HELIA SOUTHBELT HEALTHCARE
For profit - Individual
156 Beds
HELIA HEALTHCARE
Data: November 2025
Trust Grade
0/100
#544 of 665 in IL
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Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Helia Southbelt Healthcare has received a Trust Grade of F, indicating significant concerns about the facility's care quality. It ranks #544 out of 665 nursing homes in Illinois, placing it in the bottom half, and #12 out of 15 in St. Clair County, meaning there are only a few local options that are better. While the facility is showing an improving trend, decreasing from 21 issues in 2024 to 8 in 2025, it still faces serious challenges, including a concerning staffing rating of 1 out of 5 stars and a high turnover rate of 54%. Specific incidents include a failure to prevent resident-to-resident abuse that resulted in lacerations and bruising for one resident, and another resident missed nine doses of essential glaucoma medication, highlighting significant lapses in care. Overall, while there are some signs of improvement, families should weigh these serious weaknesses carefully when considering this nursing home for their loved ones.
- Trust Score
- F
- In Illinois
- #544/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $58,910 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 57 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 19%
Review needed
21 → 8 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 21 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 54%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $58,910
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: HELIA HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 57 deficiencies on record
6 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 3 residents (R9) reviewe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 3 residents (R9) reviewed for abuse in a sample of 3.Findings Include:R9's Face Sheet, undated, documents R9 was admitted to the facility on [DATE] and has a medical diagnosis of Psychoactive Substance Abuse, Blindness Right Eye Category 3, Blindness Left Eye Category 3, and Hallucinations.R9's Minimum Data Set (MDS) dated [DATE] documents R9 is moderately cognitively impaired and has displayed verbal behaviors directed towards others. R9's Care Plan R9's Care Plan Last Reviewed/ Revised 8/18/2025 documents resident is considered at risk for abuse/neglect. R9's Progress Note dated 9/8/2025 at 6:05 PM documents This resident had an altercation with another resident related to resident hitting him in the groin. Then resident started slapping other resident in the face. No injury noted Admin and Director of Nursing (DON) made aware and police was call. Stated to keep everyone separated.The Facility's Initial Serious Injury Incident and Communicable Disease Report dated 9/8/2025 documents the following: Resident to Resident Immediately separated. Administrator notified. Final to follow.On 9/11/2025 at 1:50 PM V1, Administrator, stated he got a call Monday 9/8/2025 evening that there was an incident with R9 and R10. V1 stated R9 was outside of the facility with another resident when an argument occurred and R9 made contact with R10. V1 stated nursing staff separated the residents and both were assessed. On 9/11/2025 at 1:55 PM V7, Licensed Practical Nurse (LPN) stated V22, Certified Nursing Assistant (CNA) came to her and stated that she saw R9 hit R10 and herself and V22 went outside of the facility to separate the residents and assess each resident. On 9/11/2025 at 2:05 PM V25, LPN, stated she was informed by nursing staff that R9 had hit R10. V25 stated she went outside of the facility with V7 to access R9 and R10.On 9/11/2025 at 2:24 PM R9 stated he was outside with R8 when R10 started arguing with them. R9 stated R10 hit him in his private area and R9 smacked R10 back.On 9/11/2025 at 3:16 PM V22, CNA, stated she was in a resident room passing a food tray when she saw R9 smack R10 through the room window. V22 stated she told V7 what she has seen, and they went outside along with V25 to separate the residents. The Facility's Abuse Prevention Policy, Revision Date 9/29/2022, documents This facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment.
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure residents requiring assistance for transfers wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to ensure residents requiring assistance for transfers were getting assistance and transferred with the mechanical lift for 1 of 3 residents reviewed for transfers in the sample of 11. Findings include: R3's Physician order Sheets (POS) for August 2025 documents a diagnosis of Unspecified osteoarthritis, unspecified site; Chronic venous hypertension (idiopathic) with other complications of unspecified lower extremity; Essential (primary) hypertension; Type 2 diabetes mellitus with hyperglycemia; Morbid (severe) obesity due to excess calories; Body mass index [BMI] 45.0-49.9, adult; Hyperlipidemia, unspecified; Hypothyroidism, unspecified; Other chronic pain; Insomnia; and Overactive bladder. R3's MDS dated [DATE] document R3 was cognately intact for decision making of activities of daily living. R3 uses a motorized wheelchair and is dependent on staff for transfers.R3's Care Plan with a revision date of 6/23/2025 documents. Problem: Resident is limited in (mobility/functional status) and requires the use of (mechanical lift).On 8/20/2025 at 9:33 AM, R3 stated, Several months ago during resident council I complained about the (mechanical lifts) not always working and the machines being dead when they need to use them. I talked with (V1) about them and (V5, Ombudsman). (V1) told me he will get some new batteries. (V5) has been sick but she usually always follows up with stuff. I am not sure what is happening. I usually, like to lay down at 4 PM. Some of the staff know that I like to lay down around and (V6, CNA) she is really good about asking me I want to lay down because she knows me. Over the weekend (V6) told me she could not put me down because the (mechanical lift) was not working. I was really tired, and I wanted to lay down and I had to wait an hour and a half for the battery to charge so she could put me to bed. I was so upset and in tears. This is supposed to be my home and when I am tired, and I need help they should help me back in bed when I need it. It's August now and they are still having problems with the (mechanical lift) and putting me down.On 8/20/2025 at 12:55 PM, V5, Ombudsman stated, Working (mechanical lifts) have been on ongoing issue for the past several months. When staff need the (mechanical lifts) they are not available to lay residents down and or get residents up. (V1) is a new administrator and I believe he started at the end of May as he was at the May Resident Council Meeting. (V1) said in May that he would order new batteries for the lifts. Residents are saying the lifts are not available mostly during the weekends. I personally, observed the (mechanical lift) being dead on 8/5/2025 and no staff used the manual lift and residents were not transferred. Residents and staff are still saying it is an issue that they are not getting transferred because the lifts are not available and/or the staff do not want to use the other lifts.On 8/20/2025 at 11:03 AM, V7, Certified Nursing Assistant (CNA) stated, We are constantly having issues with the (mechanical lifts) working. First, they told us it was a battery issue, and they were getting new batteries, but it is still a problem.On 8/20/2025 at 11:05 AM, V8, CNA stated, We are constantly running around trying to find a working (mechanical lift) because half the time they are not working. This has been going on for months.On 8/20/2025 at 11:07 AM, V9, CNA stated, That (mechanical lift) is dead. I think the battery needs charged. We were supposed to be getting new batteries. We have been having issues with these lifts for a few weeks now.Resident Council Meeting Notes dated 5/27/2025 document, Chargers for (mechanical lifts).On 8/22/2025 at 3:32 PM, V1, Administrator stated, We do not have a policy on batteries for the equipment, like the (mechanical lift).The Mechanical Lift Policy with a revision date of 9/8/2025 documents, The mechanical lift may be used to lift and move a resident with a limited ability during transfer while providing safety and security for the resident and nursing personnel. The mechanical lift must be able to accommodate the weight of the residents.The Resident Right Policy dated November 2018 documents, Your rights to dignity and respect. You have a right to make your own choices. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide equal access to quality care regardless of diagnosis, condition, or payment source.
Aug 2025
3 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 observation, record review, and interview, the facility failed to prevent resident to resident abuse for 1 of 6 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to prevent resident to resident abuse for 1 of 6 residents (R3) reviewed for abuse in the sample of 8. This failure resulted in R3 having lacerations and bruising. Findings Include:On 8/13/25 at 1:00 PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 was alert to self only.R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment.R3's Care Plan, with a review date of 7/22/25, documents R2 is exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. He invades other's spaces without intention, gets confused where his room is. Interventions include: approach resident in a calm manner and to calmly que and redirect. R3's Progress Note, dated 4/4/2025 at 2:17 AM, documents the following: Resident very confused. Wants to go back home, goes in others' rooms, got into verbal fight with (previous resident) in room [ROOM NUMBER] because (R3) kept going into the (previous resident's) room. Got into room [ROOM NUMBER], refused to get out of the female resident's room. Hit CNA (Certified Nursing Assistant), kicked me, the nurse. Together 3 CNAs got him into his room. Will keep monitoring.R3's Progress Note, dated 4/4/2025 at 5:13 AM, documents the following: Slept for 90 minutes, still going into other rooms, up and down, monitored behavior.R3's Progress Note, dated 4/7/2025 at 2:39 AM, documents the following: CNA informed this nurse (R3) wandered in another resident room and was attacked by resident. This nurse went in to check on (R3) and he was lying in bed, c/o (complaining of) back and neck pain. This nurse observed bruising and lacerations on his upper back and showers (shoulders). Resident AOx1 (Alert and Oriented to Self) and not able to describe what happened. Resident sent to (local hospital) for evaluation. Bed hold policy and all appropriate documents sent with resident.POA (Power of Attorney) called and informed of incident. MD (Medical Doctor) made aware.R3's Hospital AVS (After Visit Summary), dated 4/7/25, documents R3 was seen in the emergency room due to being an assault victim. R3's Abuse Investigation Final Report, dated 4/7/25, documents the following: A resident-to-resident altercation was reported to the Administrator that took place to between residents R3 and R8 (Former Resident). It was reported that R8 stormed R3 due to him trying to get into his (R8's) room. R8 was seen hitting, kicking, and scratching, R3 with scissors. The residents were immediately separated. R3 was assessed and was found to have scratches and was sent to the local emergency room for further assessment and treatment. He returned the same day with NNO's (no new orders). The scissors were taken from R8, and he was sent to the local hospital for a psychiatric evaluation. Upon his admission to the hospital, he was given an emergency discharge from the facility. R8's state guardian was notified of the decision. The facility MD (medical doctor), POA's, and local police were notified.R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male with Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia. The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.On 8/13/25 at 9:25 AM, V1, Administrator, stated he was not employed by the facility when the altercation between R3 and R8 took place. On 8/13/25 at 9:52 AM, V10, R3's Physician, stated he does not recall the incident between R3 and R8. The Abuse Prevention Policy, dated 9/29/22, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse for these residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to adequately assess and provide supervision to prevent ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to adequately assess and provide supervision to prevent elopement for 1 of 5 residents (R7) reviewed for supervision in the sample of 8.Findings Include:On 8/13/25 at 11:00AM, R7 observed up in his electric wheelchair exiting the facility through the front door. R7 was able to enter the code and stayed in front of the facility.R7's Face Sheet, undated, documents R7 has the following diagnoses: Hemiplegia and Hemiparesis following a Cerebrovascular Disease Affecting the Left Non-Dominant Side, Cerebral Infarction, Vascular Dementia, and Acquired Absence Below the Knee of Right and Left Legs.R7's Minimum Data Set, MDS, dated [DATE], documents R7 has a BIMS (Brief Interview of Mental Status) score of 12, indicating R7 has moderate cognitive impairment.R7's Care Plan, dated 1/27/23, documents R7 is limited in physical mobility R/T hemiplegia and amputation. R7 utilizes an electric w/c (wheelchair). R7's electric w/c seat belt damaged.R7's Care Plan, dated 7/18/25, documents R7 is limited in physical mobility R/T (Related To) bilateral amputation, chair bound, and hemiplegia.R7's Care Plan, dated 8/12/25, documents R7 is at risk for falls CVA (Cerebrovascular Accident) with left side hemiparesis, CAD (Coronary Artery Disease), MI (Myocardial Infarction), HTN (Hypertension), NIDDM (Non-Insulin Dependent Diabetes Mellitus), DJD (Degenerative Joint Disease), Depression and Debility secondary to CVA. R7's Progress Note, dated 7/5/2025 at 5:01 PM, documents the following: A visitor notified writer of resident being outside leaning over in wheelchair and unable to get back in the building. Staff went to assist resident and reminded resident that he is not an independent smoker and that he is supposed to follow facilities supervised smoking times due to safety concerns. Resident verbalized understanding and continued to go outside multiple times alone throughout the day.R7's Progress Note, dated 7/8/2025 at 7:20 PM, documents the following: Resident was once again outside in the front smoking, reminded him again that he is not an independent smoker and that he is supposed to follow facilities supervised smoking times due to safety concerns. Resident was upset and asked to be left alone. He continues to knowingly break smoking policy often.R7's Progress Note, dated 8/2/2025 at 5:50 PM, documents the following: Resident had fall in grassy area. Offered ER (Emergency Room) r/t fall; resident refused. Resident was educated on risks of leaving facility unattended, verbalized understanding - stated he needed cigarettes. MD (Medical Doctor) made aware. Attempted to notify POA (Power of Attorney) twice with no answer.R7's progress note, dated 8/2/2025 at 6:12 PM, documents the following: Intervention for fall-educated to remain on safe pathways around facility entrances and to not attempt to leave the facility in his chair alone.On 8/13/25 at 8:41 AM, R7 was observed in bed, eating breakfast. R7 has had both feet amputated. R7 is alert and oriented to person, place, time, and situation. R7 stated he was in his electric wheelchair and went down the hill at a decent speed, on the grass, and hit tire tracks in the grass and the whole chair flipped over his head. R7 stated his right leg had scratches from it. R7 stated he left the facility to go get cigarettes at the gas station. R7 states a black man and a white women stopped to help get him back in his wheelchair. R7 stated he then went back to the facility by himself and told staff what happened. R7 stated if he did make it down the street, he would have crossed by an open opportunity and crossed the street to get to the gas station. The road R7 is referring to is a busy 2 lane road with a center turn lane, at the end of the street, there is a stop light and pedestrian cross walk directly across from the gas station R7 was attempting to go to. R7 states he was pretty close to the road when he fell out of his wheelchair. R7 stated he was scared and could have been killed. R7 stated he did not tell anyone he was leaving the facility and stated, Why would I, I've done it before? R7 stated he is allowed to leave the facility by himself, but no one knew he left. R7 stated H*** No, he would never do this again. R7 stated his wheelchair is working fine. R7 stated did go to the hospital after the incident. R7's Progress Note, dated 8/2/2025 at 9:04 PM, documents the following: Resident allowed skin assessment once in bed. Resident has open areas noted to bilateral legs and left elbow. Areas cleansed with dressings applied. Wound care team made aware. Spoke with POA about incident and POA stated he will speak with resident about leaving facility unattended.R7's Progress Note, dated 8/4/2025 at 5:29 PM, documents the following: Fall f/u (Follow Up) day 2, resident c/o (complains of) pain to bilateral legs/back/bottom, x-rays completed to legs, no fractures noted. MD made aware of increased pain r/t fall, new order for Norco PRN (as needed), order entered, script received by pharmacy.R7's Progress Note, dated 8/5/2025 at 3:09 PM, documents the following: Resident requested ER (Emergency Room), stated he wanted to get checked out r/t previous fall. Sent to local ER for further evaluation. MD notified. Attempted to notify POA twice, left voicemail.R7's Progress Note, dated 8/6/2025 at 12:17 AM, documents the following: Resident returned to the facility and was placed to bed by 2 EMTs (Emergency Medical Technician) via stretcher. New order for Cephalexin 500 mg PO (by mouth) daily for 10 days r/t wound. Resident resting in bed, call light and side table within reach, VS (Vital Signs) WNL (Within Normal Limits).R7's Elopement Evaluation, dated 3/7/25, documents R7 is not at risk for elopement. There were no recent Elopement Evaluations in R7's record for review. R7's Fall Event, dated 8/2/25, documents R7 had an unwitnessed fall. R7 attempted to leave the facility unattended and fell. R7 is to remain on safe pathways around facility entrances and not to attempt to leave facility in his wheelchair. On 8/12/25 at 12:30 PM, V1, Administrator, stated R7 is able to go outside by himself and he likes to sit out in front of the facility. V1 stated R7 was outside, got onto the grassy area in front of the facility and fell out of his wheelchair. V1 stated R7 stated he was going to get cigarettes. V1 stated R7 still likes to go out front to sit, but they prefer and ask him to go out on the back patio, which he does. On 9/13/25 at 9:20 AM, V1, Administrator, stated R7 has is an activity care plan, documenting his desire to participate in activities of his choosing. V1 stated there is not an assessment to determine if R7 is safe to leave the property without supervision. On 8/13/2025 at 9:20 AM, V9, Registered Nurse (RN), stated R7 is not an independent smoker and is not to be outside by himself. V9 stated he would not be safe outside the facility by himself. On 8/13/2025 at 9:23 AM V8, CNA, stated R7 is not supposed to go outside and smoke by himself, but he still does it. V8 stated R7 is not safe to leave the facility by himself but doesn't see R7 has a flight risk.On 8/13/25 at 9:52 AM, V10, R7's Physician, stated if R7 is competent enough to enter the code to exit the building, then he is capable to go out by himself, R7 is disabled but not mentally incompetent. On 8/13/25 at 9:55 AM, V11, R7's Brother/POA, stated R7 is able to go outside to smoke and leave the facility property by himself. V11 stated this was an unusual situation of him going down the grassy hill instead of using the concrete or road. V11 stated the facility has policies in place to address this sort of thing. V11 stated on that particular day, he didn't make a safe decision even though his mind is with it. V11 stated it could have been worse, R7 could have gotten ran over and killed. The Elopement Prevention Policy, dated 1/2018, documents the following: It is the policy of the facility to provide a safe and secure environment for all residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide revise interventions/approaches for behaviors...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide revise interventions/approaches for behaviors in a resident with Dementia related to wandering for 1 of 1 resident (R3), reviewed for Dementia Care in the sample of 8.Findings include:On 8/13/25 at 1:00PM, R3 was observed ambulating independently on the hallway he resides. R3 was wandering on the hallway, stopping at various doors but did not enter. R3 is alert to self only.R3's Face Sheet, undated, documents R3 has the following diagnoses: Dementia, Restless and Agitation, Unspecified Psychosis, Major Depressive Disorder, Generalized Anxiety Disorder, and Insomnia.R3's Minimum Data Set, MDS, dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 2, indicating R3 has severe cognitive impairment.R3's Care Plan, with a review date of 7/22/25, documents R3 is exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. He invades other's spaces without intention, gets confused where his room is. Interventions include: approach resident in a calm manner and to calmly que and redirect. There were no revised or added resident centered interventions since 4/20/25 on the care plan.R3's Progress Note, dated 4/4/2025 at 2:17 AM, documents the following: Resident very confused. Wants to go back home, goes in others' rooms, got into verbal fight with (previous resident) in room [ROOM NUMBER] because (R3) kept going into the (previous resident's) room. Got into room [ROOM NUMBER], refused to get out of the female resident's room. Hit CNA (Certified Nursing Assistant), kicked me, the nurse. Together 3 CNAs got him into his room. Will keep monitoring.R3's Progress Note, dated 4/4/2025 at 5:13 AM, documents the following: Slept for 90 minutes, still going into other rooms, up and down, monitored behavior.R3's Progress Note, dated 4/7/2025 at 2:39 AM, documents the following: CNA informed this nurse (R3) wandered in another resident room and was attacked by resident. This nurse went in to check on (R3) and he was laying in bed, c/o (complaining of) back and neck pain. This nurse observed bruising and lacerations on his upper back and showers (shoulders). Resident AOx1 (Alert and Oriented to Self) and not able to describe what happened. Resident sent to (local hospital) for evaluation. Bed hold policy and all appropriate documents sent with resident.POA (Power of Attorney) called and informed of incident. MD (Medical Doctor) made aware.R3's Progress Note, dated, 4/07/2025 at 6:32 AM, documents the following: Resident returned to facility. NNO (No New Orders) staff will continue to monitor. No signs of distress. No c/o pain or discomfort.R3's Progress Note, dated 4/13/2025 at 7:40 AM, documents the following: Resident was seen by staff sitting on the sides of several residents' beds and was getting aggressive towards staff when asked to get out of their rooms. Resident was given PRN (As Needed) pain and anxiety medication with no results. EMS (Emergency Medical Services) were called and R2 was sent to (local hospital) for further psychiatric evaluation.R3's Progress Note, dated 4/14/2025 at 1:30 AM, documents the following: Resident had some behaviors this shift going in other resident's room. With a lot of redirecting resident finally resting in room, call light within reach. NO (New Order) from MD to increase the dose of following medications: Citalopram 20 mg (milligram) po (by mouth) daily and Rexulti 1 mg (milligram) po (by mouth) daily.R3's Psychiatry Initial Evaluation Note, dated 4/17/2025 at 12:09 PM, documents the following: Chief Complaint: Initial Assessment. History of Present Illness: 71 y/o (Year Old) Male With Dementia and Agitation. History obtained from patient and staff. Patient pleasant and cooperative with assessment with intermittent confusion. Patient was recently involved in an altercation due to his wandering behaviors, where he was assaulted by another elderly dementia patient for wandering into his room. Patient was not seriously injured, treated and readmitted after being sent to the hospital. Patient can be difficult to redirect, and staff report he can then become easily agitated. Pleasant at time of assessment with some confusion and nonsensical talk. Patient diagnosed with Alzheimer's Disease, psychosis, dementia, GAD (Generalized Anxiety Disorder), MDD (Major Depressive Disorder), insomnia, and history of alcohol dependence.R3's Progress Note dated, 4/16/2025 at 7:09 AM, documents the following: Resident had some behaviors this shift going in other resident's room. With a lot of redirecting resident finally resting in room, call light within reach.R3's Progress Note dated 4/16/2025 at 6:03 PM, documents the following: Resident continues behaviors, so I spoke with the doctor today, New Order for Zyprexa 2.5mg daily PRN and recently was placed on Rexulti 1mg, Doctor stated he will have to place the resident on these meds first before he changes medications. Resident resting in chair and cont. (continue) to monitor. R3's Progress Note, dated 4/19/2025 at 6:07 PM, documents the following: This resident continue to go into another resident's room, resident was redirected and will cont. to monitor.R3's Progress Note, dated 5/7/2025 at 5:30 PM, documents resident cont. (continued) behaviors, entering into other residents' room, prn (as needed) meds was given, resident resting in chair and cont. with care.R3's Progress Note, dated 6/19/2025 at 12:09 PM, documents the following: Pt (Patient) found wandering in another resident room. Pt went to sit on the bed and slipped and slid down to the floor. Fall was witnessed. Pt didn't hit his head, no injuries noted VSS (Vital Signs Stable), MD aware. Notified POA immediate intervention was redirecting pt. to dining room.R3's Progress Note dated, 7/17/2025 at 9:40 AM, documents the following: The Identified Offender was assessed using the Identified Offender Risk Assessment and scored a 9, indicating a compromised risk level. The resident continually exhibits significant cognitive impairment and consistent disorientation related to a diagnosis of dementia. The resident has a documented history of behavioral disturbances, including verbal aggression and sexually inappropriate behavior directed toward staff and other residents. The resident also has been known to frequently display wandering and rummaging behaviors. It has been highly recommended that ongoing monitoring and implementation of appropriate interventions should be continued to maintain the safety and well-being of all individuals within the facility.R3's Hospital AVS (After Visit Summary), dated 4/7/25, documents R3 was seen in the emergency room due to being an assault victim. R3's Abuse Investigation Final Report, dated 4/7/25, documents the following: A resident-to-resident altercation was reported to the Administrator that took place to between residents R3 and R8 (Former Resident). It was reported that R8 stormed R3 due to him trying to get into his (R8's) room. R8 was seen hitting, kicking, and scratching, R3 with scissors. The residents were immediately separated. R3 was assessed and was found to have scratches and was sent to the local emergency room for further assessment and treatment. He returned the same day with NNO's. The scissors were taken from R8, and he was sent to the local hospital for a psychiatric evaluation. Upon his admission to the hospital, he was given an emergency discharge from the facility. R8's state guardian was notified of the decision. The facility MD, POA's, and local police were notified.R3's Behavior Tracking, dated June 2025, documents there were10 times redirection and one on one care was provided and was not effective.R3's Behavior Tracking, dated July 2025, documents there were 3 times redirection and one on one care was provided and was not effective. On 8/8/2025 at 11:59 AM, R2 stated There is a man (R3) that's confused and gets into my bed. He just got in to bed with me twice this week on Tuesday 8/5/2025 and Wednesday 8/6/2025. I am paraplegic so I don't know if he touches me. He walks in and is scary. He is a lot bigger than me. When I told him to get out, he said ‘Where is the exit?' Then he went out the door. I have seen him go through my bathroom door and go into another lady's room. On 8/8/2025 at 2:20PM, V5, CNA, stated R3 is a wanderer and is all over. He gets into (R2's) snacks and she puts him out. I haven't heard of him getting into her bed. On 8/8/2025 at 2:25PM, V6, CNA, stated R3 is very busy. He goes all over, and he goes into rooms. I don't know of him getting into (R2's) bed.On 8/8/2025 at 2:30PM, V7 CNA, stated R3 thinks everyone's bed is his bed. He messes with (R2's) snack.The Dementia Clinical Protocol policy, dated 11/2011, documents the following: The staff and physician will review the current physical, functional, and psychosocial status of each individual with Dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Individuals with Dementia can also have a personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions, or other conditions causing or contributing to impaired cognition and problematic behavior. For the individual with confirmed Dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. The physician will help staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of Dementia, development of new acute medical conditions or complications, changes in resident or family wishes, etc.
