SUNNY RIDGE
For profit - Corporation
43 Beds
CASCADES HEALTHCARE
Data: November 2025
Trust Grade
23/100
#76 of 79 in ID
Photo by Sunny Ridge
Photo by Sunny Ridge
Photo by Sunny Ridge
Photo by Sunny Ridge
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sunny Ridge in Nampa, Idaho, has a Trust Grade of F, indicating significant concerns about care quality. Ranking #76 out of 79 facilities in Idaho means they are in the bottom half, and they are the lowest-ranked facility in Canyon County. The facility's trend is worsening, with the number of issues increasing from 10 in 2024 to 13 in 2025. Staffing is a relative strength, with a 4/5 star rating, though turnover is at 55%, which is slightly above the state average. However, the facility has concerning fines of $17,492, higher than 86% of Idaho facilities, and less RN coverage than 93% of state facilities, which may affect resident care. Specific incidents include a failure to prevent a resident's fall, resulting in a head laceration due to inadequate supervision, and evidence of verbal and physical abuse affecting multiple residents. Additionally, the facility did not provide adequate meal timing, leading to some residents going more than 14 hours without food, which could compromise their nutritional health. Overall, while there are strengths in staffing, the facility faces serious issues that families should carefully consider.
- Trust Score
- F
- In Idaho
- #76/79
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $17,492 in fines. Higher than 60% of Idaho facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Idaho. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 4%
Needs review
10 → 13 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 13 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Idaho average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Idaho avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $17,492
Below median ($33,413)
Minor penalties assessed
Chain: CASCADES HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (55%)
7 points above Idaho average of 48%
The Ugly 30 deficiencies on record
2 actual harm
Jan 2025
13 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to provide adequate supervision and functionin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to provide adequate supervision and functioning devices to prevent resident's fall. This was true for 1 of 3 residents (Resident #143) reviewed for accidents and falls. Resident #143 was harmed when he was being transported to the restorative dining room, and sustained a laceration on his head when he fell. Findings include:
Resident #143 was admitted to the facility on [DATE] with multiple diagnoses including Parkinson's disease, heart disease, osteoarthritis, cognitive decline, and depression.
An MDS significant change assessment, dated 4/16/24, documented Resident #143 was cognitively intact.
Resident #143's care plan, initiated 10/12/22, documented Resident #143 was at risk for falls due to impaired mobility, Parkinson's disease, weakness, unsteady gait, medications, and poor safety awareness. Interventions included foot device to wheelchair for positioning, revised 3/21/24.
This intervention was not followed.
An I&A report, dated 5/2/25, documented Resident #143 was being transported to the restorative dining room. Resident #143 legs were out stretched from a seated position. Resident #143 suddenly dropped his feet to the floor, causing him to fall. His face hit the floor before CNAs were able to catch him. The report documented he was bleeding profusely from his head. EMS (Emergency Medical Services) was called and Resident #143 was transported to the hospital for treatment.
A hospital report, dated 5/2/24, documented Resident #143 had a 3.5 centimeter laceration repair to his scalp, closed with 6 staples (a surgical staple used to close a wound), due to a fall from a wheelchair where he fell onto his knees and head.
A facility incident investigation report, dated 5/8/24, documented a CNA stated Resident #143 had been transferred to the dining room without his foot pedals before without incident. The CNA stated Resident #143 had refused to use his foot pedals.
There was no documentation in Resident #143's record that he had refused to use his foot pedals.
On 1/10/25 at 10:26 AM, the Administrator stated Resident #143 had Parkinson's disease, and he did not like the foot pedals due to the jerking which caused him pain in the ankles and potential pressure ulcers. The Administrator stated the facility could have ensured wheelchair safety measures were followed such as going slower or using a wheelchair seatbelt while resident was in motion.
The facility took the following actions in order:
-The resident was transferred to the hospital.
-The State Agency Long Term Care portal was notified.
-The physician was notified.
-Resident #143's respresentative was notified.
-Resident #143 was monitored for his injury.
-Staff were interviewed.
-The staff were educated regarding wheelchair safety: Proper transfer technique, ensuring proper fit and adjustments, navigating different terrains safely, preventing accidents and injuries, maintaining wheelchair stability, checking for wear and tear, and the importance of regular inspections.
-The care plan was updated to ensure Resident #143's feet were on the padded pedals during wheelchair mobility, and if Resident #143 refused, to reapproach and encourage him to use the foot pedals during transport for safety.
This finding represents past non-compliance with this regulatory requirement. Resident #143 had no falls since this incident, and no other incidents were found regarding other residents being injuried during transfer. At the time of the survey the facility was in substantial compliance and therefore does not require a plan of correction. There was sufficient evidence the facility corrected the non-compliance as of 6/8/24.
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 F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of medications for 1 of 5 residents (Resident #144) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medication was prescribed, the expected benefits, and the risks associated with the medications. Findings include:
The facility's Psychotropic Medication Use policy, dated July 2022, documented residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.
Resident #144 was admitted to the facility on [DATE], with multiple diagnoses including stroke, hemiplegia (paralysis) affecting the right side, and bipolar disorder (a mental illness that causes extreme mood swings).
A review of Resident #144's medical record documented a physician's order, dated 12/26/24, for Trazodone (antidepressant), 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy tube) at bedtime for Bipolar disorder.
A signed consent for Trazodone was not found in Resident #144's medical record.
On 1/9/25 at 8:00 AM, the surveyor requested a copy of Resident #144's signed consent for Trazodone.
On 1/10/25 at 10:09 AM, the Clinical Resource Nurse stated she was unable to find a signed consent form for Trazodone.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure transfer notices were provided to th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure transfer notices were provided to the ombudsman. This was true for 1 of 2 residents (Resident #6) reviewed for transfers to the hospital. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights related to transfers. Findings include:
The State Operations Manual, Appendix PP, revised on 8/8/24 documented, Before transfers or discharges of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure (a chronic progressive condition affecting the pumping power of the heart muscle).
Resident #6's annual MDS assessment, dated 5/23/24, documented Resident #6 was cognitively intact.
A review of Resident #6's medical record documented she had two unplanned hospitalizations on 10/26/24 and 12/14/24. Documentation of Ombudsman notification was not found.
On 1/9/25 at 8:00 AM, the surveyor asked for copies of hospital transfer notification to the Ombudsman.
On 1/9/25 at 11:23 AM, the Administrator stated the Ombudsman was not notified of Resident #6's transfers to the hospital and she should have been.
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, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to the residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#6 and #40) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their rights to return to their former bed/room at the facility within a specified time. Findings include:
The facility's Transfer or Discharge policy, dated 10/2022, documented a notice of facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer.
1. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including acute cholecystitis (inflammation of the gallbladder) and diabetes.
A nursing progress note, dated 9/23/24 at 8:09 PM, documented Resident #40 complained of on and off abdominal pain for the past three days. Resident #40's representative stated the surgeon told her that if ever Resident #40 had abdominal pain or fever she was to go to the hospital. Resident #40's representative took Resident #40 to the hospital.
A nursing progress note, dated 9/24/24 at 8:13 AM, documented Resident #40 was admitted to the hospital.
Resident #40's record did not include documentation that a Bed Hold notice was provided to her or to her representative when she was admitted to the hospital.
On 1/9/25 at 3:02 PM, the DON stated she was unable to find a Bed Hold notice was provided to Resident #40 or to her representative. When asked if Bed Hold notice should have been provided to Resident #40 or to her representative, the DON stated Yes Bed Hold notice should have been provided to Resident #40 or to her representative.
2. Resident #6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple diagnoses including end stage renal disease, diabetes, and congestive heart failure (a chronic condition that occurs when the heart cannot pump enough blood to meet the body's needs).
Resident #6's annual MDS assessment, dated 5/23/24, documented Resident #6 was cognitively intact.
A review of Resident #6's medical record documented she had two unplanned hospitalizations on 10/26/24 and 12/14/24, as follows:
a. A nursing progress report, dated 10/26/24, documented Resident #6 complained of increased pain and pressure to the area surrounding the colostomy. Resident #6 stated she felt more weak and shaky, and agreed to go to the ER (emergency room) for further evaluation.
A hospital report, dated 10/26/24, documented Resident #6 had an operation to incise and drain an abdominal wall abscess.
b. A nursing progress noted, dated 12/14/24, documented Resident #6 approached facility staff and stated, I need to go to the emergency room, my ostomy site hurts really bad. The ostomy site was assessed and noted to have swelling and redness, tender to the touch. Resident #6 was transported to the hospital.
A hospital report for 12/14/24 was not provided to surveyor upon request.
There was no documentation Resident #6 or her representative was provided bed hold paperwork.
On 1/9/25 at 11:23 AM, the Administrator stated bed hold paperwork was not provided to Resident #6 or her representative for either hospitalization, and it should have been provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) ha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 12 residents (Resident #16) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include:
The Resident Assessment Instrument (RAI), revised 10/1/24, documents if a PASARR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes.
Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (post traumatic stress disorder), and major depressive disorder.
Resident #16's medical record documented a PASSAR level II, dated 1/11/22 and 6/17/22, was completed.
Resident #16's admission MDS assessment, section A1500, dated 1/18/22, documented Yes, Resident #16 did have a PASSAR level II.
Resident #16's annual MDS, section A1500, dated 12/23/22, 12/6/23, and 11/29/24 documented No Resident #16 did not have a completed PASSAR level II.
On 1/8/25 at 2:30 PM, the MDS Coordinator stated Resident #16 had a PASSAR level II completed on 1/11/22. However, his PASSAR level II, dated 6/17/22 included an exemption that a level II was no longer needed, as he now only needs a PASSAR level I. The MDS Coordinator stated since Resident #16 no longer needed a PASSAR level II, she would not mark that in the MDS, and his original PASSAR level II would not carry forward. The MDS Coordinator verified Resident #16's admitting diagnoses had not changed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined the facility failed to ensure residents' medications were a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined the facility failed to ensure residents' medications were administered according to professional standards. This was true for 1 of 5 residents (Resident #17) observed during medication administration. This failed practice created the potential for Resident #17 to experience low or high blood sugar if she receives an incorrect amount of insulin. Findings include:
Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and stroke.
