dated 10/09/2022, provided on paper, documented, Discharge Recommendations: D/C (discharge) with RNP (restorative nursing program)/good staff support. Restorative Program Established/Trained - Restorative ROM program. ROM Program Established/Trained: PROM (passive range-of-motion to) BUEs (bilateral upper extremities) all joints to tolerance x 10 repetitions. Functional Maintenance Program Established/Trained - Splint and Brace Program Splint and Brace Program Established/Trained: B (bilateral) elbow splints and hand splints x four hours daily. Prognosis to Maintain CLOF (current level of function) - Good with consistent staff follow-through.
Review of Physician Orders, for R#63, dated January 2023, located in the Orders tab of the EMR, revealed there was no order for the use of splints.
Observation on 01/30/2023 from 11:28 p.m. to 1:04 p.m., R#63 was observed in bed in her room. Both arms and hands were contracted so that they were bent into fists. There were no splints or other devices in place.
Observation on 01/31/2023 at 10:02 a.m., 12:00 p.m., 1:30 p.m., and 3:17 p.m., R#63 was observed in bed with contracted arms and hands. She did not have any splints or devices in place.
Observation on 02/01/2023 at 11:00 a.m., 1:00 p.m., and 4:05 p.m., R#63 was observed in bed with contracted arms and hands. She did not have any splints or devices in place.
Observation on 02/02/2023 at 4:22 a.m. and 6:00 a.m., R#63 was observed in bed with contracted arms and hands. She did not have any splints or devices in place.
Interview on 02/02/2023 at 8:37 a.m., with a Licensed Practical Nurse (LPN) 4 stated R#63 came to the facility about six months ago with severe contractures. She stated R#63 was in therapy when she first was admitted , but stated, I don't know what they're doing for her contractures now.
Interview on 02/02/2023 at 10:00 a.m., with the Regional Nurse Consultant, revealed there were no records of a restorative nursing program or use of splints for R#63.
Interview on 02/02/2023 at 10:48 a.m., with the MDS Coordinator (MDSC), who served as the head of the restorative nursing program, stated she was unaware of the recommendation from Occupational Therapy (OT) for a restorative nursing program, including the use of splints. The MDSC confirmed that R#63 had not been provided splinting or restorative services since her discharge from therapy. The MDSC stated she had asked the therapy department to provide her with their discharge summaries so she could follow up with the recommendations, but she had yet to receive any summaries for R#63. The MDSC stated that R#63's family members reported she used splints before admission to the facility, and they were being applied by the therapists when she was receiving therapy. The MDSC stated, (R#63) should be on restorative.
2. Review of the admission Record for R#6, undated located in the Profile tab of the EMR, revealed he was admitted with a diagnosis of a right hand contracture.
Review of the most recent annual MDS assessment for R#6 dated 01/02/2023, located in the MDS tab of the EMR, revealed R#6 scored two out of 15 on the BIMS, indicating severely impaired cognition. He required extensive assistance with dressing and personal hygiene and had functional limitations in range of motion of one extremity. According to this MDS, R#6 did not receive range of motion or splint and brace assistance. He did not exhibit any behavioral symptoms, including rejection of care.
Review of Restorative Nursing Program Recommendations, for R#6 dated 11/22/2022 provided on paper, revealed, Device: Hand Splint Current Wear Schedule: five to six hours of wear daily. Goal: Maintain splint wear schedule w/ (with) skin checks post doffing. Frequency: five times a week.
Review of the Physician Orders, for R#6 dated January 2023 located in the Orders tab of the EMR, revealed an order that originated on 01/09/2023 to apply splint to right hand five to six hours daily as tolerated, with skin checks prior to and post doffing of splint, post prom exercises. There was also an order that originated on 12/05/2022 to apply a splint to right hand five to six hours daily as tolerated, with skin checks prior to and post doffing of splint, post prom exercises, to right hand/wrist, digits, all planes five repetitions /five sets.
Review of the comprehensive Care Plan for R#6, dated 12/07/2022 and located in the Care Plan tab of the EMR, revealed, R#6 requires assistance with ADLs (activities of daily living) r/t (related to) impaired balance, limited mobility, (and) limited ROM. The interventions included: PT (physical therapy)/OT (occupational therapy) evaluation and treatment as per MD (physician) orders . Rehab/restorative splint/brace program: apply to right hand daily as tolerated s/p (after) right hand/wrist/digits exercises for passive ROM as indicated.
Additionally, a Care Plan dated 01/09/2023 for R#6 documented, R#6 has limited physical mobility r/t Contracture RUE (right upper extremity). The approaches included: Restorative Nurse Aid: apply a splint to right Hand five to six hours daily as tolerated, with skin checks prior to and post doffing of splint, post PROM exercises . Monitor/document/report PRN any s/sx (signs and symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury . Provide gentle range of motion as tolerated with daily care . Document assistance as needed . PT, OT referrals as ordered, PRN.
Review of the Kardex for R#6 dated 02/01/2023 provided on paper, revealed, Nursing Rehab/Restorative: Splint/Brace Program - Apply to right hand daily as tolerated s/p right hand/wrist/digits exercises for passive ROM as indicated.
Observation on 01/30/2023 at 11:10 a.m., R#6 was observed in his room seated in a wheelchair with his right hand contracted into a fist. There was no splint or device in place.
Observation on 01/31/2023 at 10:00 a.m., 12:00 p.m., 1:32 p.m., and 4:42 p.m., R#6 was observed in his room in bed. His right hand was contracted into a fist, and there was no splint or device in place.
Observation on 02/01/2023 at 9:32 a.m., 12:00 p.m., and 3:50 p.m., R#6 was observed in his room seated in his wheelchair or in bed. His right hand was contracted into a fist, and there was no splint or device in place.
Observation on 02/02/2023 at 4:48 a.m., R#6 was observed in his room in bed. His right hand was contracted into a fist, and there was no splint or device in place.
Review of Restorative Nursing Documentation Survey Report, for R#6 dated January 2023, provided on paper, revealed, Nursing Rehab: Assistance with Splint or brace . Right hand five to six hours daily as tolerated, with skin checks prior to and post doffing of splint post PROM exercises. A review of this report revealed that the care was not signed as completed on 01/06/2023, 01/07/2023, 01/08/2023, 01/13/2023, 01/14/2023, 01/15/2023, 01/21/2023, 01/22/2023, 01/25/2023, 01/30/2023, and 01/31/2023. There were no refusals documented.
Interview on 02/02/23 at 10:48 AM with the MDSC revealed that she had noticed holes in the restorative documentation and had addressed the holes with the aides to remember to sign the report. She also stated that sometimes the restorative aides were pulled to work on the floor and could not complete restorative duties. The MDSC stated she took over the restorative program in 12/2022, and it was a struggle to get the program going because, before that, it had not been happening. She stated that R#6s splinting and range of motion program should be done daily as the physician ordered.