May 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the responsible party of a change in condition for 1 out of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the responsible party of a change in condition for 1 out of 3 residents, (R4); reviewed for Resident Rights in a sample of 11.
Findings include:
R4's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, dementia, chronic kidney disease, and Alzheimer's disease.
R2's Minimum Data Set (MDS) dated [DATE], documented staff were unable to complete the interview to determine R4's Brief Interview of Mental Status (BIMS); it does document R2's cognitive skills for daily decision making are severely impaired and inattention is continuously present, does not fluctuate.
R4's Care Plan last revised on 2/18/25, documented she has a communication deficit related to Alzheimer's dementia with interventions of, in part, to communicate with family to determine what works best for resident which was started on 12/03/2024.
Wound Management details dated 4/17/25, documented R4 had a skin tear to her right ankle identified on 4/17/25 at 2:40 PM.
R4's Medication Administration Record documented Silvadene (silver sulfadiazine) (SSD)cream; 1 %; Amount to Administer: nickel size; topical order once a day, clean right ankle with normal saline daily and as needed apply SSD cream, collagen powder and cal-alg (calcium alginate) and cover with island dressing; diagnosis unspecified skin changes dated 4/17/2025 - 4/21/2025. MAR shows the SSD cream was signed off as administered on 4/17/25-4/21/25.
On 4/30/25 at 2:37 PM, V5, family member, stated the facility had notified her on 4/1/25 that R4 had a blister on her ankle, and on 4/6/25 she visited R4, the blister was gone. On 4/25/25 V5 stated she visited R4 and noticed oozing on her right sock and asked the nurse to look at it. V4 stated R4 had an open wound covered by some gauze she was never told about. V5 stated R4's nurse told her she only noticed it that day (4/25/25) and was instructed to put betadine on it and cover it up. V5 stated she thinks R4 got the wound from rubbing up against a board that is on her wheelchair.
On 5/1/25 at 12:27 PM, V16, Licensed Practical Nurse/LPN, stated she had notified V5 of R4 having a blister on her right ankle. V16 stated she was off for 8 days after that and came back on 4/25/25 when she noticed R4's wound had deteriorated but there were already treatment orders in place for it. V16 stated V5 said she didn't know about her wound and asked to see it that day and asked what was being done to it. V16 stated she showed her it and it was not an opened wound and they were using betadine with a dry dressing over it. V16 stated she doesn't know when V5 was notified of R4's wound deterioration.
On 5/1/25 at 12:45 PM, V14, wound nurse, stated R4 had initially had a wound on her right ankle on 4/1/24, the wound doctor assessed it on 4/7/25 and it had already cleared up. V14 stated R4's right ankle wound opened up to a skin tear and new treatment orders were placed. V14 stated she remembers the POA (Power of Attorney) being present when they put new treatment orders in during rounds which take place every Monday which would have been 4/21/25.
On 5/1/25 at 1:30 PM, V15, LPN, stated she was not sure the exact date R3's POA was notified of her wound but on 4/21/25, she remembers V5 being at the facility because she had asked if we could keep R4's wound covered, and we ended up getting new orders for that.
On5/5/25 at 2:50 PM, V2, Director of Nursing (DON), stated the facility does not upload the 24-hour report form, that is something for the nurses to have for communication and we would not have after this amount of time. V2 stated she would expect a change in condition to be reported within the same shift it occurred and any attempts to contact the POA (Power of Attorney) to be documented.
On 5/1/25 at 1:58 PM, V1, Administrator, stated there is no documentation that R4's POA was notified of her change in condition for her wound. V1 stated she would have expected staff to document and report this change in condition right away.
The facility's Change in Condition Policy dated 2/2012, documented, Notification of physician and/or responsible parties shall be documented in the clinical record as well as the 24 hour report form. Status changes, which are not significant enough to be reported, must also be documented in the medical record. The Change in Condition Policy continued to document, It is the responsibility of the nursing staff to inform the resident's medical contact of any change of condition. Appropriate follow through from shift to shift is imperative for all residents with any change in condition. The nursing staff must utilize the tools provided for formal communication from shift to shift.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure medications were completely administered and failed to accu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure medications were completely administered and failed to accurately document the administration of medications for 1 out of 4 residents, (R2) reviewed for Pharmacy Services in a sample of 11.
Findings include:
R2's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, adrenocortical insufficiency, neuromuscular dysfunction of bladder, type two diabetes mellitus, and hypertension.
R2's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact.
R2's Care Plan last revised on 3/11/25 documented she presented with non-compliant behavior as evidenced by refusing medication due to wanting to take medications on her own time rather than while nurse is in her room.
R2's Medication Administration Record (MAR) dated 4/27/25 documented that she was ordered to receive the following medications by mouth that could have been left in a pill cup, hydrocortisone 10 mg (milligram) tablet, hydrocortisone 5 mg tablet, fludrocortisone 0.1 mg tablet, methimazole 10 mg tablet, toprolol 100 mg tablet, atorvastatin 10 mg tablet, and amlodipine 2.5 mg tablet. The MAR documented all these medications were scheduled to be given between 7:00 AM and 10:00 AM. R2's MAR documented all the above morning medications were administered and signed of on by V8, Licensed Practical Nurse (LPN).
R2's Progress Note dated 4/27/25 at 11:41 AM, documented that V8 stated, This nurse went to administer resident medications and resident still had meds from this morning when She stated she would take them this morning when admin to her,resident still had meds from this morning and previous meds from the hs (night) before, the resident was educated that the pills should have been taken when they were given and that I can not leave them at her bedside. resident was educated that could be a safety hazard. Resident yelled for me to put the pills back on her table or she would be reporting me. The pills were removed at this time. Resident also refuses to get bs checked at this time. MD (medical director) notified.
On 4/30/25 at 12:25 PM, V3, R2's daughter, stated R2 informed her that she woke up on 4/27/25 around 8:00 AM and heard someone come in her room while she was in the restroom, when she came out no one was there, and nothing was left. V3 stated R2 told her that the nurse came in around 10:00 AM with her morning medications but R2 fell asleep, and the nurse left them without making sure she took them. V3 stated R2 told her that at 11:45 AM the nurse came back to her room when she woke up and took her medications away refusing to let her take them because she didn't already. V3 stated R2 gets very important medications that should not be missed and asked the nurse to let R2 take them. V3 stated the nurse told her no, and was rude. V3 stated she also contacted the Director of Nurses (DON) and reported this but the only thing she said was that she would have to decide if disciplinary action is required. V3 stated R2 never did receive her morning medications on 4/27/25.
On 4/30/25 at 12:53 PM, R2 stated she got her medications later that morning, after breakfast on 4/27/25 but usually takes them during breakfast. R2 stated she ended up falling asleep after the nurse placed them in her room and left; around 10:00 AM. R2 stated she woke up around 11:45 AM when the nurse came back and saw the medications she hadn't taken yet. R2 stated the nurse took the medications and told her she couldn't have them now since she didn't take them already. R2 stated she told the nurse she would like to still take her medications, but the nurse would not allow her to and left. R2 stated if the nurse really wanted me to take them at a certain time, she should have waited for me to take them while she was there instead of leaving them in my room. R2 stated she takes important medications in the morning she doesn't like to miss including steroids for her adrenal glands, and other medications for hypothyroidism and blood pressure that she didn't receive that day.
On 5/1/25 at 11:50 AM, V8, licensed practical nurse (LPN), stated she usually leaves R2's medications in her room and she'll take them eventually but that day she had come back with R2's next dose of blood pressure medication and noticed she still had her cup of medications she'd left for R2 and a pill from the night before. V8 stated she did not want to let R2 take her morning pills at that time due to doubling up on the blood pressure medication. V8 stated R2 had fallen asleep and that was why she didn't take the medications and was mad she wouldn't let R2 take them late. V8 stated she notified the doctor through a message portal about R2's refusal but never heard back from him. V8 stated she did not ask the doctor if it would be okay for R2 to take her medications late.
On 5/2/25 at 9:47 AM, V17, R2's Endocrinologist's Medical Assistant, stated R2's doctor said her steroids could have been given at a later time.
On 5/1/25 at 9:00 AM, V1, Administrator, stated the entire facility follows the same medication pass policy.
On 5/1/25 at 11:55 AM, V1, stated it sounds like the nurse left R2's pills for her to take and R2 fell asleep then too much time had passed for the nurse to feel comfortable giving them late. V1 stated the medications are supposed to be taken while the nurse is present unless they have an order for medications to be left at bedside. V2, Director of Nursing (DON), stated V8 signed R2's medications off and when she didn't take them, the only way to document they weren't given is to make a progress note. V1 stated the doctor could have been called to see if the medication could be taken late.
The facility's Medication Administration Policy dated 10/25/14 documented, When medications are administered by mobile cart taken to the resident's location (room, dining area, etc. (Et cetera)) medications are administered at the time they are prepared. Medications are not pre-poured. The Medication Administration Policy continued to document, The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. The Medication Administration Policy also documented. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 3 of 4 residents (R3, R4, R5) reviewed for incontinent care in the sample of 8.
Findings include:
1. R3's Face Sheet, print date of 2/14/25, documents that R3 was admitted on [DATE] with diagnoses of flaccid hemiplegia affecting the right dominant side and a personal history of urinary tract infections.
R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively intact, requires partial to moderate assistance with toileting, always incontinent of urine, and frequently incontinent of bowel.
On 2/14/25 at 4:15 AM, V9 Certified Nurse Assistant (CNA), transferred R3 from the bed, to the wheelchair, and then to the toilet. V9 removed the incontinent brief. The brief was slightly soiled with urine. When R3 finished, she stood up, V9 washed her rectal area with a soapy towel. V9 pulled up the incontinent brief and R3's pants. R3 was transferred back to the wheelchair. V9 failed to cleanse the labia and urethra and failed to dry R3.
2. R4's Face Sheet, Print date of 2/24/25, documents R4 was admitted on [DATE] and has a diagnosis of an anoxic brain injury.
R4's MDS, dated [DATE], documents R4 is severely cognitively impaired, is dependent on staff for activities of daily living, is always incontinent of urine, and frequently incontinent of bowel.
On 2/14/25 at 4:25 AM, V9 checked R4 for incontinence. R4 was not soiled but V9 provide pericare. With a soapy towel, V9 cleansed the groins, labia and the urethra. V9 failed to flip the towel to a clean portion of towel. V9 rolled R4 over onto her side and cleansed the rectal area and the buttocks with the same portion of the towel. V9 placed a new incontinent brief on R4. V9 failed to dry R4.
3. R5's Face Sheet, print date to 2/14/25, documents R5 was admitted on [DATE] and has diagnoses of history of urinary tract infection and Alzheimer's Disease.
R5's MDS, dated [DATE] documents that R5 is severely cognitively impaired, is dependent on staff for activities of daily living, has an indwelling urinary catheter, and is always incontinent of stool
On 2/14/25 at 6:46 AM, V2, Director of Nurses confirmed R5 does not have an indwelling urinary catheter. V2 stated, She just came back from the hospital and they removed the catheter there.
R5's Progress Note, dated 02/06/2025 04:58 PM, documents, pt (patient) arrived back to facility at 345 pm. via stretcher. It continues, pt will start abt (antibiotic) x 12 days for UTI (urinary tract infection).
On 2/14/25 at 4:43 AM, V10 (CNA) and V9 entered R5's room to provide incontinent care. R5's brief was removed. The brief was soiled with stool and urine. V10 cleansed the groin, labia, and meatus with a soapy towel, flipping the towel over 3 times to utilize a clean portion of the towel. V10 did not dry the areas. V 9 using the same towel that V10 did used the soiled part of the towel to cleanse the rectum and the left buttocks V9 failed to dry the buttocks. A new incontinent brief was placed on R5.
On 2/14/25 at 6:02 AM, V9 stated she only uses one towel because the towels are limited. V9 was questioned why she did not dry R3, R4, and R5. V9 stated, Yes I did. I used the other end of the towel.
On 2/14/25 at 6:00 AM, V1, Administrator, stated the same section of towel should not be used for all of the incontinent care and residents should be dried after incontinent care is preformed.
The policy Perineal Care, dated 7/2017, documents, Wash perineal area wiping from front to back, 1. Separate the labia and wash area downward from front to back. 2. Continue to wash the perineum moving from inside outward to and including thighs, alternating from side to side, using downward strokes. So not reuse the same washcloth or water to clean the urethra or labia. 3. rinse the perineum thoroughly in the same direction, using fresh water and a clean washcloth. 4. Gently pat dry the perineum. It continues, Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. do not reuse the same washcloth or water to clean the labia. It continues, g. Dry area thoroughly.
Dec 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
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 1 of 3 resident's (R6) prescription eye drops were documented...
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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 1 of 3 resident's (R6) prescription eye drops were documented as administered per professional standards regarding medication administration/documentation in a sample of 3.
Findings include:
R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma.
R6's Physician's Order Sheet (POS), dated 4/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime.
The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024.
R6's Medication Administration Record (MAR) dated 4/2024 documents Latanoprost 0.005% was documented administered for all the days.
R6's POS, dated 11/2024 documents Latanoprost 0.005% 1 gtt both eyes at bedtime.
R6's MAR, dated 11/2024 documents Latanoprost 0.005% was administered on 11/1/2024. It was documented as a T for 11/2/2024 through 11/4/2024 - legend identified T as therapeutic leave. It was documented as administered on 11/5/2024 through 11/18/2024, 11/19/2024 was blank, 11/21/2024 through 11/23/2024 therapeutic leave, 11/24/2024 through 11/26/2024 initialed by staff as administered, 11/27/2024 blank.
On 12/11/2024 at 2:20 PM V25, Pharmacy Order Entry Technician, stated (R6's) prescription eye drops Latonoprost 0.005% was not refilled or delivered to the facility to be administered for the months of April 2024 and November 2024 and they would have ran out because the eye drop bottle is a 25 day supply if administered every day per physician's orders.
R6's MAR dated 11/2024 documents V31, Licensed Practical Nurse/LPN, administered Latanoprost 0.005% was administered at 9:00 PM on 11/15/2024.
On 12/12/2024 at 8:50 AM V31 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
R6's MAR dated 11/2024 documents V29, LPN administered Latanoprost 0.005% at 9:00 PM on 11/6/2024, 11/7/2024, 11/10/2024, 11/11/2024, 11/17/2024 and 11/18/2024.
On 12/12/2024 at 9:08 AM V29 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
R6's MAR dated 11/2024 documented V30, LPN administered Latanoprost 0.005% at 9:00 PM on 11/20/2024 and 11/26/2024.
On 12/12/2024 at 9:20 AM V30 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
On 12/12/2024 at 9:28 AM V2, DON (Director of Nurses) stated she noted on the pharmacy refill sheet that (R6's) eye drop Latanoprost 0.005% was not refilled in April 2024 and November 2024 and if it's a 25 day supply then she didn't understand how staff were documenting the eye drop was administered if it wasn't refilled by the pharmacy.