A physician's order, dated 9/16/24 documented Resident #17 was to receive 12 units of Insulin Aspart subcutaneously (under the skin) one time a day related to diabetes.
On 1/8/25 at 11:51 AM, LPN #1 took the Insulin Aspart pen, replaced the needle with a new one and dialed the pen to 12 units. LPN #1 then went to Resident #17's room and injected the Insulin Aspart to Resident #17's lower abdomen. LPN #1 was not observed to prime the insulin pen before dialing the prescribed dose of insulin for Resident #17.
On 1/8/25 at 12:04 PM, when asked about the preparation of insulin pen injection, LPN #1 stated she did not prime the insulin pen. LPN #1 stated it was a quick pen and it does not need to be primed.
The Insulin Aspart website, accessed on 1/14/25 stated, before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing perform an airshot (prime the needle).
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
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure pharmacist recommendations were foll...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure pharmacist recommendations were followed or addressed by the attending physician. This was true for 1 of 5 residents (Resident #31) whose pharmacist recommendation was reviewed. This deficient practice created the potential for Resident #31 to use unnecessary medications. Findings include:
The facility's Medication Regimen Reviews (MRR) policy, reviewed 4/2024, documented the Consultant Pharmacist performs MRR for every resident in the facility receiving medication upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: Resident's Name, Name of Medication, The Identified Irregularity and The pharmacist recommendation. The attending physician documents in the medical record that the irregularity had been reviewed and what action was taken to address it.
Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including breast cancer and diabetes.
A physician's order, dated 7/28/24, documented Resident #31 was to receive one milliliter of ABHR (Ativan, Benadryl, Haldol and Reglan) cream to her inner wrist three times a day related to anxiety disorder.
A Pharmacy Consultation Report, dated 7/1/24 through 9/30/24 and 12/5/24 through 12/6/24, documented, Resident #31 receives an antipsychotic, haloperidol in ABHR, for potentially inappropriate indication: Anxiety. Anxiety is not an appropriate indication to give an antipsychotic in a skilled nursing facility. The Pharmacist requested for clarification for the indication for use or discontinue the use of haloperidol. The Pharmacy Consultation Report had a portion Physician Response with three options listed for the physician to choose from:
1. I accept the recommendation(s) above, please implement as written.
2. I accept the recommendation(s) above with the following modifications:
3. I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale:
The Pharmacy Consultation Report did not include a response from the physician regarding Resident #31's use of haloperidol in ABHR.
On 1/9/25 at 4:09 PM, the DON stated she started in her position as DON about three weeks ago. The DON stated Resident #31 was a hospice resident and the Pharmacist recommendation should have been sent to the Hospice Physician as soon as it was received. She stated she did not know why the Pharmacist recommendation was not addressed by 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, it was determined the facility failed to ensure infection control prev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, it was determined the facility failed to ensure infection control prevention were maintained to provide a safe and sanitary environment. This was true for 1 of 1 resident (Resident #144) observed for infection control. This failure created had the potential to impact all residents in the facility by placing them at risk of infection. Findings include:
The CDC (Center for Disease Control and Prevention) website, updated 7/12/22 and accessed on 1/14/24 stated, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices regardless of MDRO (Multiple Drug Resistant Organism) colonization status.
Resident #144 was admitted to the facility on [DATE] with multiple diagnoses including stroke.
An EBP signage was observed outside Resident #144's door directing provider and staff to wear gloves and gown during device care or use: central line, urinary catheter, feeding tube and tracheostomy (a surgical procedure that involves creating an opening in the neck to access the trachea or windpipe).
A physician's order documented Resident #144 was on NPO (nothing per mouth).
Resident #144's care plan, initiated 12/19/24, documented he had an enteral feeding tube (a way to deliver liquid nutrition through a flexible tube to your digestive system).
On 1/9/25 at 8:51 AM, RN #1 was observed to administer Resident #144's crushed medication one at a time via Resident #144's enteral tube with gloves on. RN #1 was not wearing a protective gown while administering Resident #144's medications.
On 1/9/25 at 10:18 AM, RN #1 stated she did not wear a protective gown when she administered Resident #144's medications and she should wear one.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure influenza vaccine was administered to a resident who consent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure influenza vaccine was administered to a resident who consented to receive the vaccine. This was true for 1 of 5 residents (Resident #39) reviewed for immunizations. This deficient practice created the potential for harm should Resident #39 acquire, transmit, or experience complications from influenza.
The facility's Infection Prevention and Control Program (IPCP) policy, revised 2018, documented an IPCP was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy stated immunization was a form of primary prevention and widespread of use of influenza vaccine in the nursing facility was strongly encouraged.
Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and osteoporosis (a condition that causes bones to gradually thin and weaken).
Resident #39's Immunizations record, documented she received the Influenza vaccine on 9/8/22.
An Immunization Consent, dated 12/9/24, documented Resident #39 consented to the administration of the Influenza vaccine.
On 1/8/25 at 12:13 PM, the DON, who was also the Infection Preventionist, stated the vaccinations were offered to the resident upon their admission to the facility. The DON stated she did not know why the Influenza vaccine was not administered to Resident #39.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observation, residents and staff interviews, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served ...
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Based on observation, residents and staff interviews, it was determined the facility failed to maintain or enhance residents' dignity during dining when residents seated at the same table were served their meals at different times. This was true for 2 of 14 residents (#94 and #96) observed in the main dining room and 1 of 7 (Resident #30) observed in the assisted dining room. This failure had the potential to cause a decrease in residents' sense of self-worth and psycho-social well-being. Findings include:
1. On 1/6/25, the following were observed in the Main Dining Room:
a. Resident #7, Resident #9, and Resident #96 were seated at the same table. Resident #7 and Resident #9 were served their meal tray at 8:10 AM and 8:13 AM respectively and started eating. Resident #96 did not receive her tray until 8:29 AM (19 minutes from when the first meal was delivered to their table).
b. Resident #93, Resident #94 and Resident #95 were seated at the same table. Resident #93 and Resident #95 were observed eating their meals at 8:21 AM. Resident #94 did not receive her meal tray.
- at 8:50 AM, Resident #94 was heard saying to Resident #93 and Resident #95 Maybe I am getting my lunch. Resident #94 smiled at the surveyor and stated, Maybe they thought I am on a diet.
- at 8:57 AM, CNA #1 stated she did not know why Resident #94's meal tray did not arrive. CNA #1 asked LPN #2 to get Resident #94's meal tray because she could not leave the dining room.
- at 8:59 Resident #94 was served her meal tray (38 minutes from when Resident #93 and Resident #95 started eating).
On 1/6/25 at 2:06 PM, the DON stated residents seated at the same table should be served their trays at the same time. She said there was a confusion in the dining room this morning. The DON stated the kitchen was told Resident #94 was not going to eat her breakfast, I don't know where that information came from. The DON stated she did not know why Resident #96 also did not receive her meal tray at the same time as Resident #7 and Resident #9. The DON stated we have been trying to place the residents' meal tray at the same order as they sat at the table.
2. On 1/6/25, the following was observed in the Assisted Dining Room:
-at 8:07 AM, 6 out of 7 residents were served and already eating their meals. Resident #30 was seated at the same table with Resident #17, had not been served her meal.
-at 8:16 AM, Resident #30 received her meal (15 minutes after the meals were handed out to the other residents).
On 1/6/25 at 8:58 AM, CNA #2 explained, Resident #30's meal tray was late because she had changed dining rooms over the weekend and the kitchen still had her registered at the Main Dining Room. The meal cart for the Main Dining Room is delivered 15 minutes after the assisted dining meal cart, so Resident #30 would receive her meal later.
On 1/8/25 at 12:32 PM, the Dietary Director stated nurses will let the kitchen know when a resident changes dining rooms. The location is input into the residents' chart and the meal tickets are then printed out. If the meal is still going to the Main Dining Room, then the resident's chart has not been updated.
On 1/9/25 at 2:51 PM, the Administrator and the Clinical Resource Nurse stated the kitchen was not made aware of the change over the weekend and they should have been input into Resident #30's medical record.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Incidents and Accidents (I&As) report, residents and residents' representatives interview,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Incidents and Accidents (I&As) report, residents and residents' representatives interview, staff interviews, and residents' group interviews, it was determined the facility failed to ensure there were sufficient numbers of staff available at all times to provide nursing and related services to meet the residents' needs. This was true for 3 of 41 residents (#19, #30, and #36) reviewed for staffing concerns and had the potential to affect all residents in the facility. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received delay of care. Findings include:
a. Residents and their representatives were interviewed and stated the facility did not have sufficient staff to meet their needs.
- On 1/6/25 at 11:16 AM, Resident #144's representative stated, Staff is good and care for residents, but during meal times there are not enough staff to respond to immediate needs and he is waiting for help if he needs it.
- On 1/6/25 at 1:29 PM, Resident #34 who was cognitively intact according to her annual MDS assessment, dated 12/7/24, stated, They are short handed to get [her] ready for bed. They also take longer during meal times.
- On 1/7/25 at 11:37 PM, Resident #5 who was cognitively intact according to her annual MDS assessment, dated 12/9/24, I don't have anyone come quickly with the call light when I need my depends changed. During meal times when I need help to poop, they won't help me as they need to pass meals.
- On 1/7/25 at 2:30 PM, Resident #16's representative stated, I come at lunch and he is ready to get into bed. There is lot of lunch chaos and they aren't able to help [him]until after the lunch rush.
- On 1/7/25 at 2:32 PM, Resident #95 stated she pressed her call light and waited. Resident #95 stated she was holding her bladder and when she was unable to hold it she urinated into her bed.
b. A Resident Council Meeting was held on 1/7/25 at 9:37 AM. Ten residents attended the meeting. Seven residents stated it took up to an hour before their call lights were answered. One male resident stated, a 10 - 15 minute waiting time was reasonable. The male resident stated, It was so uncomfortable, I needed to be changed. A female resident verified she had to wait up to an hour before getting help.
c. I&As documented the following incidents:
1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including stroke and Parkinson's disease.