Interview on 02/02/23 at 11:00 a.m. with Restorative Aide (RA) 1, she stated R#6 sometimes refused to wear splints, but she could talk to him and put on the splints. RA1 further revealed being off work the last three days, and the second restorative aide was not working due to an injury. She was unaware if R#6 had received any restorative services that week. RA1 stated she did not know why he did not have splints from 01/30/2023 to 02/02/2023.
Interview on 02/02/2023 at 1:18 PM, with Director of Nursing (DON) stated she expected the staff to document any refusals on the restorative record and let the nurse know of refusals so they can re-approach the resident.
3. Review of the undated admission Record for R#4, located under the Profile tab of the EMR, revealed that
R#4 was admitted with diagnoses of contracture of muscle, muscle coordination, and muscle weakness.
Review of the most recent MDS quarterly review for R#4, dated 1/4/2023, revealed in the MDS tab of the EMR, R#4 scored fourteen out of 15 on the BIMS.
Review of the EMR under the Orders tab for R#4 revealed the physician ordered, 12/05/2022 PROM to RUE/Elbow (right upper extremity), slow static stretch as tolerated. daily, five repetitions / five sets. With rest periods prn (as needed) in between.
Review of the care plan for R#4 revealed a problem of limited physical mobility related to a contracture of the right elbow. The care plan for this problem, which showed a creation date of 11/18/2019, listed multiple interventions, including a revision on 04/22/2022 calling for staff to, Provide a gentle range of motion as tolerated with daily care.
Review of the Certified Nursing Assistant (CNA) documentation presented by the facility for 12/2022 revealed the following days on which no treatment was provided: 12/06/2022, 12/15/2022, 12/16/2022, 12/17/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/28/2022, and 12/29/2022.
Review of CNA documentation presented by the facility for 01/2023 revealed the following days on which no treatment was provided: 01/06/2023, 01/07/2023, 01/08/2023, 01/12/2023, 01/14/2023, 01/18/2023, 01/21/2023, 01/22/2023, 01/24/2023, 01/30/2023, and 01/31/2023.
Observation on 01/30/2023 at 12:02 p.m., R#4 had his right arm bent up at the elbow, and the right hand was folded in a fist.
Interview on 01/30/2023 at 12:10 p.m., with R#4 where he revealed that staff works with him sometimes on therapy for his hand.
Interview on 02/02/2023 at 9:16 a.m.,with the MDSC, who was also the Restorative Nurse, stated she was appointed Restorative Nurse in 12/2022. The MDSC printed the CNA documentation for R#4s restorative treatment and verified that the treatment did not occur every day. She confirmed that the treatments should be done, daily.
Interview on 02/02/2023 at 9:35 a.m., with Restorative Aide (RA)1 stated, When a resident goes off therapy, they are put on the restorative program. RA1 further stated that therapy staff will provide training on how to do the treatment. RA1 revealed that I see the resident every day that I work for about 15-20 minutes. I'm not here every day. I can't answer for those times that I am not here.
Interview on 02/02/2023 at 12:57 p.m., the DON stated the CNAs should be doing the treatments when the RAs were not there. The DON stated that the treatment should be documented, and the nurse should be notified of refusals, adding. I expect the treatment to be done.
4. Review of R#7's Face Sheet, located in the EMR under the Medical Diagnosis tab, revealed that R#7 was admitted with a diagnosis of contracture of the right hand and contracture of the left hand and muscle weakness.
Review of the most recent quarterly MDS, R#7 with an ARD of 01/04/2023, which was in the resident's EMR under the MDS tab, specified R#7 required total dependence with dressing and received splint or brace assistance six out of the last seven days. According to the MDS, no refusal of care was noted. C-cognition
Review of the care plan for R#7 revealed a Focus area, initiated on 09/22/2021 with a revision date of 07/12/2022, which specified that R#7 has limited physical mobility r/t contractures of bilateral hands. She has wash cloths rolled and placed in her hands. The goal specified that R#7 will remain free of complications related to immobility, including contractures, through the next review date. Care plan interventions included, Splints per orders to BUE, rolled wash cloths are placed in resident's hands.
Review of Physician Orders, for R#7, located in the resident's EMR under the Orders tab, revealed an order dated 12/05/2022 which specified, Apply a splint to the right hand and soft splint roll to the left hand, post passive ROM exercises daily to prevent progressive contracture. Observe for skin breakdown and report any to Nurse.
R#7's current Certified Nursing Assistant (CNA) Kardex revealed staff was to Apply splint as recommended and as tolerated to the right and left hands. Remove for bathing, keep the area clean and dry.
Review of the Documentation Survey Report for R#7 dated 12/2022 revealed the following Nursing Rehabilitation interventions: Nursing Rehab: Assistance with Splint Program #1- Apply to BUE and Nursing Rehab: Passive ROM Program #1 to BUE. Further review of this report revealed there was no documentation that staff provided R#7 with splinting assistance or passive ROM on 12/01/2022, 12/02/2022, 12/03/2022, 12/04/2022, 12/16/2022, 12/23/2022, 12/24/2022, and 12/25/2022.
Review of the Documentation Survey Report for R#7 dated 01/2023 revealed no evidence that staff provided R#7 with splinting assistance or passive ROM on 01/07/2023, 01/08/2023, 01/14/2023, 01/15/2023, 01/21/2023, and 01/22/2023.
Observation on 01/30/2023 at 11:35 a.m. revealed that R#7 was in her room, and her right hand was contracted in a closed fist. No splinting device or hand roll was observed on R#7s contracted right hand.
Observation on 01/31/2023 at 4:08 p.m., revealed that R#7 was in her room, and her right hand was contracted in a closed fist. No splinting device or hand roll was observed in R#7's contracted right hand. LPN1 was present in the resident's room during this observation.
Interview on 01/31/2023 at 4:08 p.m. with Licensed Practical Nurse (LPN) 1 revealed that R#7 should have a rolled washcloth in her contracted right hand. LPN1 further stated that the Restorative Aides (RA)s and Certified Nursing Assistants (CNA) are responsible for applying the splints and hand rolls to R#7's contracted hands. LPN1 stated that Certified Nursing Assistant (CNA) 3 was responsible for taking care of R#7 on 01/31/2023 from 3:00 p.m. to 11:00 p.m.
Interview on 01/31/2023 at 4:11 p.m. with Certified Nursing Assistant (CNA) 3 confirmed R#7 should have either a hand roll or a splint in her contracted right hand. CNA3 stated that on 01/31/2023, she began to work at 3:00 p.m., and she had not yet provided any care or observed R#7 during her shift. CNA3 further explained that staff was expected to monitor R#7 every two hours to make sure her splints and hand rolls were in her contracted hands.