The Facility's Medication Administration Policy effective 10/25/2014 documents, Medications are administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
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** 2. R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including dementia and pain.
R7's Minimum ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R7's Face Sheet documents R7 was admitted to the facility on [DATE] with diagnoses including dementia and pain.
R7's Minimum Data Set (MDS) dated [DATE] documented R7 was severely cognitively impaired, required substantial assistance with bed mobility and transfer, and ambulated via wheelchair.
R7's Care Plan dated 12/1/24 documents R7 is at risk for falls related to cognitive impairments.
R7's Fall Risk assessment dated [DATE] documented R7 was at risk for falls.
R7's Fall Investigation dated 12/1/24 documents R7 had a witnessed fall in the hallway. R7 was leaning forward in her wheelchair and fell to the floor, hitting her face and nose. R7 was sent to the hospital and found to have a broken nose. The intervention added was to have resident's wheelchair seat dumped.
On 12/11/24 at 11:30 AM, R7 was sitting in wheelchair in room. The wheelchair seat was not dumped. V18, R7's Family, was visiting and stated that is the same wheelchair she has always had and they have not done anything with the seat.
On 12/11/24 at 11:58 AM, V21, Physical Therapy Assistant (PTA), stated wheelchair modification is a joint effort between therapy and nursing. He was not aware of R7 getting a new wheelchair or having any recent modifications.
On 12/11/24 at 12:40 AM, V22, Registered Nurse (RN), stated therapy does the dump seats on the wheelchair.
On 12/11/24 at 1:50 PM, V2, Director of Nursing (DON), stated fall interventions should be implemented after discussing them at the morning meeting.
R7's Fall Investigation dated 12/8/24 documents R7 had a witnessed fall. The location of the fall was not documented. The intervention added was 15 minute checks for safety.
R7's Medication Administration Record (MAR) for December 2024 documents 15 minute checks were not started until 12/10/24.
On 12/12/24 at 12:49 PM, V2, DON, stated she expects progressive fall interventions to be implemented after all falls.
The Facility's Falls Management Policy documents, It is the policy of (Facility) to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.
Based on observation, record review and interview the facility failed to use a gait belt during a one person transfer, and failed to implement fall precautions for 2 of 2 residents (R7, R11) in a sample of 21 reviewed for falls.
Findings include:
1. R11's Undated Face Sheet, documents he was initially admitted to the facility on [DATE] with a recent readmission from the hospital on [DATE].
R11's Minimum Data Set (MDS) dated [DATE] documents severely cognitively impaired, substantial/maximal assistance with toilet transfer.
R11's Care Plan documents problem: ADLs (Activities of Daily Living) functional status/rehabilitation potential. R11 required extensive assistance x1 with most ADLs. Transfers via assist x1 with use of gait belt. Wheelchair is primary mode of transportation. Goal: R11 will gain strength and ADL independence to d/c (discharge) to home. Problem: R11 is at risk for falls related impaired mobility. Goal: R11 will remain free from injury. Approaches: place bed in lowest position while resident is in bed, place resident in a fall prevention program, staff with frequent reminders to res (resident) to call for asst (assistance) by using call light. Give resident verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times. Keep personal items and frequently used items within reach.
R11's Resident Progress Note, dated 11/15/2024 documents he was sent to local hospital unresponsive and faint pulse. He was admitted for altered mental status.
R11's Resident Progress Note, dated 11/21/2024 documents resident returned back to facility at 3:38 PM.
R11's Transfer Assessment, dated 11/27/2024, documents resident is not independent in transfers or ambulation. Assessment complete use gait belt with 1 assist with all transfers.
R11's Fall Risk Assessment, dated 11/27/2024, documents he is high fall risk.
R11's Fall Risk assessment dated [DATE], document moderate fall risk.
On 12/11/2024 at 10:20 AM, V19, Certified Nurse Assistant/CNA, observed propelling R11 to his bathroom. V19 instructed R11 to grab the handrail that was located right in front of the toilet in his room. V19, CNA, pulled on R11 left arm to get him to stand up. R11 started to sit down and V19 told him to step back because he wasn't on the toilet and R11's feet started to slide from under him. V19 grabbed R11's left arm to attempt to pull him up and his feet slid from under him and then V19 fell on top of R11. R11 hit the bathroom wall with his right side. R11 stated, S*** you dropped me! after he fell. V19 didn't have a gait belt on R11 when he fell. V19 then left the bathroom and reentered the bathroom at 10:24 AM with a gait belt. V19 put a gait belt around R11 and attempted to get him off the floor. V19 wasn't able to get R11 off the floor by herself so she got V20, CNA, entered the room and V19 told V20 that R11 didn't fall that she lowered him to the floor and they attempted to get R11 off the floor, they were not able able to get R11 off the floor. V21, Physical Therapy Assistant/PTA, was in the hallway at that time and V19 called him into the room. R11 was still on the floor at that time and V21 went to R11's left side, V20 went to R11's right side and V19 pulled up R11's depend and pants. V21 and V20 did a 2 person transfer and assisted R11 into his wheelchair and V19 assisted in pulling up R11's pants. When V21 entered R11's bathroom and witnessed him laying on the floor he didn't ask staff what occurred or why R11 was on the floor, he just assisted with the transfer.
On 12/11/2024 at 10:32 AM V20, CNA stated she didn't know what exactly occurred with R11 but that V19, CNA, told her she lowered him to the floor and she was there to attempt to help him up off the floor.
On 12/11/2024 at 11:15 AM V21, PTA, stated when he entered R11's bathroom R11 was already in his wheelchair and he assisted the CNAs to pull his pants up. No staff told him R11 was lowered to the floor or just had a fall.
On 12/11/2024 at 11:20 AM V20, CNA ,stated her and V19, CNA, 2 person transferred R11 from the floor to his wheelchair that morning.
On 12/11/2024 at 1:05 PM V23, R11's POA (Power of Attorney) stated the facility nurse called her today and notified her that the resident slid down the wall and it wasn't a fall. V23 stated she's in healthcare and she knows if you break the plane it's considered a fall. V23 was upset the facility nurse stated R11 didn't fall because she knows he did.
On 12/11/2024 at 10:40 AM, in a joint interview with V1, Administrator and V2, Director of Nursing/DON, V2 stated not all residents require a gait belt during a 1 person transfer but if the resident's transfer status evaluation documents how each resident should transfer. When a resident goes out to the hospital and is readmitted to the facility therapy should reevaluate the resident's transfer status to ensure it hasn't changed. V2 stated when a resident has a fall staff should notify the nurse immediately so the resident can be assessed for injuries. If a resident falls and staff fall on top of the resident that is not considered the resident being lowered the floor that is considered a fall.
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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide timely and reliable transportation for medical care for 1 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide timely and reliable transportation for medical care for 1 of 3 residents (R2) reviewed for provision of medically related social services in the sample of 21.
Findings include:
1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia, heart failure, weakness, and need for assistance with personal care.
R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, required partial assistance with bed mobility, required substantial assistance with transfer, and ambulated via wheelchair.
R2's Appointment Calendar for the month of November 2024 documents R2 had an appointment with a MD (Medical Doctor) scheduled on 11/18/24 at 11:00 AM.
The Facility's Grievance/Concern/Complaint Form from V15, R2's Family, on 11/18/24 documents, (R2) was late for her doctor's appt (appointment) today. This is the third time appt rescheduled. Transportation ran late w/another appt. Dr (Doctor) refused to see resident. Appt was rescheduled.
On 12/10/24 at 10:45 AM, V4, Transportation Driver, stated the transportation schedule book disappeared, so resident appointments were missed. He stated sometimes there are multiple resident appointments around the same time that have to be rescheduled because there is only one van and thinks R2 has missed two appointments due to overcrowding of schedule.
On 12/10/24 at 12:58 PM, V1, Administrator, stated, Our previous transportation driver was terminated, and the schedule went missing, so I know (R2) missed her appointment. We rescheduled that one, and unfortunately another resident's appointment went too late, and she missed the second one.
The Facility's Resident Rights Policy revised 8/31/23 documents, The Resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the Facility. The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication were refilled by the pharmac...
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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 1 of 3 residents (R6) medication were refilled by the pharmacy or delivered to the facility for prescribed eye drops regarding medications per physician's orders in a sample of 3.
Findings include:
R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma.
R6's Physician's Order Sheet (POS), dated 4/2024 and 11/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime.
On 12/11/2024 at 2:20 PM V25, Pharmacy Order Entry Technician, stated (R6's) prescription eye drops Latonoprost 0.005% was not refilled or delivered to the facility to be administered for the months of April 2024 and November 2024 and they would have ran out because the eye drop bottle is a 25 day supply if administered every day per physician's orders.
The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024 and 11/2024.
On 12/12/2024 at 9:28 AM V2, DON (Director of Nurses) stated she noted on the pharmacy refill sheet that (R6's) eye drop Latanoprost 0.005% was not refilled in 4/2024 and 11/2024. The nurses are responsible for notifying pharmacy for all medication refills monthly because if the nursing staff doesn't order the medication then it doesn't get delivered to the facility.
The Facility's Medication Administration Policy effective 10/25/14 documents, Medications are administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 of 3 residents (R6) medication administration record was ac...
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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 1 of 3 residents (R6) medication administration record was accurately documented for physician prescribed eye drops regarding documentation of medication administration in a sample of 3.
Findings include:
R6's Undated Face Sheet, documents R6 was initially admitted to the facility on [DATE] with a diagnosis of glaucoma.
R6's Physician's Order Sheet (POS), dated 4/2024 documents an order Latanoprost 0.005% 1 gtt (drop) both eyes at bedtime.
The Reorder Fill History from the facility's pharmacy documents Latanoprost 0.005% eye drops were not refilled for the month of 4/2024.
R6's Medication Administration Record (MAR) dated 4/2024 documents Latanoprost 0.005% was documented administered for all the days.
R6's POS, dated 11/2024 documents Latanoprost 0.005% 1 gtt both eyes at bedtime.
R6's MAR, dated 11/2024 documents Latanoprost 0.005% was administered on 11/1/2024, T was documented for 11/2/2024 through 11/4/2024 which means therapeutic leave, was administered on 11/5/2024 through 11/18/2024, 11/19/2024 was blank, 11/21/2024 through 11/23/2024 therapeutic leave, 11/24/2024 through 11/26/2024 initialed by staff as administered, 11/27/2024 blank.
R6's MAR dated 11/2024 documents V31, Licensed Practical Nurse/LPN, administered Latanoprost 0.005% was administered at 9:00 PM on 11/15/2024.
On 12/12/2024 at 8:50 AM V31 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
R6's MAR dated 11/2024 documents V29, LPN administered Latanoprost 0.005% at 9:00 PM on 11/6/2024, 11/7/2024, 11/10/2024, 11/11/2024, 11/17/2024 and 11/18/2024.
On 12/12/2024 at 9:08 AM V29 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
R6's MAR dated 11/2024 documented V30, LPN, adminstered Latanoprost 0.005% at 9:00 PM on 11/20/2024 and 11/26/2024.
On 12/12/2024 at 9:20 AM V30 stated when she documented on R6's MAR a medication was administered that means the medication was available at the facility to administer and they do not why pharmacy would say it wasn't refilled because it was available and administered per physician's orders.
On 12/12/2024 at 9:28 AM V2, DON (Director of Nurses) stated she noted on the pharmacy refill sheet that (R6's) eye drop Latanoprost 0.005% was not refilled in 4/2024 and 11/2024 and if it's a 25 day supply then she didn't understand how staff were documenting the eye drop was administered if it wasn't refilled by the pharmacy this would not be accurate documentation of the residents medical record if staff documented but didn't have the medication available to be administered.
The Facility's Medication Administration Policy effective 10/25/14 documents, Medications are administered as prescribed in accordance with good nursing principles and practices and only be persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for physical abuse in the sample of 3.
Findings include:
R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, depression, abnormalities of gait and mobility, and pain.
R2's Minimum Data Set (MDS) dated [DATE] documented R2 was cognitively intact, ambulated via wheelchair, and was independent with bed mobility and transfer.
R2's Care Plan updated 11/26/24 documents R2 is at risk for abuse and neglect.
The Facility's Initial Report sent to the (State Agency) on 11/16/24 at 10:15 PM documents V1, Administrator, was notified on 11/16/24 at 10:00 PM that R2's CNA (Certified Nursing Assistant) became agitated with her during care and touched her face in a [NAME] way. The CNA was suspended pending investigation.
R2's Progress Note by V5, Licensed Practical Nurse (LPN), on 11/16/24 documents, CNA reported to this nurse that the resident slapped her. I went down to talk to the resident and she stated that she did not slap the CNA, the CNA slapped her. Resident stated she were (was) in the bathroom and rocked her wheelchair back, the CNA asked her to stop, the resident stated she did not know what she was talking about. Resident stated she must have ran (run) over her toe because she heard her say ouch. Resident stated, then the CNA slapped her really hard.
V5's Hand-Written statement dated 11/16/24 documents, CNA came and reported to this nurse, that a resident slapped her. Another CNA pulled the night nurse to the side and stated that the CNA was lying she witnessed her slapping (R2). I went down to talk to the resident and she stated the CNA did slap her. I ask what happen, resident said she was rolling back and ran over the CNA foot, she heard the CNA say ouch. Resident stated she was turning around and the CNA slapped her.
On 11/26/24 at 11:00 AM, V5 stated, I was at the nurse's station when (V3) came and told me (R2) slapped her. I was walking down to (R2)'s room, and on the way down there (V4, CNA) told me something different. I went into (R2)'s room and (R2) stated, '(V3) slapped me really hard.'
The Facility's Undated Written Interview with V4 documents V4 went down the hall to see if one of the other CNAs would help on her hall. She heard commotion and went to see what was going on and saw the lady hit her in the face.
On 11/26/24 at 10:26 AM, V4 stated she heard commotion coming from R2's room and went to see what was going on. She saw V3 come from behind and hit R2 in the face. As V4 was going down the hall she heard V3 say R2 hit her in the face, and she was shocked V3 was saying that, because that was not what happened.
The Facility's Undated Written Interview with R2 documents R2 was in the bathroom cleaning up her dirty laundry when V3 came in from behind her and started moving her chair (wheelchair) while she was bent over picking up her clothing. R2 stated V3 continued moving her chair, and R2 had to brace her foot on the floor to ensure she did not fall out (of her wheelchair). R2 stated she put her arm up in the air and may have hit V3 at that time, but it was not intentional. She said then V3 made contact with her face and it was not a little love tap, she hit me hard. V3 told R2 she was going to tell the nurse that R2 hit her.
On 11/26/24 at 9:38 AM, R2 stated, I was in the bathroom with the doors closed getting ready to go out. (V3) came in the door, I didn't know she was back there. I'm hard of hearing. I was bent over getting dirty clothes off the floor into the hamper and all of a sudden my chair started moving. I pushed back and must have hit her foot because she squealed, then she kept pushing me. Well, I had the bag and clothes still in front of me, and she was behind me, and when she pushed again I put my arm up in the air and she said I hit her, then all of a sudden, 'Whomp.' She whopped me a good one. It was intentional. She knew she did wrong when she did it, because I saw her reflection in the mirror and she did like this (made motion of putting hand over mouth in surprise). I wasn't hurt. It just stung maybe an hour. She took that left hand and, 'Whomp.'
The Facility's Final Report sent to (State Agency) on 11/24/24 documents V3 did not return to the Facility, and her employment was terminated following the investigation.
On 11/26/24 at 8:40 AM, V1, Adminstrator stated both V3 and R2 were consistent with their interviews throughout the investigation, but she thought it was best to go ahead and terminate V3.
The Facility's Abuse Prevention Program Policy revised 12/16/16 documents, Abuse is the willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, the facility failed to permit a resident to return to the facility from the hospital for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, the facility failed to permit a resident to return to the facility from the hospital for 1 of 3 (R5) residents reviewed for discharge in a sample of 11.
Finding included:
R5's Electronic Heath Record (EHR), not dated, documents that R5 was admitted on [DATE] at 5:46 PM with diagnosis of Acute respiratory failure, unspecified whether with hypoxia or hypercapnia as Primary/admission and Dependence on respirator [ventilator] status, Quadriplegia, unspecified, Pain, unspecified, Major depressive disorder, single episode, unspecified, Neuromuscular dysfunction of bladder, unspecified, Encounter for attention to tracheostomy, Tracheostomy status, Presence of cardiac pacemaker, Personal history of pulmonary embolism, Chronic embolism and thrombosis of left femoral vein, Acute embolism and thrombosis of right peroneal vein, Extended spectrum beta lactamase (ESBL) resistance Note: Lung, Spinal stenosis, cervical region, Other nondisplaced fracture of third, fourth, and fifth cervical vertebra, subsequent encounter for fracture with routine healing.
R5's Progress Note, dated 05/16/2024 at 6:06 PM, documents that Resident arrived to facility by ambulance from (Regional) Hospital, 48 y/o male full code, was in a motor vehicle accident, has a c (cervical) spine injury. Is trach/vent, quadriplegic, previously had no feeling from neck down but can now feel some sensation of temperature. Was at (Regional) hospital prior to (hospital), tried to leave AMA (Against Medical Advice). History of refusing care and medications. Bronch done on 05/15 with no findings. Alert x's 4, has non pitting edema in all extremities. Regular diet, thin liquids, has g (gastrostomy) tube still in place, diet order submitted to dietary, evening meal tray served. wounds noted to bilateral shoulders, bilateral elbows, wound to coccyx, right shin.
R5's Care Plan, dated 5/16/2024, documents that Problem: Resident will not be able to be discharged to community due to Acute respiratory failure; Quadriplegia; and Stage 4 wounds. It also addressed R5's skin impairment, pacemaker, trach, Depression, Gtube and behaviors.
R5's Discharge Minimum Data Set, Return Anticipated, dated 9/29/2024, documents R5 was moderately impaired cognitive skills, dependent on staff for all activities of daily living.
R5's Progress Note, dated 09/29/2024 at 11:24 AM, documents that Resident sent out to (Regional Hospital) at his request. R/t (related to) wound care. All party made aware.
R5's Progress Note, dated 09/30/2024 05:19 AM resident admitted to (Regional Hospital), R/T wound care.
R5's Physician Order, dated September 2024, does not document orders for hospital transfer 9/29/2024.
R5's Progress Note, dated 10/04/2024 at 3:00 AM, documents that This writer was notified by staff that the resident made a threat regarding his ex-wife having a gun in the facility the prior weekend when she visited. The CNA noted that the ex-wife was very agitated after the resident reported he was not getting meal trays. The CNA stated she went to the kitchen and got him a tray and he refused the food. The CNA reported that the ex-wife was yelling at the DON. The CNA stated that when she went to answer the resident's call light the resident stated my ex does play about me and he stated that he had to tell his ex-wife to chill out and she had her gun too. He told the ex-wife she needed to put her gun away in case they called the police on her so she won't get banned from the facility. Upon this information being reported to the administrator the police were called and an investigation was started. This writer requested that the admissions director contact the case worker at (hospital) and inform her that that due to a pending investigation we would not be able to take the resident back until the investigation was resolved. The admissions director informed the case worker that they would have to contact her to ensure he was able to return if she did not contact prior.
R5's Progress Notes, dated 11/11/2024 at 1:54 PM, documents DISCHARGE NOTE: SSD (Social Service Director) called R5's Mother, (V9), via phone, to pick up his belongings as he has been discharged from the facility. She (V9) indicated she would make some phone calls because he is in the hospital. SSD notified the Administrator of the call.
R5's EHR was reviewed the discharge notes do not document specific need that cannot be met at facility and facility attempts to meet those needs, services available at receiving facility that meet resident's needs. No physician documentation of facility not being able to meet resident's needs. No documentation of resident and or family being notified of discharge verbally until 11/11/2024 or in writing and reason for discharge. No documentation of resident and family being notified verbally or written of bed hold.