An MDS assessment, dated quarterly MDS assessment, dated 11/20/24, documented Resident #19 was moderately cognitively intact.
An I&A report, dated 11/17/24 at 10:45 PM, documented Resident #19 was found on the floor of his room. When asked how he ended up on the floor, Resident #19 stated I crawled out of bed to get help. Resident #19 was found to be have been incontinent.
An I&A report, dated 12/22/24, documented Resident #19 was found on the floor of his room. Resident #19 stated, I was trying to go to the bathroom.
2. Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including bladder disorder, asthma and bipolar disorder.
A quarterly MDS assessment, dated 12/5/24, documented Resident #30 was cognitively intact.
An I&A report, dated 12/17/24, documented Resident #30 was found on the floor of her bathroom. Resident #30 stated Had my call light on but nobody came and I was worried I would wet myself. Resident #30 stated she was needing to go to the restroom, but staff was not coming fast enough.
3. Resident #36 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, urinary tract infection and kidney failure.
An MDS assessment, dated 11/5/24 documented Resident #36 was cognitively intact.
A care plan, initiated 10/29/24, documented Resident #36 required one person assist for toileting.
An I&A report, dated 12/22/24 at 7:00 PM, documented Resident #36 was found on the floor in his room. Resident #36 stated he fell when was walking back from the restroom.
On 1/10/25 at 9:48 AM, the DON with the Clinical Resource Nurse stated the resident census is stable, so we keep the same number of staff for each of the shifts. We follow the PPD for staffing levels required in the facility.
On 1/10/25 at 10:25 AM, the DON with the Clinical Resource Nurse stated she started in the position as DON about three weeks ago. The DON stated Resident #36 kept going to the restroom without using his call light for assistance. She stated the residents' care plan were updated to toilet them after meals and before laying down. When asked if staff were educated regarding residents' toileting program and what was done regarding residents' concerns about their call lights not being responded in a timely manner, the DON stated she would look for the documentation of education provided to the staff.
On 1/10/25 at 11:41 AM, the DON with the Clinical Resource Nurse stated she was unable to find documentation staff were educated regarding residents' toileting program as indicated in their care plan. The DON also stated she could not find documentation other residents were interviewed regarding call lights waiting time when Resident #30 stated she had her call light on but nobody came and was worried she would wet herself, and toileted herself to the bathroom and fell.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policies and procedure, review of Incidents and Accidents (I&As), and staff interview...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policies and procedure, review of Incidents and Accidents (I&As), and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 3 of 3 residents (#4, #16, and #145) reviewed for medication administration. This failure created the potential for harm if the resident's medications were not administered according to the physician's order. Findings include:
The facility's Administering Medications policy, revised 2/24, documented:
-The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions.
-Medications are administered in accordance with prescriber orders, including any required time frame.
The facility's Medication and Treatment Orders policy, revised 7/16, documented:
-Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.
1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including fibromyalgia (a chronic condition that causes widespread pain and tenderness in the muscles and soft tissues of the body), pain in the left shoulder, atherosclerosis (a hardening of the arteries), chronic fatigue, and hypothyroidism.
A physician's order, dated 3/15/24, directed staff to give Oxycontin (opioid pain medication) ER (extended release) 80 mg two times per day.
An I&A report, dated 4/9/24, documented Resident #4 accidentally received a second dose of Oxycontin on 4/8/24 after she had already taken her prescribed dosage. Resident #4 was monitored for signs and symptoms of overdose. The physician and family were notified.
A nursing progress noted, dated 4/8/24 at 3:49 PM, documented Resident #4 had slight slow and slurred speech, but could response to questions appropriately.
On 4/18/24, a competency assessment for the nurse who provided the second dose was completed.
On 1/10/25 at 10:04 AM, the DON acknowledged the incident did happen, but she was not the DON at the time. She stated the two nurses involved in the incident were no longer employed in the facility.
2. Resident #145 was admitted to the facility on [DATE], with multiple diagnoses including COPD (chronic obstructive pulmonary disease), respiratory failure with hypoxia (low levels of oxygen in the body's tissues), and chronic kidney disease with heart failure.
A physician's order, 3/29/24, documented Resident #145 was to receive the following medications:
- Miralax 17 grams every day
- Culterelle daily
- Citracal/D3
- Vitamin C two times per day
An I&A, dated 4/5/24, documented the facility did not administer Resident #145's Miralax, Culterelle, Citracal/D3, and Vitamin C as ordered by her physician.
An undated handwritten note documented Hospice informed the facility on Tuesday Resident #145 did not receive her Miralax daily or three of her supplements. Hospice had faxed the orders to the facility, which were found in the staff's email from Monday. The orders were printed out and provided to the nurse who was directed to input the orders into Resident #145's record.
On 4/4/24, physician orders for Miralax 17 grams every day, Culterelle daily, Citracal/D3, and Vitamin C two times per day were placed into Resident #145's medication orders.
The I&A documented a staff inservice, dated 4/9/24, was provided regarding the facility's Medication and Treatment Order policy.
On 1/10/25 at 10:00 AM, after reviewing the record with the DON, she stated Resident #145 did not receive the above medications as ordered. The DON stated she was not the DON at the time. She stated the nurse involved was no longer employed at the facility.
3. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including dementia, PTSD (post traumatic stress disorder), and major depressive disorder.
A physician's order, dated 10/7/24, directed staff to administer Resident #16 Clindamycin (antibiotic) HCL (hydrocloride) 300 mg four times per day for 10 days.
An I&A, dated 10/8/24, documented the day shift nurse missed giving two doses of Clindamycin HCL 300 mg on 10/7/24, the physician was notified of the error.
The nurse involved had their clinical competencies reviewed on 10/19/24.
On 1/10/25 at 10:07 AM, the DON verified the error in medication administration for Resident #16 did happen, and due to the multiple medication errors , the nurse was no longer employed at the facility.
The facility did the following:
-Notified the residents' physician and/or representatives of the medication errors.
-Corrected the error and monitored the residents' signs and symptoms.
-Provided competency evaluations for the nurses.
-Provided in-service trainings.
-The staff involved were no longer employed at the facility.
This finding represents past non-compliance with this regulatory requirement. Resident #4, #16, and #145 had no further medication errors since this incident. At the time of the survey the facility was in substantial compliance and therefore does not require a plan of correction. There was sufficient evidence the facility corrected the non-compliance as of 11/19/24.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, policy review, Food Code review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was st...
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Based on observation, policy review, Food Code review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 41 residents who consumed food prepared by the facility. This placed residents at risk for potential food contamination and adverse health outcomes, including food-borne illnesses. Findings include:
1. Food Receiving and Storage:
The FDA Food Code Section 3-302.12 Food Storage Containers, Identified with Common Name of Food documented, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food.
The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented, Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.
The Facility's Food Receiving and Storage policy, dated 2001, documented:
. -Staff to label and date (use by date) dry foods that are removed from original packaging and stored in bins.
-All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date).
-Functioning of the refrigeration and food temperatures are monitored daily, and at designated intervals throughout the day by the food and nutrition services manager or designee, and documented according to the state-specific requirements.
-Refrigerators must have working thermometers and are monitored documented for temperature according to state-specific guidelines.
On 1/6/25 at 7:35 AM, the following was observed with the Dietary Director:
-The temperature log on the resident snack and personal refrigerator and freezer was incorrectly dated and did not have daily temperatures recorded.
-The following items were opened and undated in the dry storage area: mashed potato flakes, steel cut oats, Panko breadcrumbs, packaged rice, corn starch, Oreo cookie crumbles, and grape juice mix.
-Spices were expired: hot sauce (expired 5/5/21), dry pepper (expired 11/2/22), poultry seasoning (7/26/23).
-Large plastic bins containing white substances were not labeled with item or use by date.
-Mixed vegetables in the refrigerator were opened and undated.
On 1/6/25 at 7:45 AM, the Dietary Director stated she was unaware why there were opened, undated, and expired packages of food and spices in the dry food pantry. She stated food labels and dates are normally placed on the plastic food bins. The Dietary Director stated her staff was trained to label and date opened food items, and she did not know why they were not doing it.
On 1/09/25 at 3:15 PM, a follow-up kitchen inspection was conducted with the Dietary Director. The following was observed:
-Expired spices were stored in the food preparation station: cloves (expired 1/28/20), pepper (expired 9/14/22), white pepper (expired 11/20/23), chicken flavor (expired 11/1/23), and thyme (no date).
-Opened, undated, and an iced covered package of hot dogs on the shelve directly under the freezer condenser.
-Breaded chicken patties were opened and undated.
-Ranch dressing, salad mix, and mixed vegetables in the refrigerator were opened and undated.
-The temperature log on the resident snack and personal refrigerator and freezer was incorrectly dated and did not have daily temperatures recorded.
On 1/9/24 at 3:30 PM, the Dietary Director stated she was unaware why there were expired spices in the cook's area, or why the foods were not dated and labeled. She stated all staff receive food services training and should know how to date food and throw away expired spices.
At 3:50 PM, in a joint interview with the DON and Dietary Director, neither could verify who was supposed to be recording the temperatures on the resident refrigerator, but acknowledged someone should be doing it.
2. Cleaning, Sanitation, and Food Shelves:
The FDA Food Code Section 3-303.12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water.
The FDA Food Code Section 3-305.11(A) documented food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor.
The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.
The FDA Food Code Section 6-501.14 (A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials.
The facility's Sanitization policy, revised November 2022, documented all equipment, food contact services and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. When cleaning fixed equipment (which cannot be immersed in water), the removeable parts are washed, sanitized, and non-removable parts cleaned with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution (at the effective concentration).
The facility's Food Receiving and Storage policy, dated 2001, directed staff to:
-Food in dry storage areas must be kept at least 6 inches off the floor.
On 1/6/25 at 7:35 AM, an initial kitchen inspection was conducted with the Dietary Director. The following was observed:
-Ice build-up from condensation in the freezer created water droplets that covered two boxes of unopened sausages.