Interview on 02/02/2023 at 10:45 a.m. with Restorative Aide (RA) 1 revealed that she usually will work with R#7 four days a week and places R#7's hand rolls and hand splints on her in the morning. RA1 also stated that she also will provide R#7 with a passive range of motion prior to applying the hand splints and hand rolls. RA1 specified that R#7 does not refuse to wear her hand splints and hand rolls and does not attempt to remove them.
Observation on 02/02/2023 at 10:55 a.m. (after surveyor intervention), R#7 was in bed with a splint on her contracted left hand and a hand roll in her contracted right hand. RA1 was present in the resident's room during this observation. RA1 stated she placed the hand roll in R#7's right hand and the splint on R#7 left hand during the morning of 02/02/2023. RA1 also stated that she will keep R#7's hand splints in place for one hour as tolerated. RA1 explained that when staff removes R#7's hand splint, a hand roll should be placed in the resident's contracted hand. RA1 further stated that she had worked with R#7 since May 2022, and R#7 had not experienced a decrease in the range of motion of her hands during the time she worked with her.
Interview on 02/02/2023 at 1:48 p.m. with the MDSC confirmed that the RAs and CNAs were not applying R#7's hand splints and hand rolls as ordered by the physician. The MDSC stated that R#7 should have a hand roll in her right hand when she does not have a splint in this contracted hand. She also stated that R#7's physician orders for hand splints and hand rolls needed clarification because these orders did not specify when they were to be applied and how long they were to remain on R#7's contracted hands.
Interview on 02/02/2023 at 1:00 p.m. with the (Director of Nursing) DON confirmed that the RA and CNA staff were responsible for applying the hand splints and hand rolls to R#7's contracted hands as ordered and document in R#7's medical record that they were applied.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, record review, and review of the facilities policies titled, Tracheostomy Tube Emergency Care, Procedural Competency Evaluation for Tracheostomy Care, Respirato...
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Based on observation, staff interviews, record review, and review of the facilities policies titled, Tracheostomy Tube Emergency Care, Procedural Competency Evaluation for Tracheostomy Care, Respiratory System Management Standard, and Oxygen Concentrators: In-House Maintenance, the facility failed to ensure the provision of respiratory services in accordance with professional standards for four of four residents (R) (#7, #63, #46, #80) reviewed for respiratory care out of a total sample of 33 residents. Emergency tracheostomy supplies (kits) were not maintained at the resident's bedside in case of need. Physician's orders were not specific to the equipment needed. Respiratory equipment was not maintained in a clean manner. This failure increased the residents' risk for compromised airway/respiratory distress.
Findings include:
Review of the facility-provided policy titled Tracheostomy Tube Emergency Care, dated 2020, revealed Replacement Tracheostomy tubes must always be available 1) Appropriate size tube 2) One size smaller tube a. When the appropriate sized trach tube is the smallest size available refer to ordering physician for direction.
Review of the facility-provided Procedural Competency Evaluation for Tracheostomy Care, dated 11/16/2022, revealed Equipment and Patient Preparation NOTE: Tracheostomy patients should always have a replacement tracheostomy tube at the bedside in case an emergency replacement becomes necessary.
1. Review of the admission Record for R#7, undated located in the electronic medical record (EMR), revealed R#7 was admitted to the facility with multiple diagnoses, including tracheostomy status, aphasia, and diffuse traumatic brain injury (TBI) with loss of consciousness of unspecified duration.
Review of the most recent quarterly Minimum Data Set (MDS) for R#7 dated 01/04/2023 and located EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated he was unable to complete the interview due to cognitive deficits. Facility staff assessed R#7 as severely cognitively impaired. The MDS indicated R7 had a tracheostomy and required suctioning while a resident at the facility.
Review of Physician's Orders for R#7's dated 01/18/2023, under the Orders tab located in the EMR revealed orders for a Shiley [brand] trach inner cannula size # [number] 6. The order did not specify if the Shiley was to be cuffed or uncuffed. Further review of the physician orders revealed no order for an emergency tracheostomy kit at the bedside.
Observation and interview on 01/30/2023 at 11:08 a.m. with Licensed Practical Nurse (LPN) 1, who was assigned to provide care for R#7, revealed that there was no hemostat or a lower size inner cannula in the supply cart at R#7's bedside. LPN1 stated that if the trach became dislodged, she would let the immediate supervisor and the unit manager know, then send R#7 out of the facility. LPN1 found a Shiley #5 inner cannula (lower size) in the supply room and placed it in the supply cart in R#7's room.
Interview on 01/31/2023 at 11:24 a.m. with the Interim Director of Nursing (DON) revealed that she had only worked at the facility for a week. The Interim DON stated that nurses could replace a trach tube if it dislodged if they had completed a competency; however, if the staff had not completed a competency, then the nurses would send the resident out of the facility for tracheostomy replacement.
Interview on 01/30/2023 at 3:00 p.m. with LPN2 revealed she had worked at the facility 14 years and in-service training was provided on tracheostomy care last year. LPN2 stated that if a tracheostomy dislodged, then she would send the resident out of the facility and would not replace it because she had yet to complete a competency. LPN2 indicated that the emergency trach kit should include an Ambu bag, suction kit, the same size cannula and one size lower, sterile gloves, and a hemostat at the bedside. LPN2 indicated that the facility did not have an emergency trach kit checklist or physician orders on maintaining the emergency trach kit at the bedside. LPN2 indicated she did not know how staff were ensuring that the emergency supplies were at the bedside since there was no order for them or a checklist. Observations at this time with LPN2 revealed that the hemostat was not in the supply cart at the bedside but was in R#7's top dresser drawer in a ziplocked bag. During this interview, LPN2 confirmed that R#7 has an uncuffed trach and should have a physician's order.
Interview on 02/01/2023 at 11:19 a.m. with the Medical Director revealed that if the tracheostomy dislodged, then the nurses would call 911, if the nurses have yet to receive training to replace the tracheostomy. The Medical Director also stated that if the resident's trach dislodged and the emergency trach kit was not at the bedside, it could lead to respiratory distress.
Interview on 02/01/2023 at 12:19 PM with LPN4 revealed that when residents were admitted to the facility, the admitting nurse or unit manager would enter the orders in the EMR. LPN4 stated that the unit managers would verify the orders the next day. LPN4 stated that since they only admit residents with uncuffed tracheostomies, the order did not need to state whether the trach was cuffed or uncuffed. LPN4 indicated that their policy did not state they had to have an order for maintaining emergency trach equipment at the bedside. LPN4 further revealed they were going to implement an audit checklist since the equipment was found to be missing at the bedside for R#7 and R#63 during the survey.