On 11/19/2024 at approximately 8:40 AM V1, Administrator, stated that they have not had any recent involuntary discharges. V1 stated that R5 had been discharged from the facility. V1 stated that R5 had been out of the for over 30 days and had been discharged from the facility because of this. V1 stated that this is in the facility discharge and bed hold policy.
On 11/19/2024 at 8:58 AM V4, Ombudsman, stated that she was Notified by V9 that R5 had been discharged from the facility and the facility would not take him back. V9 stated that she had not spoken with R5 as he is in the hospital. V9 stated that when speaking to the facility she (V4) was informed that R5 had been out of the facility for over 30 days and was discharged . V4 stated that she is not familiar with this 30 day reasoning and notified the facility that they had to take him back because they did not have a valid reason not to. V4 stated that they tried to say something about an issue with the ex wife but that not the resident so it does not count as a reason for discharge.
On 11/19/2024 at 9:45 AM V7, Social Worker, stated that R5 is ready for discharge. V7 stated that R5 was admitted to the hospital and started on antibiotic and antifungal medication regimen that was 6xs a day. V7 stated that they were notified that the facility could not meet that need. V7 stated that they were informed if the times were daily or twice a day the facility could accommodate. V7 stated that when calling the facility about R5's return notified that because of an investigation they can not accept R5 back into the facility. V7 stated that they have not been notified of what the investigation is. V7 stated that R5 is ready to return to the facility.
On 11/19/24 at 10:03 AM V9, R5's Mother, stated that she was upset that her son was being denied return to the facility. V9 stated that she received a call from V6, SSD, on a Monday or Tuesday. V9 stated that (V6), SSD, called her Monday November 11th at 1:46 PM. V9 stated that R5 went to the hospital frequently due to lack of care. V9 stated that she was informed that R5 was at another facility. V9 stated that R5's wounds were not being treated and that he had infections because of this. V9 stated that the facility does not have enough staff to provide the care that R5 needs. V9 stated that this facility is the only facility that cares for vent patients that is remotely close to family. V9 stated that V6 informed her at the time to pick up R5's belongings because he was discharged . V9 stated that V6 informed her that because R5 was out of the facility for over 30 days he was discharged from the facility. V9 stated that at no point did the facility communicate with V9 about discharge from the facility and never spoke to them about a 30-day rule. V9 stated that she did not receive anything in writing about R5 being discharged . V9 stated that as far as she was aware R5 was returning to the facility.
On 11/19/24 at 10:48 AM V6, SSD, stated that she was notified in the morning meeting that R5 was discharged from the facility. V6 stated that housekeeping was notified to clean room and box up belongings. V6 stated that she then placed a call to V9 and notified her that R5's belonging were ready to be picked up. V6 stated that V9 was not aware. V6 stated that she tried to explain to V9 that R5 had been out of the facility for over 30 days and was discharged because of this. V6 stated that V9 said she would be making some calls. V6 stated that she had not spoken with R5 or V9 prior to this about discharge.
On 11/19/2024 at 10:57 AM V3, Admissions Coordinator, stated that she handles the admissions and discharges. V3 stated that she is familiar with R5's discharge. V3 stated that R5 was admitted to the hospital on [DATE]. V3 stated that R5 has been out of the facility for over 30 days. V3 stated that it is their policy that if a resident is out of the facility passed 30 days then he is discharged from the facility. The hospital can send over a new referral, and we will review. V3 stated that the hospital was told this and they did and the facility denied. V3 stated that the denial was because they were aware that R5 didn't feel that the facility could meet his needs.
On 11/19/2024 at 11:14 AM V2, Director of Nursing, stated that R5 was a resident at the facility. V2 stated that R5 said that the facility could not meet his needs. V2 stated that R5 was sent to the hospital per his request. V2 stated that during the hospitalization that was investigation involving R5 and the hospital was notified that R5 could not return at that time. V2 stated that V1 handled the investigation. V2 stated that R5 had multiple complaints and refusal with care. V2 stated that several attempts were made to assist him. V2 stated that the facility tried different staff, different times and R5 would not allow care. V2 stated that there was an issue with V5, R5's ex wife, V2 stated that V5 was upset and yelling at her (V2). V2 stated that V5 did not threaten her. V2 stated that she (V2) suggested a careplan meeting and left the room. V2 stated that R5 had been out of the facility for over 30 days and was automatically discharged from the facility.
On 11/21/2024 at 9:05 AM V8, LPN, stated that she was assigned to R5 on the day of discharge. V8 stated that she been in room and spoken with R5. V8 stated that they talked about his family but nothing about his wounds until he requested to go out to hospital for wound care. V8 stated that R5 usually allows her to do his treatment but on that day he wanted to go to the hospital. V8 stated that she sent R5's Face sheet and medication list. V8 stated that she did not discuss with, give to, or send a bed hold with R5. V8 stated that she expected R5 to return to the facility.
On 11/21/2024 at 11:00 AM V1, stated that she expected the staff to follow the bed hold policy. V1 stated that the 30 days she thought was a regulation. V1 stated that they had tried to accommodate R5's needs while in the facility and R5 refused. V1 stated that several attempts were made by staff without success. V1 stated that because of the refusal the family was called and they were accusatory and not willing to help. V1 stated that the facility at that time could accommodate the R5's needs but R5 refused and wanted to be hospitalized repeatedly. V1 stated that R5 has been out of the facility for over 50 days and has been discharged from the facility.
The facility's Bed Reserve Policy Notification, not dated, documents This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to apply residents' continuous positive airway pressu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to apply residents' continuous positive airway pressure (C-PAP)/bilevel positive airway pressure (Bi-PAP) machine at bedtime as ordered for 1 of 2 residents (R3) reviewed for respiratory care in a sample of 7.
Findings include:
On 10/7/2024 at 11:26 PM, R3 was in her room. She was wearing a hospital gown, eyes were closed, door was open. R3 was not wearing a C-PAC or Bi-PAP machine.
On 10/8/2024 at 12:03 AM and again at 12:15 AM, R3 was still sleeping at a 45-degree angle, with no C-PAC machine on her face.
R3's Face Sheet, with an admission date of 08/30/2019, documented R3 has diagnoses of but not limited to Congestive Heart Failure (CHF), Type II Diabetes Mellitus, and Obstructive sleep apnea (adult) (pediatric).
R3's Minimum Data Set (MDS), dated [DATE], documented R3 is severely cognitively impaired and is dependent on staff for all her activities of daily living (ADLs).
R3's Care Plan, admission date of 08/30/2019, has no documentation regarding R3's use of a BiPAP machine at night.
R3's Physician's Orders, dated 12/04/2023, documented BIPAP Machine. Use device on mouth or throat nightly at bedtime. Inspiratory pressure 12. Expiratory pressure 8. At Bedtime 09:00 PM.
On 10/09/24 at 3:00 PM, V1, Administrator said the night nurses and respiratory therapy are responsible for putting resident's C-PAP/Bi-PAP machines on them at night. She said she would expect them to be applied nightly.
The facility's policy CPAP/BiPAP Support, revision date of 07/2014, documented Purpose 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (Pa02) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident to comfort and safety. Preparation 1. Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. It further documents General Guidelines 1. CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) can be used in conjunction with ventilation to improve oxygenation. 2. BiPAP delivers CPAP but allows separate pressure settings for expiration (EPAP) and inspiration (IPAP). 3. CPAP is used when residents have not responded to attempts to increase Pa02 with other types of oxygen delivery systems (e.g., nasal cannula). 4. CPAP may be appropriate for improving arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease.
Aug 2024
4 deficiencies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R54's Minimum Data Set (MDS) dated [DATE] documents that R54 is cognitively intact.
R54's undated Face Sheet documents perti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R54's Minimum Data Set (MDS) dated [DATE] documents that R54 is cognitively intact.
R54's undated Face Sheet documents pertinent medical diagnosis are documented as Chronic Respiratory Failure with Hypercapnia, Chronic Obstructive Pulmonary Disease with Acute Exacerbation Dependence on Respirator (Ventilator) status.
The Facility Reported Incident (FRI) dated 5/28/24. R54, age [AGE], diagnosis of dependence on a ventilator. Investigation was completed with resident, staff and other alert and oriented residents. R54 stated that (V20,Certified Nursing Assistant/CNA) came into room and touched her face with both hands and kissed her nose. Resident stated that was odd behavior for this CNA and this has never happened before during care which is why she reported it. Staff member (V21/CNA) would not return phone calls regarding incident and will not be returned to work due to lack to lack of communication. No other resident or staff witnessed this incident or any other incident.
On 08/09/24 at 3:30 PM V1 Administrator stated there were no prior reports of inappropriate behaviors by (V21/CNA). A Healthcare Background check did document that V21 was eligible to work.
On 08/09/24 at 4:06 PM V35 Respiratory Therapist stated she was the person that made the report to the (V1) Administrator about the CNA (V21) making inappropriate advances to residents. (R54) asked (V35) RT for ice and a soda. When V35 returned with the ice and soda (R54) stated she did not like that girl. She was kissing me all over my face. (R54) described the girl as the CNA with the things all over neck. CNA (V21) was noted to have skin tags on her neck. At that moment the CNA (V17 ) assigned to the hall reported to (V35 ) RT that another resident reported CNA (V21) had been kissing her inappropriately and against the resident wishes.
4. R63's Minimum Data Set (MDS) dated [DATE] documents that R63 is cognitively intact.
R63's undated Face Sheet documents R63's medical diagnosis as Amyotrophic Lateral Sclerosis and Spinal Stenosis Lumbar Region with Neurogenic Claudification.
Facility Reported Incident (FRI) dated 5/25/24 documents R63 age [AGE] with a diagnosis of ALS (amyotrophic lateral sclerosis) reported that CNA (V21) came into room and kissed her cheek which caught her (R63) off guard. She (R63) stated that the CNA (V21) left the room afterwards and no other incidents happened. Resident stated it was just odd behavior and this is why she reported the behavior. She stated she was not offended by the behavior but would like for the CNA to be more professional. Staff has not been interviewed regarding the incident as she has not returned phone calls. Staff member will not be returning to work due to lack of communication regarding this incident. Staff and alert and oriented residents were interviewed. No other residents witnessed the incident or any other incident.
The Police report dated 5-28-24 at approximately 1425 hours, documents a report of a suspicious incident involving a CNA who works there kissing residents. The Administrator stated the following not verbatim:
-She said her residents reported that they were kissed by CNA on the cheek at 0500 hours on 5-25-24.
-The CNA worked the 7:00 p.m.-7:00 a.m. shift the night of 5-24-25, so the incident had to have occurred in that time frame.
-One resident has ALS and can only communicate via her electronic tablet, and the other resident is on a ventilator.
-The residents resides in room [ROOM NUMBER]/bed 2, and in room [ROOM NUMBER]/bed 1.
- They are not friends and rarely have contact that the Administrator knows of.
-She stated that there are cameras in the hallways of the Convalescent Center, but there are none in the rooms.
-CNAs who worked with the CNA that night stated to Administrator that the CNA was acting strange that shift.
- The Administrator would speak with the residents as well as their families, to gather more information.
-One resident was able to describe skin tags on the face of the individual who kissed her which matches the description of the alleged perpetrator.
On 08/09/24 at 3:30 PM V1 Administrator stated there were no prior reports of inappropriate behaviors by CNA V21. A Healthcare Background check did document that V21 was eligible to work.
On 08/09/24 at 4:06 PM V35 Respiratory Therapist (RT) stated she was the person that made the report to the (V1) Administrator about the CNA (V21) making inappropriate advances to residents. The CNA (V17) reported that (V21) was acting weird. (V21) was walking slow, stumbling and was on the wrong hall. CNA (V17 ) reported that R63 wrote out on her computer that the CNA (V21) was kissing all over her face, starting with her hand. CNA (V21) asked (R63) if she could kiss her again. (R63) stated no but CNA (V21) kissed her on her cheek. CNA (V17) stated CNA (V21) did leave (R63's) room. V RT stated she was instructed by (V1) Administrator to have CNA (V21) leave the building. (V35 ) RT escorted CNA (V21) to the front where she exited the building.
On 08/12/24 at 10:20 AM V17 CNA stated she was the CNA assigned to R63. (R63) uses her eyes to operate a computer to communicate. (R63) stated CNA (V21) had been in her room and was kissing all over her. CNA (V21) was not assigned to that hall and had been observed going in and out of resident rooms. When CNA (V21) came out of (R63's) room, V17 CNA went into the room behind her (V21). That was when (R63) told CNA (V17) that CNA (V21) had came into her (R63) room and was kissing on her. CNA (V17 ) reported it to RT (V35 ). CNA (V17) also reported that she thought she detected the smell of alcohol on CNA V21. V35 RT stated that it was suspected that V21 reported to the job on more than one occasion under the influence and that she (V21) had made sexual comments to her in the past. According to (V17), (V21) CNA went into other residents rooms and another resident did report that (V21) had kissed her
5. R67's Minimum Data Set (MDS) dated [DATE] documents R67's Cognitive Skills for Daily Decision Making is Moderately Impaired.
R67's undated Face Sheet documents R67's medical diagnosis as Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, subsequent encounter, Other Psychoactive substance abuse, uncomplicated and Blindness right eye Category 3, Blindness left eye Category 3.
The Facility Reported Incident (FRI) dated 12/25/23 documents it was reported to the administrator that a staff member (V20) was speaking with a resident inappropriately. The administrator immediately interviewed both the resident and the son who reported the incident. Based on the information given the alleged staff member was suspended pending the investigation. Employee was terminated. On 12/27/23 an employee reported about one month ago, (V20) housekeeper came down into the laundry room where he was working and asked me if was gay out of nowhere, I shrugged him off and didn't really reply. Now ever since he's asked me that , he keeps coming down into the laundry room, smiling at me , I feel very uncomfortable being around him.
On 12/29/23, V20 housekeeper admitted to making inappropriate comments to resident and offering him (R67) a drink of alcohol.
On 8/9/24 at 11:46 AM V28, son of R67 stated his father actually reported the incident to the administrator but he (V28) was present. His father (R67) stated that the housekeeper (V20) came on to him and offered him alcohol. To his (V28) understanding (V20) was a new worker and that he was terminated that same day. R67 does express concerns for his safety. (R67) has not expressed concerns about any other incidents or his safety.
On 8/9/24 at 11:50 AM R67 stated that fa_ _ _ t came on to me. He (V20) approached me. I had not had any contact with him before. I can't remember where we were when he approached me but I do remember what he said. I did not have problems with him (V20) after that because they got rid of his a_ _. R67 stated he did not feel safe in the building and that he (R67) thinks the facility needs security guards and a monitoring system.
On 8/9/24 at 12:20 PM V23 Laundry/Housekeeper stated (V20) did ask me out. We were in the breakroom. He (V20) asked me it I liked gay men. You should try it once. A co-worker overheard the conversation and told me I should report it and I did. (V20 ) did not offer me alcohol but did state he parties a lot. (V20) behavior made me feel uncomfortable but I stayed away from him.
On 08/09/24 at 3:30 PM V1 Administrator stated there were no prior reports of inappropriate behaviors by housekeeper V20. A Healthcare Background check dated did document that V20 was eligible to work.
The Abuse Prevention Program Policy, dated 9/29/24, documents the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. As part of the resident social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of abuse, neglect or mistreatment for these residents.
Based on interview and record review, the facility failed to prevent abuse in 5 of 5 residents (R34, R53, R63, R67, R77,) reviewed for abuse in the sample of 43.
Findings include:
1. R34's Abuse Report, dated 8/4/24, documents an allegation was made that R34 made contact with R77's left arm due to R77 bumping into him with her wheelchair.
R34's Abuse Report, dated 5/18/24, documents R34 struck R77 with a wet floor sign, R77 sustained a laceration to her forehead.
R34's Abuse Report, dated 4/8/24, documents R34 struck R77. When R34 was asked why he struck R77, he stated she was too close to me.
R34's Abuse Report, dated 2/11/24, documents R34 hit R77 in the chest. When R34 was asked why he hit R77, he stated she rolled over his toes. Allegation of resident to resident abuse is substantiated.
R34's Abuse Report, dated 12/14/23, documents R77 rolled over R34's feet and he took his water mug and hit her in the elbow.
R34's Abuse Report, dated 12/6/23, documents R34 took a broom that was left on the hall by housekeeping and hit R77 with it. R77 received a cut on her right forehead. Allegation of abuse substantiated.
R34's Abuse Report, dated 11/24/23, documents R34 hit R77 on the back of the head as she rolled by him. R34 was yelling get away from me as R77 was rolling past him. Allegation in of resident to resident abuse is substantiated.
R34's Abuse Report, dated 11/14/23, documents R77 was rolling too close to R34 and he became agitated and struck R77's arm. The allegation of resident to resident abuse is substantiated.
R34's Abuse Report dated 11/6/23, documents R34 took a wet floor sign and made contact with R77. The allegation of abuse is substantiated.
R34's Face Sheet, undated, documents R34 has the following diagnosis: Dementia, Encephalopathy, Unspecified Mood Disorder and Depression.
R34's MDS (Minimum Data Set), dated 4/19/24, documents R34 has a BIMS (Brief Interview of Mental Status) of 8, indicating R34 has moderate cognitive impairment, is delusional and has physical & verbal behavioral symptoms directed towards others.
R34's Care Plan, dated 5/20/24, documents R34 exhibits harmful behavior at times and is considered at risk for abuse/neglect (per assessment) due to Dementia.
2. R77's Abuse Report, dated 8/4/24, documents an allegation was made that R34 made contact with R77's left arm due to R77 bumping into him with her wheelchair.
R77's Abuse Report, dated 5/18/24, documents R34 struck R77 with a wet floor sign, R77 sustained a laceration to her forehead.
R77's Abuse Report, dated 4/8/24, documents R34 struck R77. When R34 was asked why he struck R77, he stated she was too close to me.
R77's Abuse Report, dated 2/11/24, documents R34 hit R77 in the chest. When R34 was asked why he hit R77, he stated she rolled over his toes. Allegation of resident to resident abuse is substantiated.
R77's Abuse Report, dated 12/14/23, documents R77 rolled over R34's feet and he took his water mug and hit her in the elbow.
R77's Abuse Report, dated 12/6/23, documents R34 took a broom that was left on the hall by housekeeping and hit R77 with it. R77 received a cut on her right forehead. Allegation of abuse substantiated.
R34's Abuse Report, dated 11/24/23, documents R34 hit R77 on the back of the head as she rolled by him. R34 was yelling get away from me as R77 was rolling past him. Allegation in of resident to resident abuse is substantiated.
R77's Abuse Report, dated 11/14/23, documents R77 was rolling too close to R34 and he became agitated and struck R77's arm. The allegation of resident to resident abuse is substantiated.
R77's Abuse Report dated 11/6/23, documents R34 took a wet floor sign and made contact with R77. The allegation of abuse is substantiated.
R77's Abuse Report, dated 11/5/23, documents R78 grabbed R77's hair and made contact with her face. R77 rolled over R78's foot in her wheelchair which caused him to become agitated. The allegation of resident to resident abuse is substantiated.
R77's Face Sheet, undated, documents R77 has a diagnosis of Dementia, Alzheimer's, Anxiety Disorder and MDD (Major Depressive Disorder).
R77's MDS, dated [DATE], documents R77 has severe cognitive impairment, is delusional, has hallucinations and physical & verbal behaviors directed towards others.
R77's Care Plan, dated 7/18/23, documents R77 is exhibits wandering behaviors and is at risk for injury related to impaired safety awareness, is combative, agitated and impulsive at times. R77 has socially inappropriate/disruptive behavioral symptoms by hitting other residents, touching them and grabbing at them as she moves by them. R77 is at risk for abuse/neglect due to signs of depression, exhibiting anxiety and fear, confusion and disorientation, communication barriers, combative behaviors, self-injurious behaviors, resisting care, wandering and Alzheimer's.