-Dust build-up, with large particles, were accumulated on the refrigerator fan covers.
On 1/09/25 at 3:15 PM, a follow-up kitchen inspection was conducted with the Dietary Director. The following was observed:
-Dish cloth sanitization buckets located in the ware washing room were noted to be less than 50 parts per million.
-Dust was accumulated on the shelves near the oven where dried cooking sheets were stored.
-Dust build-up, with large particles, were accumulated on the refrigerator fan covers.
-Ice build-up from condensation in the freezer created water droplets that covered two boxes of unopened pork sausages.
-Opened, iced covered package of hot dogs on the shelve directly under the freezer condenser.
-A shelf in the dry food pantry, storing various dried foods, measured 4 inches from the floor.
-Resident snack refrigerator had a burnt-out light bulb, and the door shelf was cracked. The handle to the refrigerator door was missing.
On 1/9/25 at 3:15 PM, Dietary Aid #1 stated he changes the dish sanitization buckets every shift, and he was unaware it needed to be done more frequently. The Dietary Director clarified sanitation buckets are normally monitored and changed at least every three hours.
At 3:30 PM, the Dietary Director stated equipment storage shelves are deep cleaned at least one time per month. She did not have a record when the shelves had last been cleaned. Additionally, the Dietary Director stated the condenser fans in the freezer and refrigerator are cleaned and maintained by Maintenance. She was not sure when they had last serviced them but believed it to be within the previous month. The Dietary Director verified the shelf in the food pantry should be at least 6 inches off the floor.
On 1/10/25 at 10:37 AM, the Administrator stated there were no maintenance requests for the freezer fan cleaning, or freezer, and resident fridge repairs. The facility was not aware of when the freezer and refrigerator fans were last cleaned.
At 11:47 AM, the Administrator and Dietary Director provided the temperature logs for January 2025, but were unable to find additional temperature logs for the previous months.
Feb 2024
10 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure all pertinent inform...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure all pertinent information was provided to the receiving facility when a resident was transferred to another health care facility. This was true for 1 of 1 resident (Resident #15) reviewed for resident transfer. This deficient practice had the potential to result in adverse outcomes if residents' specific needs were not treated appropriately and in a timely manner due to lack of information provided upon transfer. Findings include:
The facility's policy for Transfer or Discharge, dated October 2022, stated, Should a resident be transferred or discharged for any reason, the following information is communicated to the receiving facility:
a. The basis for the transfer or discharge.
b. Contact information of the practitioner responsible for the care of the resident.
c. Resident representative information, including contact information.
d. Advance Directive information.
e. All special instructions or precautions for ongoing care.
f. Comprehensive Care Plan goals.
g. All other information necessary to meet the resident's needs.
Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including kidney disease and type II diabetes.
Resident #15's record did not include documentation stating pertinent medical information was provided to the receiving hospital.
On 2/22/24 at 3:02 PM, the DON stated a resident's face sheet, Advanced Directive, POST, care plan, orders, any labs performed, and a bed hold were sent with the resident when they transferred to the hospital and documented in the resident's chart. She also stated the nurse also called and gave report to the receiving hospital. The DON stated the documents that were sent with Resident #15 were not documented in his chart.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement compr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 2 of 12 residents (#23 and #33) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in their care plan. Findings include:
The facility's Comprehensive Person-Centered policy, revised March 2022, documented the care plan interventions are chosen after careful consideration of the relationship between the resident's problem areas and their cause, and relevant clinical decision making. The care plan will also include interventions addressing the underlying source of the problem not just the symptoms or triggers.
1. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit.
Resident #33's care plan, revised 12/4/23, documented staff were to monitor and document signs and symptoms of depression including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health related complaints, and tearfulness.
Resident #33's care plan did not specify how he displayed hopelessness, anxiety, sadness, what negative statements he made, or what repetitive anxious or health complaints he verbalized. The care plan did not include interventions for Resident #33's behaviors.
On 2/20/24 at 2:39 PM, the Social Services Director stated Resident #33's record did not include monitors as indicated in the care plan. She also stated the symptoms documented in the care plan were not person-centered based on how Resident #33 displayed depression.
2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including Post-Traumatic Stress Disorder (PTSD).
Resident #23's care plan, revised 1/2/24, documented Resident #23 had a diagnosis of PTSD related to his time in the Vietnam War. Staff were directed to minimize triggers related to his past trauma. The care plan directed staff to monitor for the following:
- Signs and symptoms of distress or psychosocial adjustment difficulties.
- Trauma-related triggers and adjust care to avoid triggers.
Resident #23's care plan did not include what signs and symptoms he displayed for distress or psychosocial adjustment or what his trauma-related triggers were. The care plan did not include interventions on how to avoid triggers for Resident #23 or interventions if he displayed behaviors related to trauma-related triggers.
On 2/20/24 at 2:45 PM, the Social Services Director stated Resident #23's care plan was not clear on what his triggers were, and staff would not be able to avoid them. She also stated the PTSD care plan did not have a person-centered approach and was not clear on what signs and symptoms of distress to look for.
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 I&A review, record review, and staff interview, it was determined the facility failed to ensure residents' care plans w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on I&A review, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and revised. This was true for 1 of 12 residents (Resident #10) whose care plans were reviewed. This created the potential for harm when Resident #10's care plan was not reviewed and revised to reflect his care needs. Findings include:
The facility's Care Plan policy, revised March 2022, documented the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age related cognitive decline and malnutrition.
Resident #10's care plan, revised on 3/29/23, documented Resident #10 was a fall risk and was in a room closer to the nurses station for increased supervision.
A Nutritional Assessment, dated 3/6/23, documented Resident #10's dining ability was set-up with supervision.
A quarterly MDS assessment, dated 12/8/23, documented Resident #10 required maximal assistance with transfers.
An I&A report, dated 1/12/24 at 8:45 AM, documented Resident #10 had an unwitnessed fall while in his room. The report documented a family member of Resident #10's roommate informed the staff Resident #10 was on the floor. Upon entering the room Resident #10 was noted laying on the floor on his left side in front of his wheelchair. The report documented Resident #10 was finished with his breakfast and it appeared he pushed the bedside table out of the way and leaned forward in his wheelchair and fell. The report documented the call light was within his reach but not activated. The report also documented Resident #10 obtained a skin tear to his left forehead and left elbow.
The I&A report, dated 1/12/24, included documentation that a staff in-service training was provided with education not to leave Resident #10 unattended while in his room. Staff were to encourage the use of a mask while Resident #10 was out of the room and or social distancing for increased supervision.
Resident #10's care plan, did not include documentation his fall risk interventions were reviewed or revised after his fall on 1/12/24.
On 2/23/24 at 11:09 AM, the DON stated she did not feel the care plan needed to be updated with new fall interventions. Instead, she felt the staff needed to be in-serviced on preventing further falls.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, I&A review, record review, and staff interview, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 1 resident, (Resident #10), whose record was reviewed for falls. This resulted in harm to Resident #10 when he was left unsupervised to eat in his room. Findings include:
The facility's Falls and Fall Risk policy, revised February 2022, documented, based on previous evaluation and current data, the licensed nurse would identify interventions related to the resident's specific risk and cause to try to prevent the resident from falling and or minimize complications.
1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age-related cognitive decline and malnutrition.
A quarterly MDS assessment, dated 12/8/23, documented Resident #10 had impaired lower extremeties and required maximal assistance for transfers.
Resident #10's care plan, revised 3/29/23, documented Resident #10 was a fall risk and directed staff to provide increased supervision.
A Nutritional Assessment, dated 3/6/23, documented Resident #10's dining ability was set-up with supervision, meaning staff was to remain in the room during Resident10's meals.
An I&A report, initiated on 1/12/24 at 8:45 AM, documented Resident #10 had an unwitnessed fall while in his room. The report documented a family member of Resident #10's roommate informed the staff Resident #10 was on the floor. Upon entering the room, Resident #10 was noted laying on the floor on his left side in front of his wheelchair. The report documented Resident #10 was finished with his breakfast and it appeared he pushed the bedside table out of the way, leaned forward in his wheelchair, and fell. The report documented the call light was within reach but not activated. Additionally, it documented Resident #10 obtained a skin tear to his left forehead measuring 1 cm x 1 cm and skin tear to his left elbow measuring 5 cm x 2 cm x 0.5 cm.
An I&A report, dated 1/12/24, included documentation that a staff in-service training was provided with education not to leave Resident #10 unattended while in his room. Staff were to encourage the use of a mask while Resident #10 was out of the room and/or social distancing for increased supervision.
On 11/23/24 at 11:07 AM, the DON stated Resident #10 often attempted to self-ambulate and he was a fall risk. She stated since he was left unsupervised during this fall, she felt staff needed to be in-serviced to prevent it from happening again and ensure Resident #10 was supervised until he was ready to go to bed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 1 resident (Res...
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Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 1 resident (Resident #32) whose medications were reviewed. This failure created the potential for harm to Resident #32 when she did not receive ordered medication. Findings include:
The facility's Medication and Treatment Orders policy, undated, documented drugs that are required to be refilled must be reordered from the issuing pharmacy not less than 3 days prior to the last dose being administered to ensure that refills are readily available.
Resident #32 was admitted to the facility 1/19/24, with multiple diagnoses including breast cancer, acute pain, and chronic pain.
Resident #32 was prescribed ABHR cream (Ativan, Benadryl, Haldol, Reglan compounded into a topical cream), apply 1 millilliter to inner wrist 3 times a day for pain management.
Resident #32's MAR, dated 2/1/24 through 2/21/24, documented on 2/20/24, evening shift, the medication was administered. On 2/21/24, day shift, her MAR documented the medication not available.
A narcotic sign-out sheet for ABHR cream documented on 2/20/24 at 12:00 PM the quantity on hand was 1, quantity used was 1, and quantity remaining was 0.
On 2/21/24 at 11:36 AM, the DON stated she was not sure why the medication was signed out if it was not available. She stated she would need to talk to the nurse on duty that night.