Interview on 02/02/2023 at 3:20 p.m. with the Regional Nurse Consultant revealed that physician's orders needed to be specific for each resident. The Regional Nurse Consultant stated that the tracheostomy in-services that were conducted with the nurses last year included emergency management of a tracheostomy, and she expected staff to call 911 if the tracheostomy dislodged and to have the emergency equipment at the bedside.
2. Review of the admission Record for R#63 undated, located in the Profile tab of the EMR, revealed R#63 was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia, quadriplegia and use of a tracheostomy.
Review of the most recent quarterly MDS assessment for R63 dated 11/09/2022, located in the MDS tab of the EMR, revealed that R#63 was rarely/never able to make herself understood and was unable to complete the BIMS test. The staff assessed R#63 with short- and long-term memory problems and severely impaired cognition. She did not exhibit any mood or behavioral symptoms. R#63 was totally dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene, and bathing. R#63 received tracheostomy care, oxygen, and suctioning.
Review of Physician Orders for R63 dated 01/18/2023, located in the Orders tab of the EMR revealed, Change Shiley trach inner cannula size #6 daily days for secretions and PRN (as needed) and trach care q (every) shift and PRN. Further review of the physician orders revealed no indication whether Shiley was to be cuffed or uncuffed or for an emergency tracheostomy kit at the bedside.
Observation in R#63's room on 01/30/2023 at 3:00 p.m. revealed there was no bag valve mask (a handheld tool that is used to deliver positive pressure ventilation to any subject with insufficient or ineffective breaths. It consists of a self-inflating bag, one-way valve, mask, and an oxygen reservoir sometimes referred to as an Ambu bag) or hemostat in the emergency tracheostomy supplies cart at the bedside.
Interview on 1/30/2023 p.m. with LPN1 stated she was not R#63's nurse, so could not verify what supplies were at the bedside.
During concurrent observation and interview on 1/30/2023 at 3:15 p.m., LPN4 verified there was no hemostat at the bedside and left the room, stating she would get one immediately from the supply closet. At 3:27 p.m., LPN4 returned with a hemostat and verified that there was no bag valve mask present at the bedside. LPN4 stated, That should be here, and stated she would get one immediately from the supply closet.
Review of the facility's 2020 SMS [Specialized Medical Services] Tracheostomy Tube Emergency Care policy, used to train facility nursing staff, revealed, If a tracheostomy becomes blocked or comes out, an Emergency Plan is needed. It's recommended to have two back up tracheostomy tubes at bedside. These backup tubes MUST always be readily available . Blocked Tracheostomy Tube - Thick secretions can block the airway causing shortness of breath which can lead to severe difficulty breathing.
1) Remove the inner cannula [and] replace with a clean or new one.
2) Try to remove the plug by suctioning.
3) If this doesn't work, remove the tube and replace it with a new one.
Trach Tube Replacement - If the blockage can't be removed then the entire tube should be removed.
1) insert a clean, lubricated tracheostomy tube in the stoma using the obturator (guide)
2)Hold the tube in place with your fingers
3) Pull out the obturator
4) Secure with trach ties
5) Observe patient for continued respiratory distress
6) Ensure proper placement with chest auscultation and pulse oximetry.
In a concurrent interview on 02/02/23 at 3:13 p.m. with the Regional [NAME] President of Operations (RVPO) and Regional Nurse Consultant, the Regional Nurse Consultant stated that the above policy was worded in a confusing way but was only directing the nursing staff to replace the inner cannula, not the entire tracheostomy tube. She added that the obturator was the same as the inner cannula. She stated she expected staff to call 911 if the trach dislodged.
3. Observation on 01/30/2023 at 4:01 p.m., R#46 was in bed with his nasal cannula in his nose. The oxygen concentrator had a hole in the side of the machine where a filter should be, and there was dust on the inside of the concentrator.
Observation on 02/01/2023 at 9:49 a.m., R#46 was in bed with a nasal cannula in his nose. The concentrator still had no filter on the side of the machine. Inside the machine, dust can be visualized.
Review of the admission Record for R#46 undated in the EMR revealed located in the Profile tab, revealed that R#46 was admitted to the facility with a diagnosis including shortness of breath (SOB), and chronic obstructive pulmonary disease (COPD).
Review of the EMR for R#46 dated 8/17/2022 under the Orders tab revealed physician orders O2 [oxygen] at 2L/MIN [Liters per minute] for COPD/SOB.
Interview on 02/01/2023 at 9:53 a.m., Registered Nurse (RN)1 was asked to look at the concentrator. She stated, That should not be like that. I looked at some yesterday but did not look at this one.
Interview on 02/01/2023 at 10:10 a.m., the DON stated, There should be a filter to prevent the dust and debris from getting into the machine.
4. Observation on 01/30/2023 at 10:57 a.m., R#80 had a nasal cannula in his nose. The oxygen concentrator was set at two liters, and the filter was visibly dusty. There was a nebulizer on the resident's nightstand. The mask for the nebulizer was lying on the nightstand, and it was not covered.
Observation on 01/31/2023 at 9:39 a.m., the concentrator filter was still visibly dusty. The nebulizer mask was lying on the nightstand without a cover.
Observation on 02/01/2023 at 9:44 a.m., the concentrator filter was visibly dusty, and the mask to the nebulizer was on the nightstand, lying out in the open.
Review of the admission Record for R#80, updated in the EMR revealed located under the Profile tab. The admission Record indicated the resident was admitted with diagnoses including acute respiratory failure with hypoxia (Absence of oxygen in the tissues), and COPD.
Review of the EMR under the Orders tab revealed physician orders dated 12/19/2022 Ipratropium- Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) -1 vial inhale orally every 4 hours as needed for SOB (shortness of breath). Further review of the physician's orders revealed no oxygen order.
Interview on 02/01/2023 at 10:14 a.m., LPN7 stated that the filter should be cleaned or changed, and it should not be dusty. LPN7 added that the mask for the nebulizer machine should be stored in a bag when it is not in use.
Interview on 02/01/2023 at 10:23 a.m., the DON was shown the filter on the oxygen concentrator. The DON then took it off and washed it, saying that the filters should be clean and not dusty. When asked about the nebulizer, the DON stated that the mask should be placed in a bag when it was not in use.
Interview on 02/01/2023 at 11:17 a.m., the Medical Director was asked about an order for oxygen. The Medical Director stated, There should be an order for oxygen.
Review of the facility policy, Respiratory System Management Standard dated 08/2021. revealed, Purpose To provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident. Check the physician's orders in the resident's clinical record.
Review of the facility policy titled Oxygen Concentrators: In-House Maintenance dated 12/30/2022 revealed, Cleaning the Cabinet Filter. Risk of Damage. To avoid damage to the internal components of the unit: Do not operate the concentrator without the filter installed or with a dirty filter. 1. Remove the filter and clean as needed 1. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc. 2. Clean cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent and water. Rinse thoroughly. 3. Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected multiple residents
Based on observation, interview, record review, and review of facility contracts, the facility failed to ensure the Medical Director was involved in administrative decisions, including recommending, d...