On 8/9/24 at 11:52 AM V26, SSD (Social Services Director), stated R34 has a labile mood, some days he is sweet, nice, and some days he is grumpy. V26 stated he does not care that R77 has Dementia, he wants things his way. V26 stated R34 does enjoy coming off of the Dementia Unit and enjoys visiting with the Beautician. V26 stated most of the time R34 just likes to sit in the hallway and people watch. V26 stated R77's level of cognition isn't even alert & oriented x1, she will say her name and she doesn't respond to it. V26 stated R77 is in her own world, rolls around in her wheelchair up and down the hallway, runs over their feet and has even run over her feet but she has no cognitive abilities to know what she is doing. V26 stated R77 also likes to touch things, it's like a texture thing with her and the other residents get frustrated with her. V26 stated R77 will grab at the other residents to touch them and it can become a situation because the other residents don't understand why she is doing it. V26 stated R77's husband visits frequently to feed her lunch and when he is here he holds her wheelchair in place with his foot to keep her next to him. V26 stated about the only thing they can do with R77 to prevent behaviors/abuse is to redirect her.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide activities for 4 of 4 residents (R34, R57, R72...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide activities for 4 of 4 residents (R34, R57, R72, R77), reviewed for activities in the sample of 43.
Findings include:
1. On 8/6/24 at 9:40 AM, R34 was observed in the dining room with his head down with no activities going on.
On 8/9/24 at 9:21 AM, R34 was observed up in his wheelchair sitting in the hallway. No activities going on.
R34's Face Sheet, undated, documents R34 has a diagnosis of Dementia, Encephalopathy, Unspecified Mood Disorder and Depression.
R34's MDS (Minimum Data Set), dated 4/19/24, documents R34 has a BIMS (Brief Interview for Mental Status) of 8, indicating R34 has moderate cognitive impairment.
R34's Care Plan, dated 5/20/24, documents R34 enjoys both group activities and independent leisure activities favorite act's include spirituality. R34 finds it important to listen to a variety of music, have books/magazines/newspapers available upon request, be around dogs or cats, keep up with the news, do things with groups of people, participate in their favorite activities such as listening to the TV and church act's, go outdoors and get fresh air when nice out and feeling up to it, and participating in religious activities.
R34's Progress Note, dated 4/19/2024 at 1:26 PM, documents R34 enjoys watching tv in his room and sometimes reading. Favorite activity is church, he is Baptist. Enjoys socializing w/ staff and other residents and will occasionally participate in groups or sensory groups. Will monitor activity participation and continue to invite to group activities that might be of interest.
R34's Progress Note, dated 8/2/2024 at 5:44 PM, documents R34 enjoys watching tv in his room and sometimes reading. Might join in groups if feeling up to it- Favorite activity is church, he is Baptist. Will monitor activity participation and continue to invite to group activities that might be of interest.
2. On 8/6/24 at 9:50 AM, R77 was observed in the dining room with her head down on the table, sleeping, there were no activities going on.
R77's Face Sheet, undated, documents R77 has a diagnosis of Dementia, Alzheimer's Disease, Anxiety Disorder and Major Depressive Disorder.
R77's MDS, dated [DATE], documents R77 has severe cognitive impairment, is delusional, has hallucinations and physical/verbal behaviors directed towards others.
R77's Care Plan, dated 7/18/23, documents R77 enjoys walking in the hallway, soft music, and socializing with staff or visiting family members. R77 finds it important to listen to music, have books/magazines/newspapers available upon request, being around dogs or cats, keep up with the news, do things with groups of people, participating in her favorite activities such as walking the halls, going outdoors and getting fresh air when it is nice out and feeling up to it and participating in religious activities. R77 exhibits problems such as wandering, being verbally/physically abusive, socially disruptive and resisting care, with an intervention to encourage her to participate in activities of interest.
R77's Progress Note, dated 10/15/23 at 10:24 AM, documents the following: Resident is a patient on 200 hall with other dementia patients. Resident is often confused and can be difficult to redirect at times. Will join in some group act's or sensory act's, but often prefers to listen/watch activity. Husband visits 4-5 x's a week. Will monitor activity participation and continue to encourage participation in group activities that might be of interest.
R77's Progress Note, dated 4/12/24, documents the following: Resident is a patient on 200 hall with other dementia patients. Resident is often confused and can be difficult to redirect at times. Will join in some group act's or sensory act's, but often prefers to listen/watch activity. Husband visits 4-5 x's a week. Will monitor activity participation and continue to encourage participation in group activities that might be of interest.
R77's Progress Note, dated 7/12/24, documents the following: Resident is a patient on 200 hall with other dementia patients. Resident is often confused and can be difficult to redirect at times. Will join in some group act's or sensory act's, but often prefers to listen/watch activity. Husband visits 4-5 x's a week. Will monitor activity participation and continue to encourage participation in group activities that might be of interest.
3. On 8/6/24 at 10:00 AM, R72 was observed sitting in his wheelchair in the dining room, sleeping, no activities going on.
On 8/9/24 at 9:28 AM, R72 was observed in the dining room with his back to the TV (on but no sound), sleeping, no activities going on.
R72's Face Sheet, undated, documents R72 has a diagnosis of Convulsions, Major Depressive Disorder and Hallucinations.
R72's MDS, dated [DATE], documents R72 has a BIMS score of 11, indicating R72 has moderate cognitive impairment.
R72's Care Plan, dated 9/24/22, documents R72 enjoys both group activities, especially games and church, and independent leisure activities.
R72's Progress Note, dated 3/19/24 at 3:39 PM, documents the following: Resident is a long-term patient, he enjoys watching tv in room and at times socializing with other residents, staff, and family (speaks less than he used to). He enjoys bingo (will sometimes nod off or allow chair to back away from table) and most church act's, plays dice games, and goes to men's club when feeling well. Will monitor activity participation.
4. On 8/7/24 at 9:30 AM, R57 was observed in bed, sleeping, no activities going on.
On 8/8/24 at 1:48 PM, R57 was observed in the dining room at the table, TV is on but resident is facing the wall with her back to the TV.
On 8/9/24 at 9:45 AM, R57 was observed in the dining room, sleeping. TV is on but no sound coming from it. No activities going on.
On 8/7/24 at 12:25 PM, V36, R57's Daughter, stated she would like to see R57 more involved in doing activities and going outside instead of lying in bed all day.
R57's Face Sheet, undated, documents R57 has a diagnosis of Cerebral Infarction and Major Depressive Disorder.
R57's MDS, dated [DATE], documents R57 has a BIMS of 5, indicating R57 has severe cognitive impairment, has physical behavioral symptoms and wanders.
R57's Care Plan, dated 3/22/24, documents R57 exhibits socially inappropriate disruptive behavioral symptoms at times with an intervention to encourage R57 to participate in activities of choice. R57 enjoys both group activities and independent leisure activities. R57's favorite activities include reading, arts/crafts and socializing with others. R57 finds it important to listen to music, light jazz is her favorite, have books/magazines/newspapers available upon request, to be around dogs or cats, keep up with the news, do things with groups of people, bingo, cards, reading, going outdoors and getting fresh air when it's nice out and she is feeling up to it and religious activities.
R57's Progress Note, dated 6/7/24 at 3:40 PM, documents the following: Resident is a long-term patient. Enjoys watching tv in her room and her favorite activity is reading, crafts and going outdoors (previously a smoker). Has been participating in some groups such as bingo, word games, and entertainers. Will monitor activity participation and continue to invite to group activities that might be of interest.
On 8/9/24 at 9:51 AM, V25, Activity Director, stated they offer sensory groups to the residents on the Dementia Unit. V25 stated they also bring them off of the unit for other activities. V25 stated they go on the Dementia Unit at different times during the day and offer sensory stimulation activities. V25 stated R35, R72, R57, and R77, are involved in the sensory stimulation activities and enjoy going outdoors. V25 stated they could not find the remote control to the TV this morning and that is why they couldn't adjust the volume so she turned music on for the residents on the Dementia Unit.
08/09/24 11:52 AM V26, Social Service Director, stated R34 has a labile mood, some days he is sweet, nice, and some days he is grumpy. V26 stated he does not care that R77 has Dementia, he wants things his way. V26 stated R34 does enjoy coming off of the Dementia Unit and enjoys visiting with the Beautician. V26 stated most of the time R34 just likes to sit in the hallway and people watch. V26 stated R77's level of cognition isn't even alert & oriented x1, she will say her name and she doesn't respond to it. V26 stated R77 is in her own world, rolls around in her wheelchair up and down the hallway, runs over their feet and has even run over her feet but she has no cognitive abilities to know what she is doing. V26 stated R77 also likes to touch things, it's like a texture thing with her and the other residents get frustrated with her. V26 stated R77 will grab at the other residents to touch them and it can become a situation because the other residents don't understand why she is doing it. V26 stated R77's husband visits frequently to feed her lunch and when he is here he holds her wheelchair in place with his foot to keep her next to him. V26 stated about the only thing they can do with R77 to prevent behaviors/abuse is to redirect her.
On 8/13/24 at 12:00 PM, V1, Administrator, stated they do not have a policy for activities, they follow the regulations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation the facility failed to hold and serve food at safe temperatures for therapeutic diets for 7 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation the facility failed to hold and serve food at safe temperatures for therapeutic diets for 7 out of 7 residents (R25, R47, R54, R66, R88, R90, and R92) reviewed for food procurement store/prepare/serve food in the sample of 43.
Findings Include:
R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. R25 stated during the group meeting on 8/8/24 at 2:00 PM that the food is always cold for breakfast.
R47's MDS dated [DATE] documents R47 is cognitively intact. During the group meeting on 8/8/24 at 2:00PM R47 stated that the food is always cold at breakfast.
R92's MDS dated [DATE] documents R92 is cognitively intact. On 8/8/24 at 2:00PM in the group R92 stated the food is always cold at breakfast.
R54's Physician Order Sheet (POS) dated 1/28/24 documents that R54 is on a regular diet mechanical soft. R54 MDS dated [DATE] documents R54 is moderately cognitively intact. On 8/6/24 at lunch time she was served mechanical soft beef tips that were 110 degrees Fahrenheit, which is not a safe holding temperature.
R66's POS dated 2/17/22 documents R66 is on a regular diet mechanical soft. R66's MDS dated [DATE] documents R66 is cognitively intact. On 8/6/24 at 12:45 PM R66 was served Mechanical Soft meat beef tips with gravy and the beef tips w were 110 degrees Fahrenheit, which is not a safe holding temperature.
R88's POS dated 5/9/24 documents R88 is on a mechanical soft diet with thin liquids. R88 is moderately cognitively impaired. On 8/6/24 at lunch time at 12:45 PM R88 was served mechanical soft beef tips with gravy that was 110 degrees Fahrenheit, which is not a safe holding temperature.
R90's MDS dated [DATE] documents R90's cognitive skills for decision making is moderately impaired. On 8/6/24 at lunch time at 12:45 PM R88 was served mechanical soft beef tips with gravy that was 110 degrees Fahrenheit, which is not a safe holding temperature.
The Facility's Resident Council Meeting Minutes dated 1/23/24 documents the residents suggested warm plates for food.
The Facility's Resident Council Meeting Minutes dated 5/28/24 documents the residents complained about cold food.
On 8/8/24 at 10:45 AM V29 Dietary Manager, stated we will address the cold purees and mechanical soft. We address the cold food.
8/13/24 at 10:14 AM Administrator We will try holding the puree and mechanical food in the oven. We also have bottom tray warmers for the food. (They were not in use during the tray line).
The facility policy Meal Service Temperatures dated January 2012 documents Meal's temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis Hot food shall be cooked or heated to a temperatures above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable temperatures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to complete an updated facility assessment to accurately reflect their current resident acuity levels and population. This failure has the pot...
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Based on interview and record review, the facility failed to complete an updated facility assessment to accurately reflect their current resident acuity levels and population. This failure has the potential to affect all 104 residents residing in the facility.
Findings include:
On 8/8/24 at 2:14 PM, the facility assessment, dated 1/2023 through 12/2023, was reviewed and failed to document updated resident acuity and population to develop an appropriate plan for caring for their current population. The facility has recently added a new specialty area of ventilator/tracheostomy care and treatment and is not included in the in their current resident population.
On 8/6/24 at 2:17 PM, V1, Administrator, stated they do not have an updated facility assessment.
The Centers for Medicare and Medicaid Services, form 671, documents the facility has 104 residents residing in the facility.
Jul 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 interview, observation and record review, the facility failed to provide wound care treatments as ordered by the Physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide wound care treatments as ordered by the Physician to promote wound healing in 1 of 4 residents (R2) reviewed for quality of care in the sample of 7.
Findings include:
R2's Face Sheet, undated, documents R2 has the following diagnoses: Chronic Kidney Disease, Heart Disease, Venous Insufficiency, Rheumatoid Arthritis, Chronic Non-Pressure Related Ulcer to the Buttock and Open Wound of the Left Buttock.
R2's Minimum Data Set, dated [DATE], documents R2 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R2 is cognitively intact.
R2's Care Plan, dated 3/3/22, documents R2 is at risk for impaired skin integrity.
The Wound Log, dated 7/16/24, documents R2 has a wound to his left medial buttock.
R2's Physician Order Sheet documents an order dated 6/24/24, to cleanse the left medial buttock with normal saline, apply Silver Silvadene, collagen powder and calcium alginate and cover with a dry dressing daily and as needed.
R2's Treatment Administration Record, documented the treatment was not completed on 7/9/24 or 7/10/24 due to being on hold. There was no physician order noted to hold the dressing change on those dates.
On 7/16/24 at 1:35 PM, R2 stated he has a bed sore on his rear, the dressing was changed during the day and he didn't have any problems, then it was changed to nights and it doesn't get done. R2 stated in the past week his dressing has been changed once. R2 stated he normally has a bowel movement during the day and if the dressing gets dirty, they take it off, but the day shift refuses to replace it, so if night shift doesn't do the dressing that night, it'll go for days without a dressing covering it. R2 stated he has had the area for a long time and the wound doctor told him recently that it was healing and he (R2) is worried that it will get worse because they aren't changing his dressing.
On 1/17/24 at 11:05 AM, V9, Licensed Practical Nurse, stated sometimes it's a problem with night shift not doing their treatments, so she goes through and does the ones that didn't get done.
On 7/17/24 at 11:25 AM, V2, Director of Nurses, stated she has not had any concerns brought to her attention about night shift not completing their treatments.
The Wound Management Program, dated 1/20/23, documents it is the policy of the facility to manage resident skin integrity through prevention, assessment, and the implementation and evaluation of interventions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to infuse tube feeding at a rate ordered by the physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to infuse tube feeding at a rate ordered by the physician to aid in nutrition in 1 of 4 residents (R4) reviewed for tube feeding management in the sample of 7.
Findings include:
R4's Face Sheet, undated, documents R4 has the following diagnoses: Amyotrophic Lateral Sclerosis, Protein-Calorie Malnutrition, Gastrostomy Status and Dysphagia.
R4's Minimum Data Set, dated [DATE], documents R4 receives 51% or more of his nutrition through tube feeding.
R4's Care Plan, dated 2/6/24, documents R4 is dependent on tube feeding for all nutrition and hydration needs with an intervention to administer tube feeding as ordered.
R4's Progress Note by the Dietician, dated 7/8/24 at 1:31 PM, documents R4's current body weight on 7/5/24 was 108.8 lbs, which indicates an undesirable weight loss from the previous usual body weight of 116 - 118 lbs. Decline noted since readmission last month. Continues Nutren 2.0 at 40ml (milliliters)/hr (hour) for 23 hours with 80ml flushes every 2 hours. Recommend to increase tube feeding to Nutren 2.0 at 50ml/hr for 23 hours.
R4's Progress Note, dated 7/9/24 at 2:39 PM, documents a new order was received per the dietician recommendation to increase tube feeding to Nutren 2.0 at 50ml/hr for 23 hours.
R4's Physician Order Sheet, documents an order dated 7/9/24 for Nutren 2.0 50ml/hr for 23 hrs with a continuous water flush of 80ml every 2 hours for 23 hrs daily.
On 7/16/24 at 9:00 AM, 7/16/24 at 1:30 PM, and 7/17/24 at 9:30 AM, R2's Nutren was infusing at a rate of 40ml/hr and not 50ml/hr as recommended by the dietician and ordered by the physician.
On 7/17/24 at 9:55 AM, V4, Registered Nurse, stated R4's tube feeding order was just changed and he is to be getting Nutren 2.0 at 50ml/hr for 23 hours with a continuous water flush of 80ml/hr.
On 7/17/24 at 11:00 AM, V2, Director of Nurses, stated the nurses are to check the tube feeding to make sure it is running at the correct rate.
The Tube Feeding policy, dated 7/2014, documents that it is the policy of the facility that resident's nutritional needs will be met by tube feeding when oral consumption is not possible. The procedure is to check the physician's order to determine the type and rate of the feeding and to set the pump for the rate ordered.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide and implement fall interventions as care plann...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to provide and implement fall interventions as care planned for 4 of 5 (R1, R2, R4, R5) residents reviewed for accidents.
R1's face sheet, print date 7/3/24, documented R1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, dementia, epileptic seizures, heart disease, type 2 diabetes mellitus, and depression.
R1's MDS (Minimum Data Set), dated 5/10/24, documented that R1 is cognitively intact.
R1's care plan, undated, documented that R1 is at risk for falls related to an unsteady gait and that R1 is to have the following interventions in place: reminder signs placed to remind to use call light for assistance, canoe mattress on bed, and dycem in her wheelchair to prevent sliding.
R1's EMR (Electronic Medical Record) progress note dated 12/22/23 at 10:03 am documented resident observed on floor. Resident stated she was sleeping and rolled out of bed. Injury (hematoma) noted to left side of forehead. Resident stated her pain level is at a 5. Tylenol and ice given. NP (Nurse Practitioner) is here, new order to send to ER (Emergency Room) for evaluation and treatment.
R1's EMR progress note dated 2/4/24 at 7:39 pm documented resident had an unwitnessed fall. When asking resident what happened resident states, she was trying to self-transfer herself into bed. Resident states she hit her head against her bed. No injuries noted. R1's EMR progress note dated 2/5/24 at 7:25 pm documented resident sent to ER for complaint of left rib pain, and headache. Displayed altered mental status and dehydration. Resident has fractured left rib and fractured great right toe. MD notified. Resident sent back via EMS (Emergency Medical Service) with new order of lidocaine 4% patch daily.
R1's progress note, dated 3/28/24 at 3:35 am documented the resident was observed on the floor on her buttocks attempting to transfer self to the restroom. When the resident was asked, she stated that she was having neck and head pain. Upon assessment, the resident had a small knot on the left side of forehead, but no other injuries found. The resident stated her pain was an 8 on a 0-10 numeric scale.
R1's progress note dated 4/12/24 at 7:11 am documented resident was observed on the floor attempting to transfer self from bed to wheelchair. Resident stated that her bottom was a bit sore but refused pain medication. No marks or bleeding upon assessment. R1's progress note dated 4/12/24 at 9:27 am documented immediate intervention reminder signs placed in room to use call light and ask for assist, when interviewed she stated she had no pain.
On 7/2/24 at 9:40 am R1 was observed sleeping in her bed on a regular mattress not a canoe mattress as care planned. R1's room did not have any reminder signs posted to use call light for assistance as her care plan documented. R1's wheelchair was sitting next to her bed, and it did not have dycem placed over the cushion as care planned.
On 7/2/24 at 12:30 PM V8 CNA (Certified Nurse Assistant) assigned to R1 stated that R1's only fall interventions that she is aware of is R1 is supposed to be supervised and is supposed to have a gait belt on during transfers.
On 7/3/24 at 10:35 am R1 was observed sitting up in her wheelchair. R1's wheelchair did not have dycem in the seat. R1 stated she does not recall ever having it. R1's assigned CNA, V8 stated she does not recall ever seeing dycem in R1's wheelchair.