On 2/21/24 at 3:23 PM, LPN #3 stated he could not recall what happened with the ABHR gel for the evening dose on 2/20/24.
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 F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and resident and staff interview, it was determined the facility failed to ensure two resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and resident and staff interview, it was determined the facility failed to ensure two residents' (#27 and #23) food preference requests were honored. This failure put residents at risk if they experienced hunger or weight loss from not having meals provided according to their needs or preferences. Findings include:
The Facility's Nutritional Assessment policy, revised October 2017, documented a comprehensive assessment for each resident included usual meal and snack patterns, food portion sizes, food restrictions, allergies, cultural, or religious practices that affected food choices and food preferences, food likes, dislikes, flavors, textures, and forms. The nutritional assessment was to also include documented current nutritional risk factors for or potential risk factors with a change in condition.
1. Resident #27 was admitted to the facility on [DATE], with diagnoses including congestive heart failure, type 2 diabetes complications, and severe morbid obesity.
Resident #27's dietary order, dated 7/6/22, documented his diet was a regular diet with large portions.
Resident #27's care plan, revised on 2/22/23, directed staff to provide Resident #27 with a regular diet. The care plan documented Resident #27's preference of large portions and a bedtime snack. No other preferences were documented.
Resident #27's Food & Nutrition Service Diet Order & Communication Form, dated 8/25/23, stated he preferred ham and turkey and disliked sausage.
On 2/19/24 at 8:10 AM, Resident #27 was observed eating a breakfast of cereal and banana, with eggs pushed aside. Resident #27 stated eggs made him gag, and he told the staff he did not want eggs, but he continued to receive them with every breakfast.
On 2/21/24 at 8:35 AM, Resident #27's breakfast tray was observed to include eggs with his meal. His tray card was observed and did not state, no eggs.
On 2/22/24 at 2:32 PM, the Registered Dietician (RD) stated residents could be picky, and she did not document all the likes or dislikes on the nutritional assessments, rather on the dietary profile. The RD further stated she also documented them on the tray cards and that the tray cards were frequently updated with the resident requests. She stated she was not aware of Resident #27's dislike for eggs.
On 2/23/24 at 9:35 AM, Resident #27's breakfast tray included eggs and his tray card did not state, no eggs. The RD was interviewed on 2/23/24 at 9:40 AM and stated she did update Resident #27's tray card on 2/22/24 and produced a copy which stated, no eggs. She did not provide an explanation for how Resident #27's breakfast tray included eggs and a tray card that was not updated.
2. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including palliative care and malignant neoplasm (cancer).
Resident #32's care plan, revised 1/19/24, directed staff to provide Resident #32 with a regular diet. The care plan did not document Resident #32's nutritional preferences.
Resident #32's Dietary Profile, dated 1/19/24, documented, NA under food likes and dislikes.
Resident #32's Mini Nutritional Assessment, dated 1/22/24, did not include food preferences.
Resident #32's Nutritional Assessment, dated 1/23/24, did not include Resident #32's food preferences.
Resident #32's record did not include documentation of food preferences.
On 2/20/24 at 10:39 AM, Resident #32 stated she had requested to have cereal in the morning for breakfast daily, but did not receive it and the staff only brought it after she turned down the scheduled breakfast for that day.
On 2/22/24 at 2:49 PM, the RD stated residents can be picky, so she did not document the likes and dislikes on the nutritional assessments, but they were documented on a progress note and on the Dietary Profile. She stated she also documented them on the tray card and those were updated frequently with resident requests.
On 2/23/24 at 11:00 AM, on review of Resident #32's record, the DON stated she was not able to locate Resdient #32's food preferances.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potenti...
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Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 32 of 32 residents residing in the facility who consumed food prepared by the facility, and placed them at risk of adverse outcomes including food-born illnesses. Findings include:
1. The facility's Preventing Foodborne Illness policy, Revised November 2022, documented Food and Nutrition service employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Additionally, the policy stated contact between food and bare (ungloved) hands was prohibited, as well as hair nets or caps and beard restraints were to be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens.
a. On 2/20/24 at 7:48 AM, Dietary Aide #2 was observed entering the kitchen during breakfast. She walked directly over to the bread with no observation of hand hygiene being performed. She was observed to pull the slices of bread out with her bare hand and put them on the tongs to place them in the toaster. She proceeded to use her bare hand to place bread on the tongs five consecutive times. When the bread was done, she stacked the bread with her bare hands and sliced the toast. She then walked over to the tray line and placed the slices of toast in the warmer.
On 2/20/24 at 7:52 AM, Dietary Aide #2 stated she was unsure if she touched the bread with her bare hands, but she would remove it from the warmer and put gloves on.
b. On 2/20/24 at 7:30 AM, Dietary Aide #1 was observed in the kitchen assisting with preparing breakfast trays. Dietary Aide #1 was observed to have no hair net or beard restraint.
On 2/20/24 at 7:45 AM, the Dietary Aide #1 was observed to have a black hair cap, but no beard restraint was observed.
On 2/20/24 at 8:00 AM, Dietary Aide #1 stated he had been wearing the hair cap. He also stated he was unsure what the policy was for beard restraints and was not sure if he should be wearing a beard restraint.
2. The facility's Food Receiving and Storage policy, revised November 2023, documented foods shall be received and stored in a manner that complies with safe food practices. The policy also directed staff to label food items with a use by date.
On 2/20/24 at 7:28 AM, during a kitchen inspection the following food items were not marked with a use by date:
- Sesame seed oil
- Coarse ground Black pepper
- Creamy peanut butter
- Cornbread mix
- Gluten free pancake mix
- Strawberry gelatin
- 2 trays of baked goods
- Mayonaise
- A box of Prunes opened to air
- Onions
The following items were not clearly marked if they were dated month and year or month and day:
- Ground nutmeg dated 9/21
- Seasoned salt dated 1/19
- Ground cinnamon dated 7/19
- [NAME] Leaves dated 8/3
- Black cherry drink mix dated use by 2/15
On 2/20/22 at 9:41 AM, the Chef stated the food items should have been dated and disposed of. He also stated it was unclear if food items were dated month and year or month and day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This was true for 1 of 2 outside ...
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Based on observation, policy review, and staff interview, it was determined the facility failed to ensure waste was properly contained with lids or otherwise covered. This was true for 1 of 2 outside dumpsters. This created the potential for insect and pest infestation of the facilities premises. Findings include:
The facility's Sanitation policy, revised November 2022, documented garbage and refuse containers were to remain in good condition to prevent leaks, and waste was properly contained in the dumpster with lids or otherwise covered.
On 2/20/24 at 11:45 AM, one dumpster was observed with the lid open, and bread rolls on the ground surrounding the dumpster.
On 2/23/24 at 8:30 AM, the dumpster was observed with the lid open.
On 2/23/24 at 8:33 AM, the Chef confirmed the dumpster was open and it should have been closed but it was hard to keep it closed since the nursing facility kitchen shared the dumpster with the Assisted Living facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents were monitored appropriate...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications. This was true for 4 of 8 residents (# 3, #14, #17, and # 32) reviewed for pain management. This failure created the potential for residents to experience adverse reactions due to lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include:
The Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain, dated 2022, last reviewed 6/14/23, accessed online 2/27/24, documented clinicians should maximize use of non-pharmacological and non-opioid pharmacological therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risk to the patient.
The facility's Pain - Clinical Protocol policy, revised October 2022, documented the staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. It also stated the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain.
1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including shoulder pain and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin).
Resident #4 was prescribed Oxycodone (opioid medication) 5 mg, 1 tablet by mouth every 6 hours as needed for pain level of 5-10 (on a 0-10 pain scale, where 0 is no pain and 10 is the worst pain). Resident's MAR, dated 2/1/24 through 2/22/24, did not include documentation non-pharmacological pain interventions were attempted prior to the administration of Oxycodone for 51 of 51 administrations.
Resident #4's MAR, dated 2/1/24 through 2/22/24, did not include non-pharmacological interventions for pain.
On 2/22/24 at 1:38 PM, the DON stated nursing staff did not document non-pharmacological interventions.
3. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain and opioid dependence.
Resident #17's care plan, dated 8/16/18, documented the nurse was to evaluate Resident #17's pain characteristics, quality, severity, location, precipitating/relieving factors, and utilize the pain scale, and to advise Resident #17 to request pain medication prior to her pain becoming severe. The care plan also documented to monitor Resident #17 for any change of mood, mental status, nonverbal signs of pain, resistance to care, or increased in pain or agitation.
Resident #17's care plan, dated 10/21/22, documented pain medication was to be given as ordered.
Resident #17 was prescribed Tramadol HCL (opioid medication) 50 mg tablet by mouth every 4 hours as needed for pain levels between 5-10 (on a scale of 0-10).
A facility pain interview, dated 1/25/24, documented Resident #17's pain occurred occasionally, at a level of 7 out of 10 which is moderate, and her pain occurred daily.
On 2/21/24, Resident #21 stated she felt her pain was managed but still woke her up at night.
Resident #17's MAR, dated, 2/1/24 to 2/22/22, did not include documentation of non-pharmacological interventions prior to 2 of 2 administrations of as needed Tramadol HCL for pain.
4. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the left tibia (left shin bone) and left lower end of the humerus (left arm just below the elbow on the upper forearm.)
Resident #3's care plan, dated 12/18/23, documented to evaluate her pain quality, severity, location, precipitating and relieving factors utilizing a pain scale, and to monitor Resident #3's episodes of breakthrough pain - verbal or non-verbal signs/or symptoms of pain, as well as increased agitation or resistance to care.
A physician's order, dated 12/20/23, documented to administer Oxycodone HCL ½ tablet to Resident #3 via her gastrostomy tube (a tube inserted through the abdomen that brings nutrition directly to the stomach) every 6 hours as needed for pain scale of 1 to 5.
A physician's order, dated 12/20/23, documented to administer Oxycodone HCL 1 tablet to Resident #3 via her gastrostomy tube every 6 hours for pain scale of 6-10.
A nurses' note, dated 2/12/24, documented Resident #'s medication route was changed by her physician from gastrointestinal tube to oral.