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Based on observation, interview, record review, and review of facility contracts, the facility failed to ensure the Medical Director was involved in administrative decisions, including recommending, developing and approving facility policies related to pneumococcal vaccination and emergency tracheostomy care. This failure had the potential to contribute to ongoing deficient practice for emergency tracheostomy care for two (Resident (R) 63 and R7) residents with tracheostomies and four (R34, R61, R79, and R14) of five residents reviewed for pneumococcal vaccination.
Findings include:
Review of the facility's policy dated 11/16/2017 Medical Director Agreement, provided on paper, revealed, Duties of Medical Director: . Assist in development of a medical-nursing plan of care for each resident . (and) Assist in the development and implementation of resident care policies.
1. The facility was cited with deficient practice at F695: Respiratory Care related to non-specific tracheostomy orders, lack of emergency supplies at the bedside, and inconsistent staff knowledge regarding emergency procedures in the event the tracheostomy tube (trach) became dislodged.
Interview on 02/01/2023 at 11:19 a.m. with the Medical Director, revealed his understanding is the staff should call 911. I'm not sure what kind of training the nurses have gone through for that. The Medical Director stated he was not sure whether the trach order should specify whether it was cuffed or not. He further revealed that he had no idea what to expect the nurse to do. Probably just continue with what orders they came with from the hospital, that's just common sense. The Medical Director stated he had not provided the staff with any education regarding emergency trach care, as he was not a pulmonologist, and stated he had not reviewed the facility's emergency trach care policy or discussed trach care in the Quality Assurance meetings. The Medical Director added, I would prefer not to have trach patients here. The Medical Director revealed that potential outcome of not having emergency trach supplies at the bedside included that a resident could experience respiratory distress.
Review of the facility's 2020 SMS [Specialized Medical Services] Tracheostomy Tube Emergency Care policy included directions to remove the tube and replace it with a new one and, Trach Tube Replacement - If the blockage can't be removed then the entire tube should be removed.
Interview on 02/02/23 at 3:13 PM with the Regional [NAME] President of Operations (RVPO) and Regional Nurse Consultant, the RVPO stated the Medical Director would probably not be involved in staff education on tracheostomy care and emergency trach care policies, as the trach vendor would be responsible for setting up the trach, educating the staff, and assisting with supplies, including the emergency kit. The Regional Nurse Consultant added the SMS Emergency Tracheostomy Care policy was the education SMS had been providing to nursing staff.
2. The facility was cited with deficient practice at F883: Immunizations, related to a failure to update the pneumococcal vaccination policy and procedure with the newest immunization requirements and a failure to ensure residents received one or both appropriate doses of the pneumococcal vaccine series or had documented refusals. Cross-reference F883.
In a telephone interview on 02/02/2023 at 1:58 p.m. with the Medical Director stated he had not been involved in the creation/revision of the pneumococcal vaccination policy nor had he reviewed it. The Medical Director stated he had not provided education to the facility staff on the updated CDC pneumococcal vaccination guidance.
In a concurrent interview on 02/02/2023 at 3:13 p.m. with the RVPO and Regional Nurse Consultant, the RVPO stated the Medical Director signed off on all facility policies every year at an annual policy review Quality Assurance meeting. She stated he would assist with reviews and sign but would not necessarily be expected to update the policy with current CDC guidelines as these were only recommendations and not requirements.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policies, Age Summary and Average Age and Pneumococcal Va...
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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 policies, Age Summary and Average Age and Pneumococcal Vaccine, the facility failed to ensure its Pneumococcal Vaccination policy reflected current recommendations/standards of practice. In addition, the facility failed to ensure that four of five residents (R) (#34, #61, #79, #14) reviewed for immunizations received the pneumococcal vaccination series or had documented refusals. These failures had the potential to increase the spread of pneumonia among unvaccinated residents.
Findings include:
Review of the facility's 02/02/2023 Age Summary and Average Age report, provided on paper, revealed there were 39 of 86 residents under age [AGE] in the facility.
Review of the facility's 2017 Pneumococcal Vaccine policy revealed, Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series (both 23-valent pneumococcal polysaccharide vaccine AND 13-valent pneumococcal conjugate vaccine for residents [older than] 65), and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. A review of the policy revealed no evidence it was updated/revised in response to the current recommendations.
1. Review of the Centers for Disease Control and Prevention (CDC) 01/24/2022 Pneumococcal Vaccination: Summary of Who and When to Vaccinate, accessed on 01/30/2023 at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html revealed, Adults 65 Years or Older: . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you give 1 dose of PCV (pneumococcal conjugate vaccine) 15 or PCV20. If PCV15 is used, this should be followed by a dose of PPSV (pneumococcal polysaccharide vaccine) 23 at least one year later . If PCV20 is used, a dose of PPSV23 is NOT indicated. For adults 65 years or older who have only received PPSV23, CDC recommends you may give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you give PPSV23 as previously recommended.
Interview on 02/02/2023 at 8:24 a.m. with the Infection Preventionist (IP), she confirmed the facility's policy had not been updated to reflect the revised CDC guidance to offer PCV15 and PCV20, as this was not a requirement but a recommendation.
Interview on 02/02/2023 at 11:10 a.m. with the Regional Nurse Consultant stated, We are still using the [PCV] 13 and [PPSV] 23. She was not aware of the revised recommendations and that the policy still needed to be updated. The Regional Nurse Consultant added that she had clarified with the facility's pharmacy and was told CDC is now recommending PCV15 and PCV20; however, this was just a recommendation, and it was fine to continue to use PCV13 and PPSV23 only.
In a telephone interview on 02/02/2023 at 1:58 p.m., the Medical Director stated he was aware of the updated guidelines for pneumococcal vaccination and that the facility should have updated the policy and should be offering PCV15 and PCV20.
In a concurrent interview with the Regional [NAME] President of Operations (RVPO) and Regional Nurse Consultant on 02/02/2023 at 3:13 p.m., the RVPO stated she had clarified with the pharmacy that the PCV15 and PCV20 are the doses recommended by the CDC, but they were not required, only recommended.