R2's face sheet, print date 7/3/24, documented R2 was admitted to the facility on [DATE] with diagnoses hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, heart disease, chronic kidney disease, cellulitis of left lower limb, abnormalities of gait and mobility, and osteoarthritis.
R2's MDS, dated [DATE], documented R2 is cognitively intact.
R2's care plan, undated, documented resident is limited in ability to walk in room. Requires assistance of 1 with wheeled walker. Resident will ambulate in room with assistance and required device. Resident is at risk for falls related to recent hospitalization, generalized weakness, and deconditioning. Requires assist with ambulation, gait unsteady. Approach: provide resident an environment free of clutter and provide toileting assistance, requires assist of
R2s EMR progress note, dated 3/16/24 at 3:21 pm, documented resident observed on floor in bathroom, when asked what happened resident stated she was going to the bathroom. Resident was assisted into wheelchair by 2 staff members, immediately assessed with no injuries.
R2's EMR progress note, dated 6/24/24 at 11:55 pm, documented resident noted on the floor in bathroom. Resident was attempting to self-transfer and became weak and had a fall per resident's statement. Resident assessed and noted to have a skin tear to left forearm as well as left dorsal hand. Resident also have a hematoma noted to the crown of head. It continued; ROM (range of motion) within normal limits, resident was assisted to wheelchair by nurse and CNA. At the time of transfer resident was incontinent with one shoe off, no grip sock on left foot. resident transferred to local hospital via EMS.
R2's EMR progress note, dated 7/2/24 at 1:39 pm, documented resident is alert and oriented times 4. Resident had unwitnessed fall in bathroom. Upon assessment no injuries noted. It continues, no socks and shoes on left foot. No shoes nor socks noted on right foot.
On 7/2/24 at 12:35 pm R2 was observed ambulating out of her bathroom unassisted with bare feet. R2's room was observed to be cluttered with the following items on her floor around her bed and recliner: a large weave basket full of items, a large plastic basket, 5 plastic bags full of items, 2 large potato chip boxes, a 12 pack of soda, a large blanket, 3 magazines, a full trashcan with the contents overflowing onto the floor, and a large plastic storage tote. R2's EMR did not document any education nor assistance provided to the resident regarding the importance of a clutter free environment as care planned nor did R2's care plan address proper footwear during ambulation.
On 7/3/24 at 0915 am R2 stated that facility staff have not offered her any assistance with organizing her room nor in offering other personal storage arrangements for her large number of belongings. R2 had a bandage on her left hand and a bandage on her left arm. R2 stated that she had obtained skin tears to her left hand and arm from a prior fall.
R4's face sheet, print date of 7/3/24, documented R4 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, hypertensive heart disease, reduced mobility, need for assistance with personal care, and frontal lobe function deficit.
R4's MDS, dated [DATE], documented R4 is severely cognitively impaired.
R4's care plan, undated, documented resident is at risk for falling related to cognitive impairment, decreased safety awareness, impulsiveness with attempts to stand or self-transfer without assistance. This care plan documented approach: provide proper, well-maintained footwear, non-slip socks in bed while shoes are not on.
R4's EMR progress noted, dated 4/29/24 at 3:47 am, documented this nurse was alerted by the CNA that the resident was observed on the floor in his room by his bed. Upon entering the resident's room, this nurse observed the resident sitting on the floor facing the door, with his back against his bed. This nurse asked the resident why he was sitting on the floor, the resident states, I was trying to sit on the side of the bed, and I felt my feet slide and I started to slip of the side of the bed, so I lowered myself to the floor and just sat here. The resident had regular socks on at this time. It continues, the immediate nursing intervention is to have resident's bed in the lowest position at all times while resident is in it and that resident is to have no slip socks on while in bed, and while he doesn't have shoes on.
On 7/2/24 at 1:18 pm R4 was observed sleeping while sitting up at his bedside with his head resting on his bedside table and R4 had his feet placed on the floor. R4 was wearing regular white socks. R4 did not have shoes nor gripper socks on as documented in his care plan.
R5's face sheet, print date 7/3/24, documented R5 was re-admitted to the facility on [DATE]. R5's census sheet documented an original admission date of 10/23/17. R5's face sheet documented R5 has diagnoses of fracture of right humerus, muscle weakness, osteoporosis, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, age-related cognitive decline, hypertension, congestive heart failure, type 2 diabetes mellitus with diabetic nephropathy, chronic obstructive heart disease, osteoarthritis, and chronic respiratory failure with hypoxia.
R5's care plan, undated, documented resident has potential for falls or trauma related to gait instability, muscle weakness, ADL (activities of daily living) dysfunction, and debility contributing diagnosis: respiratory failure, anemia, COPD (chronic obstructive pulmonary disorder, CHF (congestive heart failure), and cellulitis of right foot with an approach of floor mat placed beside bed.
R5's MDS, dated [DATE], documented R5 is cognitively intact.
R5's EMR progress note, dated 1/17/24 at 1:30 am documented resident found on the side of bed. Complained of pain and discomfort to neck, right elbow, and right shoulder. Attempting to perform range of motion. Resident grimaced and yelled in pain. 911 called and report given, 2 EMTS arrived at this time to transport to local hospital.
R5's progress note, dated 1/17/24 at 9:33 am, documented sent to ER, it continues bedside mat to be placed prior to return from hospital.
R5's progress note, dated 1/26/24 at 8:34 am, documented resident interviewed this am after return from hospital post fall, resident states that what she remembers is feeling as though she was falling when she was repositioning in bed, states I felt like I was falling from a chair. Diagnosis of proximal right humerus fracture at hospital, immediate intervention was mat to bedside.
On 7/2/24 at 1:20 PM, R5 was observed in bed with high humidity oxygen running to her tracheostomy. Resident did not have a mat on her floor nor anywhere in her room. R5 shook her head no when asked if she ever has a floor mat next to her bed.
On 7/3/24 at 10:30 AM, R5 was again observed in bed and neither side of the bed had a mat placed next to it. R5's assigned CNA, V9 and V10 stated that R5 has never had a mat next to her bed nor are they aware of her having it in her care plan.
On 7/3/24 at 8:35 AM, V3, CPC (Care Plan Coordinator) stated that any fall interventions on the care plan are supposed to be in place for each resident.
On 7/3/24 at 11:07 AM, V2, DON (Director of Nursing) stated that the fall interventions listed in the residents' care plans should be in place.
The facility's Falls Management policy, dated July 2017, documented it is the policy of Helia Healthcare to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. It continues, 1. A fall risk assessment will be completed on all residents upon admission, re-admission, after each fall and quarterly thereafter. 2. Resident's identified as high risk will have fall prevention addressed on the plan of care.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide insulin for the first five days of admission for one of thre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide insulin for the first five days of admission for one of three residents( R2) reviewed for significant medications errors in the sample of 9.
Findings Include:
R2's Minimum Data Set, dated [DATE] documents R2 is moderately cognitively impaired.
R2's Electronic Health Record under CCD (Continuity of Care) Diagnosis documents Type 2 Diabetes without complications was added on 5/13/24.
R2's Face Sheet documents R2 was admitted on [DATE].
R2's admission Note dated 5/13/24 resident admitted to facility via family transportation from (Another State). resident present A&Ox2-3 (Alert and Oriented). Resident in good spirit with minor confusion on where he is. Resident currently has on a back brace related to recent fall and sustained T12 fracture as well as 11th and 12th rib fracture per family and referral paperwork. resident noted to be in minimal pain at this time. Resident transferred to bed two assist with a cane. VS (Vital Signs) 98.5,85,16,177/79,100 RA (Oxygen Saturation on Room Air). Resident does have swelling to bilateral lower extremities with bandages to the back of each heal resident requested to stop assessment. Resident did state that he was tired from the long drive and would like to finish admission process the following morning when daughter in-law arrives back to facility. Resident in currently resting in bed with call light within reach no complaints at this time plan of care continue. MD (Medical Doctor) and Management made aware of resident's arrival.
admission Paperwork sent over from A Out of State Medical Center Discharge Paperwork dated 5/13/24 documents Medication Active: Insulin Aspart Novolog Sliding scale. Trauma Progress Note dated 5/13/24 documents DM ( Diabetes Mellitus) No home medications Sliding Scale Insulin.
R2's MAR (Medication Administration Record) dated 5/13/24 through 5/31/24 documents Lantus Solostar was ordered from 5/20/24 through 6/7/24. R2's MAR for May also documents R2's Novolog Flexpen Insulin Sliding Scale before meals and at bedtime was ordered on 5/18/24. R2's June MAR documents Lantus Solostar 10 units from 5/20/24 through- 6/7/24. ( No Diabetic Medication was ordered from 5/13/24 until 5/18/24).
R2's MAR dated 5/13/24 through 5/31/24 documents that R2's finger blood sugars range from 138 through 397 starting on 5/18/24 through 5/31/24.
On 6/27/24 at 1:00 PM Licensed Practical Nurse (LPN) V4 stated we missed it because they didn't actually send over a sliding scale.
On 6/28/24 at 8:00 AM V17 Pharmacist stated not receiving the Lantus (long acting insulin) would be a significant medication error. the Sliding Scale Insulin not so much, because he would only receive that if his blood sugar was high.
The facility policy admission to Facility dated 7/2014 Prior to or at the time of admission the resident's attending physician must provide the facility with information needed for the immediate care of the resident. Including orders covering at least b) Medication Orders including a medical condition or problem associated with each medication example diabetes.
Jun 2024
1 deficiency
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 F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to take and record food temperatures before and during m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to take and record food temperatures before and during meal service, to maintain food at the proper temperatures when delivering meals to the residents, and to perform glove changes and hand hygiene during serving of the food. This has the potential to affect all 114 residents residing at the facility.
The findings include:
1. R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Anemia, Hypertension (HTN), Hyperlipidemia, Morbid obesity, Sleep apnea, Right Below Knee Amputation (RBKA), Major depressive disorder, COVID-19, and Chondrocalcinosis.
R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact.
On 6/3/24 at 3:15 PM, R3 stated, I eat in my room and in the dining room, and the food is ok, but it is always cold, especially the potatoes. I told a supervisor this once, who told me she would test a french fry from the kitchen, and I insisted that she tried one from my plate, so when she did, she realized it was cold on the inside.
2. R5's Face Sheet, undated, documents R5 was originally admitted to the facility on [DATE] with diagnosis of Trans Ischemic Attack (TIA), Cerebral Infarction, Hemiplegia, Dysphagia, Anemia, Pulmonary Embolism (PE), Atherosclerotic Heart Disease (ASHD), HTN, Peripheral Vascular Disease (PVD), Type 2 Diabetes Mellitus (DM), Polyneuropathy, Hyperlipidemia, Hypothyroidism, Anxiety Disorder, Major Depressive disorder, Bipolar Disorder, Osteoarthritis, Chronic Obstructive Pulmonary Disease (COPD), and Asthma.
R5's MDS, dated [DATE], documents R5 is cognitively intact.
On 6/3/24 at 1:35 PM, R5 stated, I would say the food is not hot, may be somewhat warm at times, but can be cold at times too. Quite a bit of the food is cold and is not warm enough.
3. R4's Face Sheet, undated, documents R4 was admitted to the facility on [DATE] at 4:45 PM and was discharged to the hospital on 5/29/24 at 6:00 AM with diagnosis of Respiratory failure, Effusion, Congested Heart Failure (CHF), COPD, HTN, and Interstitial pulmonary disease.
R4's Care Plan and MDS was not completed due to a very short stay at the facility.
On 6/4/24 at 9:15 AM, V4, R4's Sister, stated, My sister was at the facility and called me and said that the staff are treating her badly and they give her awful food that is always cold. I live in Miami and my sister calls me with complaints and I feel they are not taking good care of her.
R4's Nursing Note, dated 5/28/24 at 4:49 PM, documents Resident arrived to facility at 1645 (4:45 PM), resident is A&Ox4 (alert and oriented x 4), vitals as follow BP (blood pressure)- 106/62, P (pulse)-115, r (respirations)-18, t (temperature)- 97.5. Resident is clear from bumps or bruises to entire body, no open areas noted, normal skin tags or moles on upper body, resident wears glasses for reading, resident has own teeth in mouth, upper and lower bilateral extremities are weakened, unable to perform full ROM (range of motion) rt (related to) weakness, bilateral 2+ pitting edema to bilateral lower extremities. resident requires 2 assist when transferring in and out of bed, resident is able to verbalize needs.
On 6/4/24 at 2:45 PM, V9, Certified Nursing Assistant (CNA), stated Residents do complain of cold food at times. We try to get the food to them as quickly as possible once it is delivered to the hall.
On 6/4/24 at 11:20 AM, V6, Cook, was seen putting all the food from the stove/oven onto the steam table and then covering the pans with aluminum foil with no temperature check. When asked about checking temperatures of the food, V6 stated that he checked the temperatures when he got them out of the oven. When asked to see the temperature log, V6 stated that he did not know where it was.
On 6/4/24 at 11:25 AM, V5, Dietary Manager (DM), stated, We temp the food when we put it on the steam table and before we plate the food and send it out to the residents. We check the food in the oven to make sure it is 180 degrees F. (Farenheight) and then check it again in the warmer to make sure it is still at least 135 degrees F. When asked about calibrating the thermometer prior to taking temperatures, V5 stated The maintenance man does that when we get a new one in, but I can calibrate it now if you want. V5 obtained a cup of ice water, and the thermometer was reading 31.8 degrees F. V5 checked all the food in the steam table with no gloves on. All foods were at appropriate temperatures.
On 6/4/24 at 11:50 AM, V5 was asked for the temperature logs, and he found one in his office. Upon investigation, the food temperature logbook was last documented in February 2024 with only four entries documented that month. There were no further temperatures documented since. The temperature logbook for the refrigerator and freezer is also last dated February 2024. When questioned, V5 stated that he is the one who checks the fridge and freezer every day and he does not document it anywhere. V5 stated, I guess I'm assuming that the cook is checking the temperatures like he should, but there is no way to know if that is happening and I guess that's my fault. I started in February 2024, and it seems like they were doing it before I started so not sure why they quit doing it. I realize we are supposed to keep temperature logs for these things. The freezer and refrigerator were at appropriate temperatures.
On 6/4/24 at 11:56 AM, there was one warming cart plugged into the wall and was warm to touch on inside. The gauge was not functioning so could not read temperature. This cart was the one the 200-hall trays were place in and delivered to residents on the 200-Hall. Plates of food were placed in the warmer, covered by plastic wrap and no lid. When asked, V7, Prep Cook, stated that they can't put the lids on the plates when in the warmer because they don't fit.
On 6/4/24 at 11:57 AM, foil removed from the food pans on steam table and first plate of food done. Plates of food were placed on an open plastic cart and delivered uncovered to residents sitting in the dining room. V6, [NAME] did not check temperature on the mechanical soft food and when asked to do so, V6 grabbed the thermometer and stuck it into the food pan without wiping it off first. The temp was 204 degrees F.
On 6/4/24 at 12:05 PM, while V6 was plating food, he left the steam table with his gloves on and went over to the sink, turned it on and washed off a knife, then returned to the steam table and began serving food again with same gloves on.
On 6/4/24 at 12:20 PM, last tray was sent to the dining room residents. The 200-Hall trays were started.
On 6/4/24 at 12:30 PM, V6 left the serving line again to go to sink, turned on the water, and washed a knife and a cutting board, then returned with the same gloves on and began serving food again. When V6 was asked about the Pureed food, V6 stated We only have two residents who get pureed food. I made it up when the food got done around 10:00 AM and put it on plates and then put the plates in the microwave to wait until those residents were ready. When the residents are ready, we warm them up in the microwave and temp it before serving it. V5 was seen warming the pureed food up in the microwave, checked the temperature and was only 130 degrees F., V5 then put it back in to warm it up some more, then rechecked the temp which was 145 degrees F. V5 gave plate to V8, Dietary Aide, to deliver to resident.
On 6/4/24 at 12:42 PM, all lunch trays for 200-Hall were on an open plastic cart and delivered to residents on that hall. This was 22-minutes since first plate was placed on the cart for the 200-Hall. There were 18 trays, covered in plastic wrap, then a plate lid placed on top. V6 then began plating food for the 400-Hall.
On 6/4/24 at 12:52 PM, the 400-Hall lunch trays were delivered to the 400-Hall on an open plastic cart. The last tray was delivered to a resident on the hall at 1:00 PM, 10 minutes after food was plated. V6 then began to plate food for the 300-Hall.
On 6/4/24 at 12:57 PM, the 300-Hall trays were delivered on an open plastic cart with seven trays wrapped in plastic wrap and a plate cover. The 100-Hall plating of food was started and delivered.
On 6/4/24 at 1:03 PM, The 500-Hall, the last hall, plates were prepared and placed on open plastic cart and delivered to residents on 500-Hall. A sample test tray was the last tray received after all residents received their meals. At 1:07 PM the test plate was made and placed on the open plastic cart and delivered to the 500-hall. At 1:12 PM, the last lunch tray was delivered. At 1:15 PM, the test tray temped with the following temperatures: BBQ Chicken: 120 degrees F., Macaroni and Cheese: 108 degrees F., [NAME] Beans: 110 degrees F., Pudding cup was no longer cold and was lukewarm, the drink had no ice and was warm to drink. Overall, the food had appropriate taste and texture, was palatable, but the food upon eating it was no longer hot, and was more like lukewarm to touch.
On 6/4/24 at 11:40 AM, V5 stated, We use the warming cart but there are not a lot of plug-ins in the halls, so I don't think the staff are plugging it in. We do get a lot of complaints of cold food, and we are working with the DON (Director of Nursing) to figure out why and what to do about it. I don't know where the problem lies, but we send the food out hot.
On 6/6/24 at 12:20 PM, V16, Assistant Director of Nursing (ADON), stated, We are working with the Dietary department for the complaints of cold food. We are trying to get the CNAs to get the food to the residents faster. Going forward, I think we will be involving the management team to start helping to pass out the trays, so the residents get them faster.
On 6/6/24 at 8:35 AM, V14, CNA, stated Dietary will deliver the food cart with trays on it and yell Trays Here and if I hear it, I will start delivering the trays to the residents. If I am in a room doing care, I might not hear it and will see it when I come out of the room. Residents do complain of their food being cold and if they do, I will warm it up in the microwave for them.
On 6/6/24 at 8:40 AM, V15, CNA, stated Residents always complain about cold food. There is a lot of running to the microwave to warm their food up. The kitchen will bring the cart out and put it at the top of the hall. The problem is, the trays are in no order so when we grab a tray, we have to take it to the resident's room, which may be at the end of the hall, then set it up for the resident, then go back to top of the hall to get another one. It takes some time. If the trays were in order, we could walk the cart down the hall and deliver the trays in order and be more efficient.
On 6/6/24 at 9:15 AM, after performing peri-care on a resident for approximately 20-minutes, two CNAs were seen exiting the room to find the breakfast food cart sitting in the hall. Unknown how long it has been sitting there. CNAs began delivering trays at that time.
The Facility's kitchen food temperature logbook had temperature check sheets in the book, with the last temperature check documented was on February 12, 2024.
On 6/6/24 at 10:20 AM, When asked for copies of the temperature log sheets for the refrigerator and freezer, V1, Administrator, stated For some reason, V5, DM, threw away the old temperature logs that you saw on Tuesday (6/4/24).
On 6/4/24 at 11:30 AM, V8, Dietary Aide, was seen in the kitchen with a hairnet covering the top and back of her head with the hair in front hanging down past the net. V8 was later seen delivering food trays without a plate cover to the residents in the dining room.
The Facility's Meal Service Temperatures Policy, dated January 2012, documents Meal temperatures shall be monitored by the Dietary Manager and the cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165 degrees. Cold food shall be chilled to a temperature below 40 degrees. Temperatures shall be taken and may be recorded on the food temperature record. Food which does not meet the appropriate temperatures shall be removed and reheated or rechilled prior to service. Purpose: To ensure appropriate food temperatures during meal service and to ensure appropriate food holding temperatures. To comply with federal and state regulations governing meal service. Procedure: 1. The [NAME] shall take temperatures of food (as appropriate) during meal preparation to ensure food is cooked or chilled to the appropriate temperature. Temperatures shall also be taken once food is placed on the steam table prior to the start of meal service. 2. Temperatures shall be recorded on the Temperature Report Form at each meal. 3. Food which registers temperatures outside acceptable range shall be removed and reheated or rechilled to meet acceptable temperatures.