A physician's order, dated 12/20/23, documented to administer Oxycodone HCL ½ tablet by mouth to Resident #3 every 6 hours as needed for pain scale of 1 to 5.
A physician's order, dated 12/20/23, documented to adminster Oxycodone HCL 1 tablet by mouth to Resident #3 every 6 hours for pain scale of 6-10.
Resident #3's MAR, dated 2/1/24 to 2/22/22, did not include documentation of non-pharmacological interventions prior to 5 of 5 administrations of as needed Oxycodone HCL for pain.
Resident #3 confirmed her pain interventions to manage pain in her left leg and left arm were pain pills and no other interventions were offered that she was aware of.
On 2/22/22 at 10:30 AM, the DON and the Regional Nurse stated the facility did not utilize non-pharmacological pain interventions prior to administration of as needed pain medications to all residents.
2. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including palliative care and malignant neoplasm (cancer).
Resident #32's care plan, dated 1/19/24, documented the licensed nurse was to evaluate pain quality, severity, and location.
A physician order, dated 1/19/24, documented the following, Pain Monitor: are you free of pain? If no, indicate response through chart code.
Resident #32's MAR, dated February 2024, documented Resident #32 experienced pain for 7 of 60 monitoring opportunities.
Resident #32's record did not include additional monitoring on pain management or non-pharmacological interventions.
On 2/22/24 at 9:30 AM, Resident #32 was observed laying in bed with tears running down her face and facial grimacing. Resident #32 stated she made a request for medication.
On 2/22/24 at 9:40 AM, Resident #32's nurse brought pain medication to her and asked what her pain level was, Resident #32 stated, above a 10, more like a 20. No non-pharmacological interventions were observed offered to Resident #32 for her pain.
On 2/23/24 at 11:05 AM, the DON confirmed the facility was not monitoring pain levels or offering non-pharmacological interventions.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age related cognitive decline and maln...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including age related cognitive decline and malnutrition.
Resident #10's record included an order to cleanse her coccyx (tailbone) wound with wound cleanser, pat dry, apply skin prep to surrounding healthy tissue, then apply hydrocolloid dressing to site until resolved.
On 2/20/24 at 2:05 PM, LPN #2 was observed providing wound care to Resident #10. LPN #2 remove the soiled dressing and provided incontinent care around the wound. She then proceeded to cleanse the wound without changing her soiled gloves.
On 2/20/24 at 2:11 PM, LPN #2 stated she did not realize she had not changed her gloves after she provided incontinent care, before cleaning Resident #10's wound. LPN #2 stated she did change her gloves before applying the dressing.
2. Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including shoulder pain and pressure ulcers (Injury to skin and underlying tissue resulting from prolonged pressure on the skin).
On 2/222/24 at 11:10 AM, LPN #1 was observed providing wound care to Resident # 14. LPN #1 removed the soiled dressing and then proceeded to cleanse wound without changing her soiled gloves.
On 2/22/24 at 11:20 AM, LPN #1 stated she should have changed gloves after removing the old dressing and before cleansing Resident #14's wound. She stated did not realize she had not changed her gloves after removing the dressing from Resident #14's wound.
Based on observation and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when hand hygiene was not performed for 2 of 2 residents (#10 and #14) observed for infection control. This failure created the potential for cross-contamination and infection. Findings include:
Feb 2023
7 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, resident interview, and staff interview, it was determined the facility failed to protect residents' rights to be free from physical and verbal abuse. This was true for 6 of 10 residents (#2, #7, #35, #36, #37, and #136) reviewed for abuse. This failure resulted in harm to Resident #2 and Resident #136. This failure also placed residents at risk of ongoing abuse and potential physical and psychosocial harm. Findings include:
The facility's Abuse Prevention Program policy, revised 12/2016, stated the facility would protect residents from, as well as prevent, all types of abuse, neglect, misappropriation of property, and exploitation by anyone including staff and other residents. The policy defined the following:
Verbal Abuse - The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance; regardless of their age, ability to comprehend or disability.
Physical Abuse - Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.
This policy was not followed.
1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on side of the body) and hemiparesis (weakness on one side of the body) following stroke, and heart failure.
A quarterly MDS assessment, dated 3/26/22, documented Resident #2 was cognitively intact.
A facility reported incident investigation, initiated 4/10/22, documented RN #2 and LPN #1 heard Resident #2 yell at someone to stop hitting her. RN #2 entered the activity/dining room and saw Resident #38 hitting Resident #2 on her left arm and yelling at her to move from where she was seated. RN #2 separated the two residents by moving Resident #38 and placing her next to a medication cart. Resident #2 was assessed and found to have a bruise to her left arm and left hand. Resident #38 had no injuries identified.
The incident report documented the SSD interviewed Resident #2 on 4/14/22. Resident #2 stated Resident #38 approached her and said, This is my place, you don't belong here, get out of my chair. Resident #2 stated Resident #38 then started to hit her on the back of her neck, her back, and all over. The SSD also interviewed Resident #38. Resident #38 stated she did not hit anyone.
The incident report documented the following interventions:
- Resident #2 and Resident #38 were separated.
- Resident #38 was placed on 15-minute checks for 72 hours for increased supervision.
- Head to toe assessments were completed for both residents. Resident #2 was found to have a bruise to her left forearm and left hand. Resident #38 had no injuries were identified.
- Resident #2's bruises were monitored until healed.
- The SSD conducted psychosocial monitoring for both residents.
- The physician was notified and reviewed Resident #38's medications. A new order was received for Resident #38 to discontinue Trazodone (antidepressant) 50 mg in three days and start Zyprexa (antipsychotic) 5 mg daily for dementia and behavioral disturbance.
- Resident #38's care plan was reviewed and updated.
A psychosocial note, dated 4/14/22 at 12:25 PM, documented Resident #2 was visited by the SSD. Resident #2 stated she was fine and knew Resident #38 was old and had problems. Resident #2 stated she was okay, and the incident was over.
On 2/6/23 at 10:03 AM, Resident #2 stated about three months ago, Resident #38 hit her all over her upper body. Resident #2 stated, I had black and blue marks all over me and I was hurt. Resident #2 stated the staff intervened and took Resident #38 away from her and she was kept safe by the staff.
On 2/8/23 at 3:59 PM, the DON stated Resident #38 hit Resident #2 while they were in the dining room. The DON stated Resident #38 had no history of prior altercations with another resident and it was the first time Resident #38 had an outburst with another resident. The DON stated Resident #38 was monitored for 72 hours after the incident and there were no concerns observed.
The facility failed to ensure Resident #2 was free from physical abuse.
2. Resident #35 was admitted to the facility on [DATE], with multiple diagnoses including amyotrophic lateral sclerosis (a fatal type of motor neuron disease characterized by progressive degeneration of nerve cells in the spinal cord and brain) and adult failure to thrive.
A quarterly MDS assessment, dated 7/22/21, documented Resident #35 was cognitively intact.
A facility reported incident investigation, initiated 7/21/21, documented Resident #35 reported to the facility CNA #3 was rude to him, threw his arm out of her way, and left his room without placing his blankets back on him.
The report documented during the facility's investigation, two other residents (#36 and #136) reported they experienced abuse as follows:
a. Resident #36 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including COVID-19 and diabetes mellitus with diabetic neuropathy (nerve damage).
A quarterly MDS assessment, dated 1/19/21, documented Resident #36 was cognitively intact.
When Resident #36 was interviewed, she stated she felt ignored by staff and they just throw blankets on her and don't ask if she needs anything else.
b. Resident #136 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), and type 2 diabetes mellitus with diabetic neuropathy.
A quarterly MDS assessment, dated 12/26/22, documented Resident #136 was cognitively intact.
The investigation report documented when Resident #136 was interviewed, she stated she felt uncomfortable asking LPN #2 for medications since she was rude to her and she felt LPN #2 viewed her as a medication-seeker when she told her, You better watch the Percocet [a narcotic pain medication], because it is very addicting.
The investigation report summary documented the allegation of abuse was unsubstantiated by the interdisciplinary team. The report also stated, However, lack of customer service was substantiated.
The investigation report documented the following interventions:
- Resident #35's arm was assessed, and no injuries were observed. His psychosocial needs were assessed, and none were noted. His physician was notified, and he was offered counseling services, which he declined.
- CNA #3 was suspended for 2 days during the investigation and received counseling related to customer service and compassionate care expectations.
- LPN #2 received education related to her approach and perception of being rude and or labeling residents related to their medication regimen.
- Education related to professional conduct was added to the annual in-service abuse training for all staff.
On 2/10/23 at 11:10 AM, the Administrator and the DON stated no further disciplinary actions were documented for LPN #2 and CNA #3 after the incident and annual in-service abuse training was conducted for all staff in 2021 and 2022. The Administrator stated she was not working at the facility at the time of the incidents or during the investigation. She said she would not have addressed the incident as customer service issues, but as issues with unacceptable behavior and a mild type of verbal abuse. Both the Administrator and the DON felt the current staff were appropriately trained regarding abuse.
The facility failed to ensure Residents #35, #36, and #136 were free from physical and verbal abuse.
3. A facility reported incident investigation, dated 11/5/22, documented LPN #1 reported the following allegations of abuse by CNA #2:
- On 11/5/21, LPN #1 asked CNA #2 to assist Resident #36 out of her wheelchair and into her bed. After CNA #2 went into Resident #36's room, LPN #1 overheard her tell Resident #36, I told you, you needed to wait and if you keep leaning forward in the wheelchair, I won't get you up tomorrow. LPN #1 spoke with CNA #2 about the inappropriateness of her conversation. CNA #2 verbalized understanding.
- On 11/6/21, LPN #1 gave Resident #7 her nectar-thickened coffee per her request. LPN #1 overheard CNA #2 ask Resident #7, Who gave you this coffee? You can't have it, it's not thickened. LPN #1 returned to where Resident #7 was and noted she did not have her coffee and was visibly upset and waving her hands and pointing to where her coffee used to be. LPN #1 spoke to CNA #2 about the inappropriate action of taking things away from residents and telling them they cannot have them. CNA #2 replied she would ask first next time.