2. a. Review of R#34's Immunizations tab in the electronic medical record (EMR). revealed no information regarding the offering or providing the pneumococcal vaccination series or whether the vaccine had already been received. Review of R34's undated Client Information sheet, provided on paper by the IP, revealed no information regarding the pneumococcal vaccination series. According to the facility's 02/02/2023 Age Summary and Average Age report, R#34 was over age [AGE].
b. Review of R#61's Immunizations tab in the EMR revealed no information regarding the offering or providing the pneumococcal vaccination series or whether the vaccine had already been received. A review of R#61's undated Client Information sheet, provided on paper by the IP, revealed that R#61 received a dose of PPSV23 on 11/28/2012; however, no additional information was provided. According to the facility's 02/02/2023 Age Summary and Average Age report, R#61 was over age [AGE].
c. Review of R#79's Immunizations tab in the EMR revealed no information regarding the offering or providing the pneumococcal vaccination series or whether the vaccine had already been received. A review of R79's undated Client Information sheet, provided on paper by the IP, revealed that This client has no immunizations associated with it. According to the facility's 02/02/2023 Age Summary and Average Age report, R79 was over age [AGE].
d. Review of R#14's Immunizations tab in the EMR revealed no information regarding the offering or providing the pneumococcal vaccination series or whether the vaccine had already been received. A review of R14's undated Client Information sheet, provided on paper by the IP, revealed no information regarding the pneumococcal vaccination series. Per the facility's 02/02/2023 Age Summary and Average Age report, R#14 was over age [AGE].
Interview on 02/02/2023 at 4:34 p.m. with the IP, she stated she did not have any additional immunization information other than what was provided and referenced above.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on staff interviews, record review, and a review of the facility policy titled, Clinical Staffing Standard, the facility failed to ensure the required Registered Nurse (RN) coverage of at least ...
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Based on staff interviews, record review, and a review of the facility policy titled, Clinical Staffing Standard, the facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week. There was no RN scheduled, or the Director of Nursing (DON) repeatedly served as the RN over a three-month period, although the facility census, which was higher than 60 residents per day, prohibited the DON from also serving as a charge nurse. This deficient practice had the potential to affect all 87 residents and allow them to go without having their clinical needs met by an RN.
Findings include:
Review of the policy titled Clinical Staffing Standard, dated 08/2021, revealed, Standard To provide nursing services regarding licensed nurses and certified nursing assistants 24 hours daily in order to meet the care and service needs of the residents that reside in the facility. Procedure. RN staffing will follow state, federal regulations.
Review of the Facility Assessment, dated 11/17/2022, revealed an average daily census of 86.5.
Review of an untitled staff schedule record revealed that there was either no RN scheduled or the DON was scheduled for RN coverage on the following days:
Twelve days were not covered during 01/2023: 01/01/2023, 01/07/2023, 01/08/2023, 01/19/2023, 01/20/2023, 01/23/2023, 01/24/2023, 01/25/2023, 01/26/2023, 01/27/2023, 01/30/2023, and 01/31/2023.
One day was not covered during 12/2022: 12/25/2022.
Two days were not covered during 10/2022: 10/02/2022 and 10/04/2022.
Interview on 02/02/2023 at 8:02 a.m. with the Director of Nursing (DON), stated that the Infection Preventionist (IP) and Licensed Practical Nurse (LPN) 3 make the schedules. The DON stated, I started last Tuesday, I have not had the chance to check the schedule. I know the DON should not be scheduled as the RN, but in a pinch, you do what you have to do.
Interview on 02/02/2023 at 10:30 a.m. with the IP and LPN3 were interviewed about the RN coverage on the schedule. The IP stated, We use the DON and sometimes the Administrator as the DON coverage. When informed that the regulation indicates the DON cannot serve as the RN when the census is higher than 60, the IP stated, I was not aware of that.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, review of the dietary staffing schedules, and review of facility policy, the facility failed to have sufficient dietary staff to ensure food was stored, prepared, and ...
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Based on observation, interview, review of the dietary staffing schedules, and review of facility policy, the facility failed to have sufficient dietary staff to ensure food was stored, prepared, and served in a sanitary and safe manner. Routine cleaning schedules were not followed due to a lack of sufficient staff to perform these duties, and food preparation surfaces, equipment, dishes, and service/cooking ware were found not to be clean and/or in good repair. Foods were not dated/labeled and/or sealed, and equipment, such as scoops, was not stored in a manner to prevent contamination. The lack of staff had the potential to affect 85 of 87 residents who consumed food from the kitchen.
Findings include:
Review of the facility's undated policy titled, Cleaning and sanitizing dietary areas and equipment specified, All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations.
During an observation and initial kitchen walk through on 1/30/2023 beginning at 9:35 a.m., the kitchen was found to have surfaces that were covered with accumulated dried food, rust, and/or grease. Equipment, such as the can opener, mixer, oven, deep fat fryer, and microwave, was not clean. Dishware that was stored and ready for use was unclean and contained residue and/or was wet with moisture. Opened food supplies were not sealed, labeled, and/or dated. Handwashing supplies (paper towels) were not stored in a manner to prevent contamination.
Review of the 1/2023 monthly dietary staffing schedule revealed two employees or less were scheduled to work in the kitchen on the first shift for 27 of 31 days. Two employees or less were scheduled to work in the kitchen on the second shift for 29 of 31 days during 1/2023.
Review of the kitchen's 1/2023 cleaning schedule, which was posted in the kitchen during the initial walk through on 1/30/2023, revealed the dietary staff were not completing the daily cleaning schedules.
During interview on 1/30/2023 at 3:15 p.m., with the Dietary Manager (DM) revealed that all the kitchen areas and equipment should be kept clean and foods should be labeled, dated, and completely closed when stored. The DM stated that the dietary department was understaffed, and it was hard for dietary staff to get everything done, including preparing resident meals and completing the kitchen cleaning schedules when there were not enough staff. The DM confirmed that the dietary staff were not completing cleaning schedules because there were not enough staff to complete the daily cleaning assignments.
During an additional interview on 1/31/2023 at 2:51 p.m., with the DM revealed there were currently three vacant positions in the dietary department. The DM explained that the kitchen is budgeted to schedule two employees to work the first shift and two employees to work the second shift. The DM further stated that if she could schedule three employees to work in the kitchen on first shift and three employees to work in the kitchen on second shift, that would make staffing in the kitchen sufficient so that staff had time to complete the kitchen daily clean schedules, as well as prepare and serve resident meals as scheduled.
During an interview on 2/02/2023 at 8:10 a.m., Cook1 stated that she had been working double shifts in the kitchen for a while and It is rough. [NAME] 1 stated that when there are only two dietary employees working in the kitchen each shift, they were not able to complete the daily cleaning schedule. Cook1 stated, that the kitchen needs more help to be able get everything completed.
During an interview on 2/02/2023 at 11:45 a.m., the facility's Registered Dietitian (RD) consultant revealed the dietary staff should be keeping the kitchen clean per the cleaning schedules. The RD further stated that she was aware the dietary department was having issues with staffing shortages which made it difficult for the staff to get everything completed.
During an interview on 2/02/2023 at 2:55 p.m., the facility's Regional [NAME] President indicated the facility needed to take a close look at the staffing in the kitchen.