The Facility Resident Census dated 6/4/24, documents that the facility has 114 residents residing in the facility.
Apr 2024
1 deficiency
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
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make sure medications were provided and given for 1 of 3 residents, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make sure medications were provided and given for 1 of 3 residents, (R2) reviewed for significant medications in the sample of 18.
This failure resulted in R2 missing, 9 doses of his Glaucoma medication, which is a significant medication error.
Findings Include:
R2's Minimum Data Set, (MDS), dated [DATE] documents, R2 is severely cognitively impaired.
R2's Care Plan dated, 05/03/23, did not document anything about his Glaucoma, for bedside usage of Glaucoma medications.
R2's Physician Order Sheet, (POS), dated 11/08/23, documents, Brimonidine/Timolol 0.2%-0.5% BID, (Twice Daily), may have drops at bedside, for resident to insert.
R2's POS dated, 02/19/24, documents, Brimonidine/Timolol 0.2%-0.5%), May have drops at bedside, Pharmacy last filled on 02/03/24.
R2's Progress Note, dated 02/19/24, documents, order for eye drops, clarified with Pharmacy. Insurance will pay for eye drops every 18 days. Resident is allowed to keep eye drops at bedside, resident also has Timolol drops and Brimonidine drops, separate for use when the Timolol-Brimonidine mix is not available. Drops, administered to resident, by me personally, resident aware of the procedure for administration, ordering and storage.
R2's Medication Error/Discrepancy Report, dated 02/19/24, documents, from 02/17/24 through 02/19/23 Brimonidine/Timolol, eyedrops were empty. Individual drops used, related to combo order not available. Med, (medication), is out, an unable to obtain, (more combination drops), individual was used. Education to nurses and family, 2 eye drops were used VS, (versus), the combo eye, family states, eye drops were out of date, by manufacturer, this was verified as out of date.
On 04/02/24 at 10:45AM, V13 [NAME] Specialist stated, We sent the facility Brimonidine/Timolol on February 4th and February 23.
On 04/02/24 at 10:50AM, V14 Pharmacist stated, We sent the combo medication of Brimonidine/Timolol on 11/08, 12/05, 01/13, 02/02, 02/21, and 03/31, and we always sent the combo dosages. We did not put that in the convenience box. We only have Atropine in that box.
On 04/02/24 at 12:08AM, V2 Director of Nursing, (DON), stated, Well the family insist that he keep it at his bedside. The bottle is good for 18 days. It hit on the weekend. It was a refill too soon. We found two separate bottles not the combination medication. The bottles were sent back with him from the hospital. So that is what we used. We verified that the manufacturer's date, was not outdated even though the bottle had been opened. So, we gave the medication, until after the weekend, where we could order it. We have now made sure, an extra bottle in the Convenience Box. The family insist that he keeps the medication at bedside, but he is not always alert and we feel he should not have it at the bedside. We don't know the bottle was emptied.
R2's Medication Administration Records, (MAR), were reviewed for the months of January and February the Brimonidine/Timolol was given in January. R2 missed dosages of this medication on February 15th, AM dose, February 17th, both the AM and PM dosage. February 18th, the AM dose. February 21st, the PM dose and February 26th, the AM dose. R2's MAR for January and February, also documents, may have drops at bedside for resident to insert himself. R2's MAR for the month of March, and R2 missed one dose of Brimonidine/Timolol on 03/04/24.
On 04/3/24 at 1:38PM, V16 covering Primary Care Physician stated, in the community people can miss dosages, but it is unacceptable for doses to be missed in a Skilled Nursing facility.
On 04/03/24 at 1:00PM, V15 Pharmacist stated, it is a significant medication error.
Mar 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure resident showers for activities of daily living were being gi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure resident showers for activities of daily living were being given for 5 of 8 residents (R2, R3, R5, R7 and R8) reviewed for activities of daily living to maintain good grooming and personal hygiene in the sample of 10.
Finding include:
1-R3's Minimum Data Set, (MDS) dated [DATE] document R3 was cognitively intact for decision making of activities of daily living. The MDS also documents R3 has impairment on both sides of the lower extremity, and documents for Shower/bath R7 requires substantial/maximal assistance with helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
On 3/12/2024 at 10:03 AM, R3 stated, I am not getting my showers, it has been a few weeks now since I last had a shower. I like to get showers and always feel better after I get a shower.
R3's Shower Sheets documents, a Bed bath was given on 3/12/2024, (3/12/2024 to 3/21/2024 (9 days without a shower), 3/8/2024, 3/5/2024 and 2/27/2024 (Seven days without a shower and/or bath).
2- R7's MDS dated [DATE] document she is moderately impaired for cognition of activities of daily living.
R7's Shower Sheets dated 2/23/2024 documents R7 received a shower yesterday 3/20/2024 and before 3/20/2024 the last shower documented was 2/24/2024 (25 days later).
On 3/12/2024 at 10:28 AM, R7 stated she had just received a shower yesterday, but she has not been getting two showers a week.
3- R5's MDS dated [DATE] documents, he is moderately impaired for cognition, he has impairment on both sides of his lower extremities and for Shower/bath he is dependent on staff, and staff does all of the effort.
R5's Care Plan documents resident is limited in mobility/functional status and requires the use of a mechanical lift.
On 3/12/2024 at 10:23 AM, R5 stated it had been over a month since I had a shower. Every time I ask, staff say, they say they are shorthanded and too busy. I don't think it is fair that I did not get my showers.
R5's Shower Sheets documents he had showers on 3/19/2024 (two days ago), 3/8/2024 (eleven days), and 2/23/2024 (14 days). R5 was not receiving showers two times a week.
4- R2's MDS dated [DATE] document, R2 was cognitively intact for decision making of activities of daily living. He has impairment on one side of the lower extremity and uses a wheelchair. For showers/bathe self, he is partial/moderate assistance, helper does less than half the effort. Help lifts or holds trunk or limbs and provides more than half the effort.
R2's Care Plan with a start date of 2/29/2019 documents, (R2) has the potential for complications from contractures related muscle atrophy and lack of joint movement associated with prolonged immobility and recent left below knee amputation (LBKA). R2's Care Plan with an edit date of 1/22/2024 also documents R2 has limited ability to transfer self, related to recent LBKA.
On 3/12/2024 at 10:19 AM, R2 stated I am supposed to get a shower twice a week. I always feel better after I have a shower, it helps me relax. I need help with my shower, and they don't have enough staff to give everyone showers. I am not getting my showers two times a week.
R2's Shower Sheets were reviewed and documents he received a shower on 3/19/2024 (Tuesday), a partial bed bath on 3/16/2024, a shower on 3/5/2024 (11 days), 3/2/2024 shower (3 days) and 2/27/2024 (4 days).
5-R8's grievance dated 1/25/2024 documents, Also reports he hasn't had a shower in two and half weeks.
CNA Inservice dated 1/10 and 1/11 documents, Showers-follow process-includes shaves and nails while doing showers.
The Bathing a Resident Policy with a revision date of July 2014 documents, It is the policy of (Facility) that residents will receive a shower/bath which will be scheduled regularly and prn (as needed).
The Resident Right Policy with a revision date of August 31, 2023, documents, The resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety.
Mar 2024
2 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
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure Physician Orders were being followed and residents were free ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure Physician Orders were being followed and residents were free from any significant medication errors for 1 of 6 residents (R2) reviewed for medication errors in the sample of 24.
This failure resulted in R2 not receiving her medications and being hospitalized for six days with a diagnosis of urinary tract infection and urosepsis.
Findings include:
R2's Physician Order Sheet for February 2024 documents, a diagnosis of thyrotoxicosis; adrenocortical insufficiency; heart failure. R2's POS does not document, any loss of an adrenal gland. R2's POS with a start date of 2/26/2024 documents, hydrocortisone 10 milligrams (mg), once a day. The POS with start date of 7/20/2023 documents, triple dose of hydrocortisone for illness, nausea, abdominal pain or cramping.
R2's Minimum Data Set, dated , 12/22/2023 documents, R2 is cognitively intact for cognition for activities of daily living. The MDS documents, she uses a walker and is independent.
R2's Medication Administration Record, (MAR), for January 2024 does not document any order for triple dose of hydrocortisone PRN for
illness, nausea, abdominal pain or cramping.
R2's MAR for February 2024, does not document, any Physician Orders of triple dose of hydrocortisone was administered to R2.
R2's Progress Notes, document, she was in the hospital from [DATE] to 2/5/2024 and 2/17/2024 to 2/22/2024.
R2's Progress Notes dated, 2/16/2024 at 9:57 AM, SSD, (Social Service Director), was asked to speak to the resident's daughter, (V6) via phone, to set up a Care Plan Meeting. Writer offered to set up the meeting and (V6) indicated she wanted to talk about her mother's current presentation and the need to send her to the hospital now. Using strength-based validations, SSD attempted to focus on the specific areas that were of concern at this time. (V6) indicated the fall from this morning, and overall decline in functioning without a change in her medications as recommended by the Endocrinologist, have resulted in the request to send the resident to the hospital. SSD continued, the conversation with the resident present and she was in agreement to go to the hospital. SSD will f/u, (follow up), with the floor Nurse to confirm the request to send the resident to the hospital.
R2's Endocrinology, Progress Notes dated, 12/20/2023: documents DX; Left 1-adrenalectomy for cortisol producing adrenal nodule 13, January 2023. 2- Secondary Adrenal insufficiency resolved with return of pituitary ACTH production, 3-Primary adrenal insufficiency, 4-Multinodular goiter/hyperthyroidism. (None of these dx are in the POS for the facility). Hospital records, also documents, Triple the dose of hydrocortisone for illness, nausea abdominal pain or cramping. Illness and increase in hydrocortisone will likely require increase in insulin.
On 2/29/2024 at 3:09 PM, R2 stated, I got out of the hospital on Monday. I went because two weeks prior I had gone to (Hospital) I remember the Nurse coming in and saying that I had to go to the hospital, and he was telling me my whole face, arms and legs were swollen at that time. I was there for about a week. I came back a couple days and then was sent out again, because the second time I felt really bad and not normal. Aching, hot and cold, body pains, I just felt like I had the flu. All I know is that they almost coded me, then I was in the ICU, (intensive care unit), for a few days. They removed my adrenal glands, because I do not produce cortisol. I am supposed to take hydro cortisol every day. My Endocrinologist called them and sent them a fax that they should increase my dosage and the facility did not increase my cortisol and they are thinking that is why I ended up at the hospital. I just got out of the hospital, and they said I had a bad UTI. I wanted to go to the hospital before a few days night before and called my daughter and said something about the ambulance because they did not think I was bad enough but if she wanted to take me then she could take me to (hospital). Then two days later it was snowing, and I went over to (Hospital) and they said I had a UTI, (urinary tract infection). I have been here since 6/19/2023. I am starting to feel better.
On 3/1/2024 at 12:32 PM, V27, Pharmacist stated, I would expect all Physician orders to be followed, all medications to be administrated per Physician orders. All medications should be given per Physician orders. Any medication not given I would say should be given.
On 3/1/2024 at 1:13 PM, V23, Physician Internal Medicine Endocrinologist stated, The facility should have been following my orders and (R2) should have been receiving the hydrocortisone due to her medical condition and her issues with her adrenal gland. I would consider this a significant medication error and it could have easily contributed to her having to go out to the hospital and having a urinary tract infection.
R2's Hospital Records dated 2/16/2024 documents, Patient has a history of recurrent UTI, (urinary tract infection). Recent admission on [DATE] to 2/5/2024, patient developed UTI and urosepsis.
The Facility Physician Order Policy with a revision date July 2014 documents, It is the policy of the (Facility) that physician a orders will be obtained by a licensed personnel and followed. If those orders are not followed for any reason, the Physician and Director of Nursing will be promptly notified.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure showers were being given for 7 of 8 residents (R3, R6, R7, R8...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to ensure showers were being given for 7 of 8 residents (R3, R6, R7, R8, R9, R10, R11) reviewed for showers in the sample of 24.
Finding include:
On 2/23/2024 at 11:38 AM, V4, Ombudsman stated, I am not sure what is happening in the facility. I have been getting several complaints from multiple residents about not getting showers. I have approached the Administrator on several occasions because every time I go out to the facility there is another person complaining about it. When I ask the Administrator what is going on she tells me she does not understand and has no reason why the showers were not being done. I am not sure why this is happening, and residents are not getting their showers.
1-R7's Minimum Data Set, (MDS), dated [DATE] documents, R7 was moderately impaired for decision making of activities of daily living. R7 was documented as using a wheelchair.
R7's Care Plan 2/22/2022 documents, R7 is limited in ability to transfer self-related to decreased mobility, episodes of vertigo and decreased safety awareness.
On 2/23/2024 at 1:39 PM, R7 stated, My biggest concern is that we are not getting our showers anymore. I hate to complain but I feel better when I get a shower. I think they need more help because there is not enough staff to give everyone their showers.
2-R6's Minimum Data Set, (MDS), dated [DATE] documents, R6 was cognitively intact for decision making of activities of daily living. He is in a wheelchair and required substantial/maximal assistance from staff for shower/bath.
R6's Care Plan dated 7/11/2023 documents R6 has impaired mobility related to his diagnosis of impaired mobility and related to his diagnosis of obesity, and weakness. Approach: Assist as needed.
On 2/23/2024 at 4:20 PM, R6 stated his biggest issue is the facility does not have enough staff and they are no longer getting their showers. There is only one staff member, and they will put you to bed but they do not have enough time to get you a shower. I have had two brain surgeries but still know I did not get my shower like I am supposed to.
3-On 2/23/2024 at 4:24 PM, R10 stated, My biggest issues are that we are not getting showers. Why are we not getting our showers?
4-R8's MDS dated [DATE] document R8 was cognitively intact for decision making in activities of daily living. R8's MDS also documents she has a left hemi-arthroplasty revision and diagnosis of cancer. R8 is receiving ADL, (Activities of Daily Living), therapy and Restorative therapy for her bed mobility.
On 2/23/2024 at 4:28 PM, R8 stated, she was not getting her shower getting residents their showers.
5- R3's MDS dated [DATE] documents, R3 was cognitively intact for decision making in activities of daily living.
R3's Care Plan dated 8/4/2023 for ADL's documents, R3 needs limited/extensive assist for ADL's related to cervical disc degenerations.
On 2/26/2024 at 4:32 PM, R3 stated, he was not getting his showers like he was supposed to get. He said he has told the staff and the ombudsman that this is a problem.
Grievance dated 12/29/2023 documents, for (R9), Family visited resident in new room, (V6) visits several times during the day. (R9) has not been showered or had a change of clothes.
Grievance dated 2/5/2024 by R11 documents, Resident reports he wanted his shower in the morning, however, the floor CNA were unable to give shower until later in the afternoon. Resident reports he 'might as well forget it.'
Grievance for R18 dated 1/25/2024 documents, Wife states, also reports he hasn't' had a shower in two and half weeks.
Grievance for R22 dated 1/25/2024 documents, Resident states it has been 3 weeks since she had a shower. She states she is told this is due to staffing issues. Action Taken: Education provided on process of showers to be followed.
The Resident Right Policy with a revision date of 10/2017 documents, 'The resident has the right to a safe, clean comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety.
Nov 2023
3 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 interview, and record review, the facility failed to supervise a resident that is a high risk fall falls while toiletin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to supervise a resident that is a high risk fall falls while toileting for 1 of 3 (R7) residents reviewed for falls in the sample of 9. This failure resulted in R7 falling and sustaining a fracture to T12.
Findings Include:
R7's Face Sheet documents an admission date of 11/8/2023. Diagnosis to include Acute Coronary Thrombosis not resulting in Myocardial Infarction, Vitamin B12 Deficiency Anemia due to intrinsic factor deficiency, Transient ischemic Attack (TIA), and Cerebral Infarction without residual deficits, Weakness, Pain in Left Leg and Hypertension.
R7's care plan dated 11/12/2023 documents R7 is new to facility and needs time to acclimate to facility life, favorite act. is playing bingo. Interventions include: Inform R7 of upcoming activities by: provide activity calendar, verbal reminders, encouragement.
R7's Minimum Data Set, MDS not yet finalized.
R7's fall risk assessment dated [DATE] documents R7 is high risk for falls.
R7's Progress Notes dated 11/12/23 documents in part, Resident is A & O (Alert and oriented) x 2/3, verbal & able to make needs known. Resident has L (left) sided weakness due to an old CVA; drop foot noted as well with brace in place. Resident noted to have slurred speech upon admission
R7's progress notes dated 11/14/2023 at 4:32 PM by V3 (Licensed Practical Nurse) documents this nurse was called to R7's room. Upon entering room, R7 noted to be on floor in bathroom, next to toilet. R7 stated she fell trying to get to toilet from wheelchair, stating her wheelchair was unlocked. R7 reported hitting right side of head but denied pain. no visible injuries noted by writer upon assessing area. R7 alert/orientated at baseline. Able to move all extremities at baseline. Writer attempted to obtain post fall vitals, R7 refused. Writer educated R7 on importance of using call light system for assistance when needed, and importance of locking wheelchair when ambulating from wheelchair. Understanding verbalized by resident. R7 then requested to go to hospital related to fall. Sent to hospital.
R7's progress notes dated 11/17/2023 at 10:23PM document R7 returned from hospital at this time. R7 able to make needs known, speech garbled from previous Cerebral Vascular Accident, CVA. R7 transferred to bed with assist x 2. Denies pain. skin warm dry and intact. Left sided weakness noted.
R7's History and Physical dated 11/14/2023 documents, R7 presented to local hospital after sustaining an unwitnessed fall at nursing home. R17 stated that she fell while transferring out of her wheelchair in the restroom. Soon after wards R7 started complaining of left hip and [NAME] pain. Impression of CT scan: Acute appearing fracture of T12 with 25% loss and no retropulsion. Operative findings document T12 kyphoplasty with spine jack 8cc of freshly made bond cement was instilled in T12 vertebral body.
On 11/21/2023 at 12:00PM, V2 (Director of Nursing) stated, I think what happened with R7 was inadequate footwear and not locking wheelchair.
On 11/21/2023 at 11:10AM, V13 stated, I was the CNA working when R7 fell recently. I had her in the restroom and I was assisting her roommate with something. R7 must've gotten up and she fell to the floor. She had her shoes on. She just got up.
On 11/21/2023 at 3:00PM, V3 ( Licensed Practical Nurse) stated, From what I remember that day, (V13) came and got me and R7 was on the floor in the bathroom. (V13) said R7 was in the bathroom and (V13) was helping the roommate. R7 tried to get up and fell. I think she just got impatient and tried to get up herself and fell.
On 11/22/2023 at 10:00AM, V15 (Nurse Practitioner) stated, Since R7 was assisted to the restroom, the staff member should've stayed in the restroom and provided supervision.
Facility's fall policy dated 7/2017 states It is the policy of (Facility Name) to assess and manage resident falls through preventions, investigation, and implementation and evaluation of interventions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform timely incontinent care for 2 of 3 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform timely incontinent care for 2 of 3 residents (R1, R2,) reviewed for Activities of Daily living in the sample of 9.
Findings Include:
1. R1's Face Sheet documents an admission date of 3/30/2022. Diagnosis includes: History of Malignant Neoplasm to Bladder, Right Below the Knee Amputation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease
On 11/16/2023 at 11:40AM, R1 stated to V3 CNA and V4 LPN that she was dirty with a bowel movement (BM). V3 nor V4, did not do incontinent care while in room. At 12:00PM V7, CNA, completed incontinent care to R1. No issues noted.