- On 11/6/21, LPN #1 entered Resident #37's room and noted she was visibly upset. When asked what was wrong, Resident #37 told LPN #1, I have never been treated so badly in my life. When asked what happened, she stated she asked CNA #2 for her toiletry bag so she could brush her teeth, CNA #2 responded, Can't you do it yourself? When Resident #37 asked her again, CNA #2 told her, You can do it yourself. She then set up Resident #37's oral care supplies on her bedside table instead of near the sink. LPN #1 went to speak with CNA #2 about the incident and CNA #2 walked away from LPN #1.
The incident report summary documented the following interventions:
- CNA #2 was suspended from working atht the facility.
- Resident #7's, #36's, and #37's physicians were notified.
- Additional residents were interviewed and did not voice abuse issues.
- Psychosocial assessments were conducted, and follow-ups were performed for 7 days for Residents #7, #36, and #37 by the SSD and no concerns were identified.
- Abuse education was conducted for all staff on 11/8/21.
On 2/10/23 at 11:10 AM, the Administrator and the DON stated CNA #2 was an agency nurse and was suspended during the investigation and terminated on 11/8/21. Her agency was informed of the incidents and terminated CNA #2's contract on 11/12/21.
The facility failed to ensure Residents #7, #36, and #37 were free from abuse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' Physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' Physician's Order for Scope of Treatment (POST) and medical record were consistent with their advanced directives. This was true for 1 of 5 residents (Resident #11) whose records were reviewed for advance directives. This failed practice created the potential for harm if residents' wishes regarding end of life or emergent care were not honored if they became incapacitated. Findings include:
The facility's policy for Advance Directives, revised [DATE], documented the following:
- Residents' wishes were communicated to their direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record.
- The plan of care for each resident was consistent with his or her documented treatment preferences and/or advance directives.
This policy was not followed.
Resident #11 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), and atherosclerosis of arteries (build-up of a fatty substance called plaque in the arteries causing restricted blood flow) in her left leg.
Resident #11's physician orders, dated [DATE], documented she was a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive).
Resident #11's record included a POST, dated [DATE], and signed by her physician on [DATE]. The POST documented Resident #11 chose to have a DNR code status (with no CPR or life support interventions) with comfort measures only.
Resident #11's care plan, initiated on [DATE], and revised on [DATE], documented her code status was Full Code.
Resident #11's profile page of her electronic medical record (EMR), accessed on [DATE], documented her code status as Full Code.
When asked to find a resident's code status, the ADON, 1 RN, 2 LPNs, and 2 CNAs stated they would first look at the resident's profile page on the EMR.
On [DATE] at 9:25 PM, the DON stated residents' code status on the EMR were based on their physician orders.
The facility failed to ensure Resident #11's medical record and POST were consistent with her wishes.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received a written notice of discharge 30 days before the resident was discharged or transferred, and informed of their rights to appeal the transfer or discharge from the facility. This was true for 1 of 3 residents (Resident #39) reviewed for transfer and discharge. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfer or discharge from the facility. Findings include:
The facility's Transfer or Discharge Notice policy and procedure, revised March 2021, stated the following:
*Residents and his or her representative were given a 30-day advance written notice of an impending transfer or discharge from the facility.
*An explanation of the resident's rights to appeal the transfer or discharge to the state, including:
- the name, address, email and telephone number of the entity which receives appeal hearing requests
- information about how to obtain, complete and submit an appeal request
- how to get assistance completing the appeal process
This policy was not followed.
Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, diabetes mellitus, asthma and hypertension.
A Discharge Planning Review, dated 7/30/22, documented Resident #39's overall goal was to remain in the facility.
A care plan, initiated on 8/30/22, documented Resident #39 had no plans for discharge and did not want to be asked at each assessment.
A Notice of Resident Transfer and Discharge, dated 12/12/22, documented as per the admission agreement, the facility must transfer/discharge a resident when the facility determined that such action was appropriate in order to meet the resident's needs for healthcare services. The notice documented Resident #39 needed a memory unit and would be transferred to an Assisted Living Facility (ALF). The Notice of Resident Transfer and Discharge documented Resident #39's representative had the right to appeal the decision to the appropriate state long-term care agency at the address provided in the notice. The notice also documented that if Resident #39's representative needed help in obtaining an appeal form or assistance in completing the form or submitting the appeal request, she may contact [blank space] at this facility. On the blank space was handwritten N/A (not applicable). This document was signed by Resident #39's representative on 12/13/22.
A nurse's note, dated 12/13/22 at 1:31 PM, documented Resident #39 was discharged to an ALF. The same day the the 30-day notice was signed by her representative.
There was no documentation in Resident #39's record the facility spoke to her and/or her representative the need to be discharged to a memory unit.
On 2/8/23 at 10:45 AM, the DON stated she remembered Resident #39 had issues with the staff and other residents and felt her discharge from the facility was more of a facility initiated discharge due to her advancing dementia. It was for her safety and safety of the other residents in the facility. The DON stated they believed it would be better for Resident #39 to be in a memory unit. The DON reviewed Resident #39's Notice of Transfer or Discharge and stated N/A should not be written on the appeal section since the facility initiated the discharge. The DON stated the name of the Administrator or her name should be written on the space provided. The DON stated N/A should be written if it was a resident initiated discharge.
The facility failed to provide a 30-day advance notice of discharge to Resident #39 and/or her representative, and the chance for her and/or representative to appeal for the discharge.
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 F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure there w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure there was an ongoing activity program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was true for 1 of 1 resident (Resident #12) reviewed for activities. This failure created the potential for harm if residents experienced boredom and lacked meaningful activities throughout the day. Findings include:
The facility's Activity Program policy, revised June 2018, documented activities were considered any endeavor, other than routine activities of daily living, in which the residents participated, that was intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. The policy also stated activity programs were offered and based on the comprehensive resident-centered assessment and the preferences of each resident.
This policy was not followed.
Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (weakness of the heart leading to a buildup of fluid in the body), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), dementia, and aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking).
An admission MDS assessment, dated 5/19/22, documented Resident #12 was severely cognitively impaired.
A care plan, initiated on 5/12/22, documented Resident #12 was deaf and it was important to her to engage in daily routines that were meaningful to her preferences. Resident #12's care plan documented she liked to participate in exercise such as volleyball with groups of people, looking out the window, laying down to rest, meditating, praying, thinking, watching TV/movies by herself in her room, and participating in religious services.
A Care Conference progress note, dated 10/21/22 at 11:38 AM, documented Resident #12's representative stated Resident #12 was always sleeping when she came to visit her in the afternoon. The progress note documented Resident #12 laid down after lunch on a regular basis and right before or after breakfast was the best time to visit her.
On 2/6/23 at 10:05 AM, 2/7/23 at 10:16 AM, 2/8/23 at 10:36 AM and 2/8/23 at 3:03 PM, residents group activities were observed in the Assisted Dining Room. The activity on 2/7/23 was a church service with gospel music playing on TV. Resident #12 was not observed in any of these activities.
Resident #12 was observed on the following days:
- On 2/6/23 at 10:35 AM, she was in bed, awake making unintelligible sounds and her TV was on.
- On 2/6/23 at 11:17 AM, she was in the hallway near the nurse's station, sitting quietly in her wheelchair.
- On 2/6/23 at 2:41 PM, she was observed in her bed, sleeping.
- On 2/7/23 at 8:45 AM, she was observed sitting in her wheelchair near the nurse's station. At 8:56 AM, CNA #1 assisted her to bed.
- On 2/7/23 at 10:16 AM, she was observed sleeping in her bed while the church service was being held in the Assisted Dining Room. Resident #12's care plan, documented she liked to participate in religious activities.
- On 2/7/23 at 2:31 PM, she was observed sleeping in bed.
On 2/10/23 at 10:18 AM, the AD stated she provided 1:1 activities to Resident #12 such as sensory activities, which included having her try foods with different taste, smell kits, and applied lotion and massaged her hands if Resident #12 allowed it. The AD stated Resident #12 was always sleeping and she put a note on the door in the nurse's station for the CNAs to keep Resident #12 awake during a certain time for activity. When the surveyor looked at the door inside the nurse's station, there was no note posted on the door. The AD stated, The note was there about three weeks ago.
The facility failed to ensure there was an ongoing activity program to support Resident #12's physical, mental, and psychosocial well-being.
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 observation, record review, and staff interview, it was determined the facility failed to ensure professional standards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 3 of 12 residents (#12, #85 and #86) reviewed for standards of practice. Specifically:
- Resident #12 was at risk of neck and back discomfort or obstructed airway when her head and posture were not supported. Resident #12 was also at risk of constipation or bowel obstruction when her physician's order for her bowel care was not followed.
- Resident #85 was at risk of infection and a worsening wound when physician orders were not followed.
- Resident #86 was at risk of infection when his physician orders for dressing changes were not followed.
These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practices. Findings include:
1. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (weakness of the heart leading to a buildup of fluid in the body), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), dementia, and aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking).
An admission MDS assessment, dated 5/19/22, documented Resident #12 was severely cognitively impaired.
a. Resident's #12's care plan, revised 7/12/22, included an intervention to have her sit in the hallway when she was out of bed as she would allow for increased supervision. There was no documentation in Resident #12's care plan to place a pillow to support her head or posture while she was up in her wheelchair.
A physician progress note, dated 10/13/22, documented Resident #12 was sleeping in her wheelchair across from the nurse's station with her head cranked forward.
A physician progress note, dated 12/15/22, documented Resident #12 was seen for a 60-day visit. The physician documented Resident #12 was sitting in her wheelchair in the hall slumped over and sleeping soundly.
On 2/6/23 at 11:17 AM, 2/10/23 at 9:58 AM, 2/10/23 at 9:58 AM, and on 2/10/23 at 10:31 AM, Resident #12 was observed sitting in her wheelchair. Resident #12's body was leaning to her left side and bent forward, and her head was almost resting on the arm rest of her wheelchair. There was no supporting device for her head or to support her posture.