Cross-reference F812.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review, and review of facility policy, the facility failed to store, prepare, and serve foods in a sanitary and safe manner. Handwashing supplies were not store...
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Based on observation, interview, record review, and review of facility policy, the facility failed to store, prepare, and serve foods in a sanitary and safe manner. Handwashing supplies were not stored in a manner which prevented contamination. Food preparations surfaces, equipment, dishes, and service/cooking ware were not clean and/or in good repair. Foods were not dated/labeled and/or sealed. Scoops were stored in dried food products. Routine cleaning schedules were not followed. Cold food temperatures were not accurately taken to prevent the spread of food-borne illness. This had the potential to affect 85 of 87 residents that received an oral diet.
Findings include:
Review of the facility's undated policy titled, Cleaning and sanitizing dietary areas and equipment, specified, All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations.
1. Observation during the initial kitchen walk through on 1/30/2023 beginning at 9:35 a.m., revealed the following:
a. Upon entering the kitchen, two dietary employees were observed working in the kitchen. The employees stated the Dietary Manager (DM) was not present, but she would be at the facility later in the day. The paper towel dispenser at the kitchen hand sink was empty and a stack of loose paper towels was placed on the eye wash station next to the hand sink.
b. A food preparation table's drawer was unclean with accumulated dried food and rust. Food preparation utensils and food service utensils including spatulas, large serving spoons and measured serving ladles were stored inside this unclean drawer. The lower shelf of the food preparation table had rust on it that could be wiped away with a paper towel. Four of four food preparation pans that were stored on this table's lower shelf were unclean with a greasy residue.
c. A large container of lids stored on the shelf of the food preparation table was unclean with accumulated food debris and a partial eggshell. Five metal lids stored inside of this container had dried food spills on them.
d. The kitchen's microwave oven had grease residue on its top and dried food splatters on its inner cooking compartment.
e. The kitchen's large manual can opener was unclean, with a black substance on its blade and base.
f. The kitchen's large mixer, which was covered and ready for use, was unclean, with dried food splatters.
g. A metal shelf that was over the kitchen's two compartment sink was unclean with rust build up. Three of three food preparation pans stored on this shelf were very wet.
h. The two kitchen ovens were unclean with accumulated burned food spills on the inside of their doors and metal cooking racks.
i. One exterior side of kitchen's deep fat fryer was unclean with a heavy accumulation of dried food and grease.
j. The kitchen floor was unclean with blackened areas and loose food debris. The floor between the kitchen's deep fat fryer and stove was unclean with accumulated grease and food spills.
k. The metal shelf under the kitchen's steam table was unclean with accumulated loose food debris and rusted areas.
l. Eight of 12 clear plastic cups that were stored and ready for use were unclean with a brown residue, that appeared to be dried tea, which could be wiped away with a paper towel.
m. Fifteen of 15 insulated plate covers that were stacked tightly together and ready for use on kitchen's tray line area had accumulated moisture on the interior portion of their lids.
n. One of the kitchen's large upright freezers had an accumulation of rust on one of its interior corners. Observations of foods stored inside this freezer revealed two bags of a unidentified breaded food products that were unlabeled, undated and not completely closed. Additionally, stored in this freezer was a large sealed large bag of what appeared to be chopped ham that was not labeled or dated.
o. One of the kitchen reach-in refrigerators had a container that had approximately 15 hardboiled eggs in it that was unlabeled and undated.
p. The kitchen's outside walk in freezer had a bag of an unlabeled and undated food product that was on the freezer's floor. Additionally, one 15.75 pound box of cheese omelets, one 20 pound box of cookie dough, and a large bag of an unlabeled and undated frozen food product were stored partially opened in this freezer.
q. In the kitchen's dry storage area, there were four large storage bins that had sugar, flour, corn meal and rice stored inside of them. Further observations revealed each bin also had a large scoop stored inside and the handle of each scoop was in direct contact with the food product stored inside of the bin. Also, observed in the kitchen's dry storage area were a 4.5-pound container of dried seasoned salt and an 80 ounce bag of dry grits that were stored partially opened.
Review of the kitchen's 1/2023 cleaning schedule, that was posted in the kitchen during the initial walk through on 1/30/23, revealed the dietary staff were not completing the daily cleaning schedules.
On 1/30/2023 at 3:05 p.m. the DM, who was onsite, was shown and informed of the concerns that were observed during the initial kitchen walk through that was conducted during the morning of 1/30/2023.
During interview on 1/30/2023 at 3:15 p.m., the DM revealed all the kitchen areas and equipment should be kept clean and foods should be labeled, dated, and completely closed when stored. The DM stated that the dietary department was understaffed, and it was hard for dietary staff to get everything done including preparing resident meals and completing the kitchen cleaning schedules when there was not enough staff. The DM confirmed that the dietary staff were not completing cleaning schedules because there were not enough staff to complete the daily cleaning assignments.
During interview on 2/02/2023 at 8:10 a.m., Cook1 stated that she had been working double shifts in the kitchen for a while and, It is rough. Cook1 explained when there are only two dietary employees working in the kitchen each shift, they are not able to complete the daily cleaning schedule. Cook1 stated the kitchen needs more help to be able to get everything completed.
Interview on 2/02/2023 at 11:45 a.m. with the facility's Registered Dietitian (RD) consultant revealed the dietary staff should be keeping the kitchen clean per the cleaning schedules. The RD further stated that she was aware the dietary department was having issues with staffing shortages which made it difficult for the staff to get everything completed.
2. Observation on 1/31/23 at 11:48 a.m. revealed the dietary staff were in the process of setting up the kitchen's lunch tray line for the resident lunch meal service. Observation revealed Dietary Aide (DA)1 appeared to be utilizing a thermometer to monitor the internal temperature of a carton of milk that was in a container of ice with other cold beverages and desserts. Upon closer observation, DA1 was observed to have the thermometer's probe inserted into the ice that was directly next to a carton of milk (rather than measuring the temperature of the milk, itself.). Interview with DA1 at this time revealed placing the thermometer in the ice (rather than in the actual food/beverages) was her usual way of monitoring the temperatures of the cold items being served from the tray line.
Cross Reference F802.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0888
(Tag F0888)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility policy titled, COVID-19 Data Tracker, the facility failed to me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility policy titled, COVID-19 Data Tracker, the facility failed to meet the requirement for 100% compliance, which requires that all staff working in the facility have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control Prevention (CDC). Eight-nine of 90 current staff were either fully vaccinated against COVID-19 vaccination or had been granted an exemption or delay in accordance with CDC guidelines, for a compliance rate of 98.9%. One staff member, Licensed Practical Nurse (LPN) 6, was identified as having a medical exemption; however, there was no valid contraindication for this exemption, In addition, the facility failed to ensure nine of ten unvaccinated and exempt staff were tested for COVID-19 twice weekly per the facility policy.
Findings include:
Review of the Centers for Disease Control and Prevention (CDC) COVID-19 Data Tracker website, accessed at https://covid.cdc.gov/covid-data-tracker/#datatracker-home on [DATE], revealed the facility's community transmission rate was high.
Review of the facility's undated Employee Covid 19 [sic] Vaccine Tracking Form, provided on paper by the Infection Preventionist (IP), revealed 88.9% of facility staff were fully vaccinated. There were ten unvaccinated staff out of a total 90 employees. Two of the ten unvaccinated staff had medical exemptions, and the other eight had religious exemptions.
1. Review of the CDC website, Overview of COVID-19 Vaccines, accessed on 02/01/2023 at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/overview-COVID-19-vaccines.html, revealed, The following are not included in the vaccines: . No food proteins such as eggs or egg products, gluten, peanuts, tree nuts, nut products, or any nut byproducts. (COVID-19 vaccines are not manufactured in facilities that produce food products).
Review of Licensed Practical Nurse (LPN) 6's 11/17/2021 Request for Information from Medical Provider, provided on paper by the Infection Preventionist (IP), revealed, [LPN6] is allergic to eggs, can't take flu, or COVID vaccination . Anaphylactic shock when exposed to eggs or egg components . Test patient routinely as per protocol for COVID-19. She is very allergic to eggs with a history of severe reactions in the past . Avoid COVID vax at this time d/t [due to] egg reaction/allergy. The request for a medical exemption from the COVID vaccine was signed by LPN6's Nurse Practitioner.
Interview on 02/01/2023 at 11:17 a.m. with the Medical Director, he stated, The COVID vaccine does not have egg in it to my knowledge . an egg allergy would not be an appropriate reason for a medical exemption.
Interview on 02/02/2023 at 8:33 a.m., the IP stated that the corporate office was responsible for approving or denying medical exemptions, and she had nothing to do with them.
Review of the facility's undated Mandatory COVID-19 Vaccination Policy revealed, Employees may request an exception from this mandatory vaccination policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination . All such requests should be submitted to the administrator at the facility and then forwarded to the [NAME] President of Human Resources. These forms will be handled in accordance with applicable laws and regulations.
2. Review of the facility's undated Mandatory COVID-19 Vaccination Policy revealed, Any person being granted a medical or religious accommodation will be required to obtain and provide a copy of 2 negative COVID-19 tests each week at least 3 days apart. Copies of these test results must be provided to the administrator and will be maintained in a separate medical file for each person.
Review of the facility's January 2023 County Positivity Testing/Employees, employee's requests for medical or religious exemption, and work schedules, provided on paper by the IP, revealed the following:
a. Certified Nurse Aide (CNA) 6 received an approved religious exemption on 11/20/2021 and had worked at the facility throughout January 2023. She was not tested for COVID-19 twice weekly, with testing documented on 01/27/2023, 01/23/2023, 01/09/2023, 01/05/2023, and 01/02/2023.
b. LPN6 was approved for a medical exemption on 11/17/2021 and worked at the facility throughout January 2023 (Refer to Example #1.) She was not tested twice weekly, with testing for COVID-19 documented on 01/17/2023.
c. Restorative Aide (RA) 1 received an approved religious exemption on 01/28/2022 and worked in the facility throughout January 2023. She was not tested twice weekly, with testing for COVID-19 documented on 01/16/2023, 01/12/2023, 01/09/2023, 01/05/2023, and 01/02/2023.
d. LPN8 received an approved religious exemption on 09/19/2022 and worked at the facility throughout January 2023. There was no record of COVID-19 testing for LPN8.
e. CNA8 received an approved religious exemption on 06/06/2022 and worked at the facility throughout January 2023. She was not tested twice weekly for COVID-19, with testing documented on 01/12/2023 and 01/24/2023.
f. CNA7 received an approved religious exemption on 01/21/2022 and worked in the facility throughout January 2023. She was not tested for COVID-19 twice weekly, with testing documented on 01/12/2023.
g. Physical Therapist (PT) 1 received an approved religious exemption on 12/14/2022 and worked on 01/01/2023, 01/08/2023, 01/22/2023, and 01/29/2023. There was no record of COVID-19 testing for PT1.
h. The Maintenance Director (MD) received an approved religious exemption on 02/11/2022 and worked at the facility throughout January 2023. He was not tested twice weekly for COVID-19, with testing documented on 01/27/2023, 01/20/2023, and 01/05/2023.
i. Dietary Aide (DA) 1 received an approved religious exemption on 01/09/2021 and worked on 01/12/2023, 01/14/2023, 01/15/2023, 01/19/2023, 01/24/2023, and 01/26/2023. There was no record of COVID-19 testing for DA1.
In an interview on 02/02/2023 at 8:24 a.m., the IP stated that the protocol for unvaccinated staff was to be tested twice weekly. She stated she had records of twice weekly testing for all exempt employees, and was asked to provide the records at this time. On 02/02/2023 at 1:02 p.m. and at 4:34 p.m., additional records of testing for unvaccinated staff were again requested, but not provided. No additional records were provided prior to the survey exit.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 31% turnover. Below Georgia's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s). Review inspection reports carefully.
- • 32 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $20,910 in fines. Higher than 94% of Georgia facilities, suggesting repeated compliance issues.
- • Grade F (24/100). Below average facility with significant concerns.
Bottom line: Trust Score of 24/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Comfort Creek's CMS Rating?
CMS assigns COMFORT CREEK NURSING AND REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered 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 Comfort Creek Staffed?
CMS rates COMFORT CREEK NURSING AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 31%, compared to the Georgia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Comfort Creek?
State health inspectors documented 32 deficiencies at COMFORT CREEK NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 29 with potential for harm, and 1 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 Comfort Creek?
COMFORT CREEK NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BEACON HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 98 certified beds and approximately 77 residents (about 79% occupancy), it is a smaller facility located in WADLEY, Georgia.
How Does Comfort Creek Compare to Other Georgia Nursing Homes?
Compared to the 100 nursing homes in Georgia, COMFORT CREEK NURSING AND REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.6, staff turnover (31%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Comfort Creek?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Comfort Creek Safe?
Based on CMS inspection data, COMFORT CREEK NURSING AND REHABILITATION CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Georgia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Comfort Creek Stick Around?
COMFORT CREEK NURSING AND REHABILITATION CENTER has a staff turnover rate of 31%, which is about average for Georgia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Comfort Creek Ever Fined?
COMFORT CREEK NURSING AND REHABILITATION CENTER has been fined $20,910 across 2 penalty actions. This is below the Georgia average of $33,288. 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 Comfort Creek on Any Federal Watch List?
COMFORT CREEK NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.