On 2/9/23 at 12:01 PM, the ADON stated they tried to place a pillow to Resident #12's left side but most of the time she threw the pillow away.
On 2/10/23 at 10:42 AM, LPN #1 stated a lateral support (rectangular or square shaped devices that mount to the back posts of the wheelchair and rest against the user's trunk to increase the user stability and balance) was tried for Resident #12 to keep her position up while she was in her wheelchair, but Resident #12 continued to lean to her left side. LPN #1 stated they were also concerned Resident #12 might develop a pressure ulcer while using the lateral support. LPN #1 stated a pillow was provided to Resident #12 to support her head but sometimes she would throw it away. When asked to place a pillow to support Resident #12 while she was sitting in her wheelchair, LPN #1 took a pillow from Resident #12's room and used sign language to communicate with Resident #12. Resident #12 raised her head a little and LPN #1 placed the pillow to Resident #12's left side of her head. Resident #12 rested her head on the pillow.
The facility failed to ensure Resident #12's head and posture were supported while she was up in her wheelchair.
b. Resident #12's physician orders included the following:
- Sennalax-S (a laxative) 8.6 mg, give two tablets by mouth two times a day for bowel care.
- Miralax Powder (a laxative), 17 g, give by mouth as needed for constipation in 4-8 ounces of fluid if resident has not had a bowel movement in past 72 hours, and give 17 g by mouth one time a day for constipation for 3 days.
- Dulcolax suppository (a laxative) 10 mg, insert one suppository rectally as needed for constipation if no result from Miralax by next shift.
- Fleet enema, 7-19 g/118 ml, insert one dose rectally as needed for constipation if no result from Dulcolax within 2 hours. If no result from Fleet enema, call the physician or advanced practice provider.
Resident #12's Bowel Movement Records, dated 1/12/23 through 2/10/23, documented she did not have a bowel movement from 1/22/23 through 1/25/23 (4 days), 1/27/23 through 1/29/23 (3 days), 1/31/23 through 2/2/23 (3 days) and 2/4/23 through 2/8/23 (5 days).
A TAR dated 1/1/23 through 2/7/23, documented Resident #12 was administered a Dulcolax suppository on 1/21/23 after not having a bowel movement for two days, and on 1/26/23 after not having bowel movement for four days.
There was no documentation Resident #12 was offered or received Miralax powder when she did not have a bowel movement for three days as directed by the physician.
On 2/8/23 at 3:17 PM, the ADON reviewed Resident #12's record and stated the physician order for bowel care for Resident #12 was not followed. The ADON stated the Miralax powder should have been administered to Resident #12 when she did not have a bowel movement for three days as ordered by the physician instead of the Dulcolax suppository.
The facility failed to follow the physician's order for Resident #12's bowel care.
2. Resident #86 was admitted to the facility on [DATE], with multiple diagnoses including right knee arthritis due to bacteria and diabetes mellitus.
Resident #86's physician's order, dated 1/18/23, documented Change catheter site transparent dressing, indicate external catheter length and upper arm circumference (10 centimeter above antecubital - the surface of the arm in front of the elbow) and notify the practitioner if the external length has changed since the last measurement every day shift every Friday weekly.
A nurse' note, dated 1/26/23, documented Resident #86 returned to the facility after a new PICC line was placed to his left upper extremity.
A 2/2023 MAR, documented Change catheter site transparent dressing. Indicate external catheter length and upper arm circumference (10 cm above antecubital). Notify practitioner if the external length has changed since last measurement every day shift every Friday weekly, start date 1/20/23. The MAR documented Resident #86's transparent dressing was changed on 2/3/23.
On 2/8/23 at 10:26 AM, RN #1 administered Resident #86's normal saline to his PICC line. Resident #86's transparent dressing on his PICC line, dated 1/26/23 (13 days earlier), was peeling off and a dark colored material was observed over the insertion site of the PICC line. RN #1 stated Resident #86's transparent dressing should be change every Friday and as needed.
On 2/8/23 at 10:42 AM, the DON reviewed Resident #86's record and stated his dressing changes were not completed.
The facility failed to ensure Resident #86's PICC line dressing was changed as needed.
3. Resident #85 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, urinary tract infection, weakness and stage II pressure ulcer (a partial-thickness skin loss).
A 2/2023 TAR, directed staff on 2/3/23 to cleanse Resident #85's wound to her coccyx with a wound cleanser, pat dry, apply skin prep (a liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films) to surrounding healthy skin, apply Silvasorb (use to promote healing of skin ulcers and wounds) to wound bed and cover it with silicone bordered foam until resolved, every day shift. The TAR documented Resident #85 received treatment for her wound to her coccyx on 2/3/23, 2/4/23, 2/5/23, 2/6/23, 2/7/23, 2/8/23 and 2/9/23.
On 2/10/23 at 10:49 AM, LPN #1 removed the old dressing from Resident #85's wound to her coccyx which was dated 2/8/23, sprayed Resident #12's wound with a wound cleanser, patted it dry, applied Silvasorb, covered it with a foam dressing, and dated 2/10/23.
On 2/10/23 at 11:05 AM, LPN #1 stated Resident #85's wound was not changed on 2/9/23 because her old dressing was dated 2/8/23. LPN #1 stated Resident #85's wound to her coccyx should be changed every day.
The facility failed to ensure Resident #85's wound dressing was changed daily.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 1 resident (Resident #12) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of foot care. Findings include:
The facility's Care of Fingernails/Toenails policy, revised February 2018, documented nail care included daily cleaning and regular trimming, and the purpose of this procedure was to prevent infections.
This policy was not followed.
Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (weakness of the heart leading to a buildup of fluid in the body), bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows), dementia, and aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking).
An admission MDS assessment, dated 5/19/22, documented Resident #12 was severely cognitively impaired.
A physician's order, dated 5/17/22, directed staff to obtain a podiatry consult for Resident #12 as needed.
A podiatrist progress note, dated 6/22/22, documented Resident #12's left and right nails were moderately thickened, discolored, and elongated with subungual (under the toenail or fingernail) debris. The podiatrist debrided Resident #12's nails using sharp nail nippers and a grinder to reduce her discomfort. The progress note also documented Will return in 2-3 months or sooner PRN [as needed].
On 2/8/23 at 3:24 PM, Resident #12's toenails were observed with the ADON. Resident #12's toenails on her right third and fourth toes, and on her left first, third and fifth toes were thick, yellowish in color, long and curling downward. The ADON stated the facility was looking for a podiatrist to come and see the residents. The ADON stated Resident #12's toenails should have been filed and not kept that long.
The facility failed to ensure Resident #12 received foot care for his toenails.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and resident and staff interview, it was determined the facility did not offer a bedtime sn...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and resident and staff interview, it was determined the facility did not offer a bedtime snack and allowed residents to go more than 14 hours between meals. This was true for 3 of 16 residents (#3, #8, and #25) interviewed for concerns with food. This failure had the potential to impact residents in the facility who wanted a bedtime snack or who were at risk for nutritional compromise and had the potential to harm residents if they experienced hunger, low blood sugar levels, or did not receive adequate nutritional support for healing or weight loss. Findings include:
Sixteen residents were asked if they had any concerns with their food and three residents stated they had issues regarding snacks. Their statements are as follows:
a. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease ( a central nervous system disorder that affects movement, often including tremors) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
When interviewed, Resident #3 stated the staff did not offer her bedtime snacks. She added that staff refused her requests for snacks in the past.
b. Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including end stage kidney failure and type 2 diabetes with chronic kidney disease.
When interviewed, Resident #8 stated staff did not offer her bedtime snacks.
c. Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure, type 2 diabetes, and respiratory failure.
When interviewed, Resident #25 stated staff did not offer him bedtime snacks and often refused his requests for snacks without telling him why.
The facility's meal schedule posted outside of the 2 dining rooms stated breakfast was served between 7:45 AM and 8:00 AM, lunch was served between 11:45 AM and 12:00 PM, and dinner was served between 4:45 PM and 5:00 PM. The schedule did not include bedtime snacks.
A policy regarding bedtime snacks was requested from the facility and was not provided.
On 2/9/23 at 9:30 AM, a room adjacent to the residents' main dining room was observed with a refrigerator and counters stocked with snack items.
On 2/9/23 at 10:12 AM, the Administrator and the DON were interviewed. The DON confirmed snack rounds were not conducted in the evenings and had not been for months. She stated they used to have the snacks delivered to the nurses' station for snack rounds. Now the snacks are kept in the refrigerator in the dining room kitchen at the end of the hall and were available if a resident requested them.
The facility did not offer a bedtime snack and allowed residents to go more than 14 hours between meals.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 30 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $17,492 in fines. Above average for Idaho. Some compliance problems on record.
- • Grade F (23/100). Below average facility with significant concerns.
- • 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Sunny Ridge's CMS Rating?
CMS assigns SUNNY RIDGE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Idaho, 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 Sunny Ridge Staffed?
CMS rates SUNNY RIDGE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Idaho average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Sunny Ridge?
State health inspectors documented 30 deficiencies at SUNNY RIDGE during 2023 to 2025. These included: 2 that caused actual resident harm and 28 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Sunny Ridge?
SUNNY RIDGE 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 CASCADES HEALTHCARE, a chain that manages multiple nursing homes. With 43 certified beds and approximately 39 residents (about 91% occupancy), it is a smaller facility located in NAMPA, Idaho.
How Does Sunny Ridge Compare to Other Idaho Nursing Homes?
Compared to the 100 nursing homes in Idaho, SUNNY RIDGE's overall rating (1 stars) is below the state average of 3.2, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Sunny Ridge?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Sunny Ridge Safe?
Based on CMS inspection data, SUNNY RIDGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Idaho. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sunny Ridge Stick Around?
Staff turnover at SUNNY RIDGE is high. At 55%, the facility is 9 percentage points above the Idaho average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Sunny Ridge Ever Fined?
SUNNY RIDGE has been fined $17,492 across 1 penalty action. This is below the Idaho average of $33,254. 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 Sunny Ridge on Any Federal Watch List?
SUNNY RIDGE 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.