R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive impairments and is frequently incontinent of bowels. MDS dated [DATE] documents R1 requires extensive assist with bed mobility, transfers, and toileting.
R1's care plan updated 7/11/2023 documents Requires assistance with Toileting for BM and requires assist with urostomy care.
2. R2's Face Sheet documents an admission date of 6/16/2023. Diagnosis include Congestive Heart Failure, Dysuria, Pressure Induced Deep Tissue Damage of Right Heel Pressure of Left Heel Stage 2, Pruritis.
On 11/16/2023 at 11:20AM, R2 stated I am wet right now, and I am supposed to get a shower. I haven't been changed since 5:00am. R2 noted to be sitting in bed at an awkward angle with legs dangling off bed and very slumped down in the bed.
On 11/16/2023 at 11:30AM V3, LPN, went into R2's room. V3 stated to R2 Why are you sitting this way in the bed? R2 replied she was waiting for a shower. V3 left room without assisting R2 to reposition or to provide incontinent care. At 12:00PM V4, CNA, and V7, CNA, assisted R2 from bed to shower chair. R2 was visibly wet and had feces falling to the floor when transferred.
R2's MDS dated [DATE] documents R2 has no cognitive impairments and requires extensive 2+ assist with bed mobility and transfers. R2 is always continent of bladder and frequently incontinent of bowel.
R2's care plan dated 7/27/2023 documents R2 is at risk for impaired skin integrity related to incontinent of bowel and bladder and decreased mobility.
On 11/16/2023 at 11:10AM V4, CNA, stated We only have 2 CNA's on this hall, and this is the heaviest hall. I am still doing showers that were supposed to be done yesterday.
On 11/16/2021 at 3:00PM, V1 (Administrator) and V2 (Director of Nursing) state they would expect incontinent care to be completed on an every 2 hour basis.
Facility Perineal Care policy dated 7/2017 states, The purpose of this procedure is to provide cleanliness and comfort to the residents and to prevent infections and skin irritation, and to observe the resident's skin condition.
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 F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ostomy care consistent with professional stan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ostomy care consistent with professional standards of practice for 2 of 2 residents (R1, R4) reviewed for ostomy care in the sample of 9.
Findings include:
1. R1's Face Sheet documents an admission date of 3/30/2022. Diagnosis includes History of Malignant Neoplasm to Bladder, Right Below the Knee Amputation, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease.
On 11/16/2023 at 11:15AM, V4(Certified Nursing Assistant/CNA) came into R1's room. V4, CNA, stated to R1 Lets drain your ostomy bag. When V4 pulled down R1's sheet, V4, CNA, stated I have never seen a dressing on there before.
Surveyor observed an abdominal pad over stoma site. V4, CNA, stated, I will have to get the nurse. V4, CNA, and V3, Licensed Practical Nurse, LPN, came into room within minutes. V4, LPN, removed abdominal pad. Dark yellow drainage noted on abdominal pad. Skin around stoma site appeared dark red and irritated. V3, LPN, began to clean stoma site and reapply urostomy bag. R1 complained of pain and cried out OWWWW, Don't Do That Again, during cleaning of site. R1 denied knowing who applied the abdominal pad and not the urostomy bag.
R1's Minimum Data Set, MDS, dated [DATE] documents R1 has no cognitive impairments and is frequently incontinent of bowels. MDS dated [DATE] documents R1 requires extensive assist with bed mobility, transfers, and toileting.
R1's care plan updated 7/11/2023 documents R1 has ileo-conduit to divert urine related to history of bladder cancer. R1 at times will rip off her urostomy bag herself increasing risk for urinary tract infection, UTI. Interventions include check the stoma every shift. Record the size, color, presence/absence of skin breakdown, presence/absence of infection. Document urinary output every shift Record the amount, type, color, odor. Observe for leakage. Check the skin surrounding the stoma every shift. Record condition of skin, presence/absence of breakdown, rash, infection.
On 11/16/2023 at 11:20AM, V3 stated. I don't know who put this pad on here (R1). I did not get the message passed to me that only a pad was over her stoma site and not a urostomy bag.
On 11/16/2023 at 2:20PM, V2 (Director of Nursing/DON) stated, I know about the abdominal pad over R1's stoma site. The nurse that was working overnight must not have known where the extra stoma bags were. I will do some education for her. She also has a bit of a language barrier.
2. R4's Face Sheet documents an admission date of 6/23/2023. Diagnosis include Chronic Obstructive Pulmonary Disease, History of Colon Cancer, Hypertension, Benign Prostatic Hyperplasia.
On 11/16/2023 at 10:30AM, R4 stated, I have had the colostomy for 20 years. I empty it myself. At this time colostomy bag appeared full.
On 11/16/2023 at 3:00PM no orders documented addressing R4's colostomy on order sheet or treatment administration record.
R4's order sheet dated 11/16/2023 at 3:27PM documents, Change Colostomy bag every week and as needed. Once a day on Friday AM daily 08:00 AM - 10:00 AM.
On 11/16/2023 at 11:00AM, V6 (Registered Nurse/RN) stated, We do colostomy bag changes on an as needed basis. R4 will drain his own. He has had a colostomy for many years.
On 11/17/2023 at 8:00AM, V2 stated We did not have an order for R4's colostomy care. We have it now and added it.
Facility policy dated 7/2017 states, The purpose of this procedure is to promote cleanliness, and to protect the peristomal skin from irritation, breakdown, and infection.
Facility policy dated 7/2014 states, It is the policy of (Facility Name) that residents with a colostomy receive care to prevent skin irritation.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications as ordered by the physician for 1 of 6 resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer medications as ordered by the physician for 1 of 6 residents (R3) reviewed for pharmacy services in the sample of 13.
Findings include:
R2's Face Sheet, undated, documents R2 has the following diagnoses: Hyperlipidemia, Seizures, Heart Disease, Major Depressive Disorder and Pneumonia.
R2's Minimum Data Set, dated [DATE], documents R2 is cognitively intact.
R2's Care Plan, dated 5/4/22, documents R2 receives scheduled medications for seizure disorder and to administer medications as ordered.
R2's Medication Administration Record (MAR) documents the following physician orders: 8/13/23 through 8/21/23 - Augmentin (Amoxicillin Clavulanate) 875 milligrams (mg)/125 mg twice daily (BID) for Pneumonia; 8/22/23 through 8/31/23 - Augmentin 875 mg/125 mg BID for Pneumonia; 10/6/22 - Atorvastatin 20 mg daily (Qd); 12/13/22 - Venlafaxine 37.5 mg Qd; 10/6/22 Valproic Acid 250 mg give 3 tabs every 8 hours.
R2's MAR goes on to document the following information: Augmentin was not given 13 times from 8/13/23 through 8/21/23; Atorvastatin was not given 15 times in August 2023, 18 times in September 2023 and 5 times from 10/1/23 - 10/18/23; Valproic Acid was not given 3 times in September 2023. All medications were documented as not administered due to medication not being available.
R2's Progress Notes document the following: 8/13/2023 at 4:01 AM, Resident returned to facility from emergency room with a new order for Ondansetron and Augmentin. Discharge paperwork states antibiotic is for aspiration pneumonia. Orders entered; 8/13/2023 at 6:07 PM, Resident was placed on Amoxicillin for pneumonia, but has not received antibiotic; 8/22/2023 at 5:16 PM, Resident is falling asleep all day during activities, eating, and rolling down the hall. Writer asked the resident if he knew what was causing him to fall asleep and he never responded. Will continue to monitor until further evaluation. 8/23/2023 05:53 PM, Resident continues on antibiotic without any complication at this time. History of Present Illness: Patient seen today sitting in wheelchair in activity room. He is alert and oriented, pleasant, and cooperative. Patient denies pain, shortness of breath, nausea, and dizziness. He was started on Augmentin 875/125 mg BID for 10 days with an end date of 8/31/23 for pneumonia.
R2's Progress Note failed to document that the physician or pharmacy was notified that the Augmentin, Atorvastatin, Venlafaxine or Valproic acid was not available and not administered.
On 10/19/23 at 3:15 PM, V2, Director of Nurses, stated when a medication is not available, staff are to notify either her or V5, Assistant Director of Nurses, and they will contact the pharmacy to get the medication. V2 stated if the medication is not given, the nurses should notify the resident's physician.
The Administration of all Medications policy, dated 10/25/2014, documents the policy is to administer medications in a safe and effective manner. The policy documents the physician shall be notified of any held medications.
Sept 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 4 of 4 (R1,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 4 of 4 (R1, R2, R3, R41) residents in the sample of 6.
Findings include:
R1's admission Record undated documents, R1 was admitted to the facility on [DATE].
R1's EMR, (Electronic Medical Record), documents, R1's medical diagnosis includes chronic kidney disease stage 4, atherosclerotic heart disease, chronic peripheral venous insufficiency, morbid obesity, rheumatoid arthritis.
R1's Care Plan dated 03/03/22 documents, Problem: Resident is limited in mobility/functional status and requires the use of (mechanical) lift and 2 attends. Res totally dependent on staff for mobility.
R1's Care Plan dated 03/03/22 documents Problem: Bathing: Independent--Set up--Assist of 1--Assist of 2 Total Assistance dependence -X-N/A.
R1's MDS, (Minimum Data Set), dated 06/02/23 documents, a BIMS, (Brief Interview for Mental Status), score of 15 out of 15. The MDS documents, that R1 requires extensive assistance of one person for bed mobility. R1 is total dependence of two plus persons for transfer. R1 is total dependence of one person for toilet use, personal hygiene, and bathing. R1requires extensive assistance of two plus persons for dressing. R1 is not steady, only able to stabilize with staff assistance.
R1's Facility Grievance form submitted by his wife dated 09/20/23 documents, He did not get a bed bath Saturday. Summary Findings: Resident was given a bed bath on 09/17/23.
R1's Facility Grievance form submitted by his wife dated 09/26/23 documents, Wife reports she spoke to DON two and half weeks ago about resident not receiving showers. States as of today he has not had one. No investigation or resolution documented on grievance form.
R1's Point of Care History dated 08/28/23 to 09/27/23 documents, that resident had a bath/shower on 09/05/23, 09/07/23, 09/12/23, 09/13/23, 09/17/23, 09/19/23, 09/20/23, 09/25/23, and 09/26/23. In 30-days resident has had 9 showers according to facility documentation.
R2's admission Record undated documents, that R1 was admitted to the facility on [DATE].
R2's EMR documents, R2's medical diagnosis includes unspecified Alzheimer's disease, muscle weakness generalized, other reduced mobility, need for assistance with personal care.
R2's Care Plan dated 11/09/21 documents, Problem: Bathing: Independent--Set up--Assist of 1-X- Assist of 2 Total Assistance dependence--N/A.
R2's Care plan dated 02/22/22 documents, Problem: Resident is limited in physical mobility R/T, (related to), decrease mobility of all exts, (extremities), and weakness.
R2's MDS dated [DATE] documents, a BIMS score of 15 out of 15. The MDS documents, R2 requires supervision of one person for bed mobility, locomotion on unit, locomotion off unit, eating, and toilet use. R2 requires limited assistance of one person for transfer, dressing, and personal hygiene. R2 requires physical help in part of bathing activity of one person. R2 is not steady, only able to stabilize with staff assistance.
R2's Facility Grievance form dated 09/20/23 documents, Hasn't had a shower in a week. No investigation or resolution documented on form.
R2's Point of Care History dated 08/28/23 to 09/27/23 documents, that resident had a bath/shower on 08/30/23, 09/07/23, 09/09/23, 09/10/23, 09/11/23, 09/12/23, 09/17/23, and 09/27/23. In 30 days, Resident has had 8 bath/showers.
R3's admission Record undated documents, that R3 was admitted to the facility on [DATE]. R3's EMR documents, that R3's medical diagnosis includes Diagnosis: Rheumatoid arthritis, weakness, other reduced mobility, need for assistance with personal care.
R3's Care Plan dated 09/02/22 documents Problem: Bathing: Independent--Set up--Assist of 1-X-- Assist of 2 Total Assistance dependence--N/A.
R3's MDS dated [DATE] documents, a BIMS score of 14 out of 15. The MDS documents, that R3 requires extensive assistance of one person for bed mobility, dressing, and personal hygiene. R3 is total dependence of one person for bathing.
R3's Facility grievance form dated 09/12/23 documents, Resident also states, she isn't getting bed baths. No investigation or resolution documented, for shower on form.
R3's Point of Care History dated 8/28/23 to 09/27/23 documents, that resident received a bath/shower on 08/30/23, 09/14/23, 09/19/23, 09/21/23, and 09/26/23. In 30 days, resident has had 5 showers.
R41's admission Record undated documents, that R41 was admitted to the facility on [DATE].
R41's EMR documents, that R41 medical diagnosis includes Diagnosis: Paraplegia unspecified, urinary tract infection, pressure ulcer of unspecified buttock stage 2.
R41's Care Plan dated 05/30/23 documents, Problem: Resident is totally dependent on nursing for all aspects of care R/T limited mobility, decreased strength, and disease process. R41's MDS dated [DATE] documents, a BIMS score of 15 out of 15. The MDS documents, that R41 is total dependence of two plus persons for bed mobility and transfer. R41 is total dependence of one person for dressing, eating, toilet use, and personal hygiene, and bathing.
R41's Point of Care History dated 08/27/23 to 09/26/23 documents, that resident had a bath on 08/30/23, 09/13/23, and 09/21/23. In 30 days, resident has had 3 baths/showers.
During this investigation, no observation was made of residents getting showers or baths.
On 09/27/23 at 2:14 PM, R3 was observed to have unkempt hair.
On 09/22/23 at 2:19 PM, R41 stated, that he does not get showers. He stated that he received a bed bath about a month ago.
On 09/27/23 at 2:08 PM, R1 stated, that it has been 18 days since he has had a shower or bath.
On 09/27/23 at 2:11 PM, R2 stated, that the staff are getting better with showers. She stated that she had a shower today and has been getting showers twice a week.
On 09/27/23 at 2:14 PM, R3 stated, that she cannot remember when the last time she got shower or bath. She stated that the staff say that the residents refuse but they never ask us if we want a bath or shower. She stated that last time she had shower was a couple weeks ago by her daughter.
On 09/28/23 at 7:50 AM, V2, DON, (Director of Nursing), stated, that she has already started to in-service her staff and put a plan of correction in place for showers.
Facility policy Bathing a Resident dated July 2014 documents, It is the policy of (Facility) that residents will receive a shower/bath will be scheduled regularly and PRN.
Aug 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician in 4 of 7 residents (R1, R2, R4 and R6) reviewed for medication administration in the sample of 9.
Findings include:
1. R1's Medication Administration Record (MAR), documents R1 is on the following medications: 6/22/23 thru 7/15/23 - Erythromycin 5 milligrams (mg)/gram (gm), administer to the left eye three times daily (TID) for Cellulitis of the Left Orbit; 7/7/23 - Amlodipine 10mg daily for Hypertension (HTN); 6/12/23 thru 6/22/23 - Gentamicin 0.1% apply to left eye TID for acute Angle Closure Glaucoma. R1's MAR goes on to document Erythromycin was not given 5 times as ordered from 6/22/23 thru 7/15/23 due to the medication not being available, Amlodipine was not given 10 times in 6/2023 due to the medication not being available and Gentamicin was not given 8 times in June 2023 due to the medication not being available.
2. On 8/3/23 at 8:50 AM, R2 stated, they frequently run out of her pain medications, so she was having to stash them so she could get pain relief when she was out, but they found them and took them out of her room. R2 stated the last time they ran out was this past Sunday (7/30/23).
R2's Face Sheet, undated documents R2 has the following diagnosis: Rheumatoid Arthritis, Osteoarthritis, Pain, Diabetes and HTN.
R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact.
R2's MAR, documents the following orders: 10/7/22 - Hydrochlorothiazide (HCTZ) 12.5mg daily; 2/24/23 - Prednisone 10 mg daily; 10/7/22 - Tradjenta 5mg daily, 5/9/23 - Sucralfate 1gm four times daily (QID); Hydrocodone 5/325mg every 4 hours. The MAR goes on the document HCTZ was not given 3 times in 7/2023 due to the medication not being available, Prednisone was not given 4 times in 6/2023 due to the medication not being available, Tradjenta was not given once in 6/2023 and twice in 7/2023 due to the medication not being available, Sucralfate was not given 8 times in 6/2023 due to the medication not being available and Hydrocodone was not given 6 times in 6/2023 and 3 times in 7/2023 due to the medication not being available.
R2's Care Plan, dated 9/2/22, documents R2 is at risk for increased pain due to Rheumatoid Arthritis, has Rheumatoid Arthritis and was admitted with an oral steroid, is at risk from complications due to Diabetes and to administer medications as ordered.
3. R4's MAR, documents R4 is on the following medications: 3/15/23 - Hydroxyzine 25mg give 1/2 tablet twice daily (BID) for Generalized Anxiety Disorder; 7/26/23 thru 8/1/23 - Doxycycline 100mg BID for Cellulitis; 10/25/23 - Potassium Chloride 40 milliequivalents (meq)/15 milliliters (ml) BID for Edema; 1/5/22 - Atorvastatin 10mg daily for Hyperlipidemia; 11/5/22 - Furosemide 80mg BID for Edema; and 5/25/23 - Carvedilol 3.125mg BID for Congestive Heart Failure. R4's MAR goes on to document R4 was not given Hydroxyzine 9 times in 6/2023 and 7 times in 7/2023 due to medication not being available, Doxycycline as not given twice in 7/2023 due to medication not being available, Potassium Chloride was not given 5 times in 6/2023, Atorvastatin was not given 5 times in 6/2023, Furosemide was not given 5 times in 6/2023 and Carvedilol was not given 3 times in 6/2023 and 1 time in 7/2023.
R4's Care Plan, dated 7/11/23, documents R4 is at risk for complications related to edema, has the potential for weakness, fatigue confusion, chest pain, dizziness, syncopal episodes, and palpitations related to cardiac dysrhythmias and to administer medications as ordered.
4. On 8/3/23 at 9:15 AM, R6 stated, via communication device, she has to beg for the midnight nurse to come and give her medicine.
R6's Face Sheet, undated, documents R4 has a diagnosis of Amyotrophic Lateral Sclerosis (ALS).
R6's MDS, dated [DATE], documents R4 is cognitively intact.
R6's MAR documents a physician's order, dated 4/7/23, for Tiglutik 50mg/10ml, administer 10ml every 12 hours. R6's MAR goes on to document the Tiglutik was not given 5 times in 7/2023 due to the medication not being available.
On 8/4/23 at 11:05 AM, V21 (MDS Coordinator) stated if a medication is not available, the nurse can reorder it on the computer, print it out and fax or call the pharmacy to get the medication. V21 stated they do have an electronic medication supply that has some medications available that the nurses can access.
The General Dose Preparation and Medication Administration, dated 1/1/13, documents the facility staff should comply with facility policy, applicable law, and the state operations manual when administering medications and administer the medications within timeframes specified by the facility.
Aug 2023
6 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview the facility failed ensure the initial skin assessment was done in a timely ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview the facility failed ensure the initial skin assessment was done in a timely manner, weekly skin assessments were completed, timely turning and repositioning was done, incontinent care was done in a timely manner, and interventions were put into place to prevent an avoidable pressure ulcer for 1 of 3 (R1) residents who were reviewed for pressure ulcers in a sample of 16.
This failure resulted in R1 developing a sore to her left buttock and her right inner thigh.
Findings include:
On 07/26/23 at 9:45 AM, R1 was observed in 15-minute increments until 11:45 AM, sitting in her bed on her back with the head elevated and R1 leaning to the right side. During this time R1 was not turned, repositioned, or checked for incontinence. At 11:45 AM, V13 (Certified Nursing Assistant/CNA) went into R1's room and lowered the head of her bed. V13 then went out of the room to gather stuff to do incontinent care. R1 remained on her back with her head flat until V13 Came back into the room at 12:05 PM.
On 07/26/23 at 10:14 AM, R1 said, she is leaning towards her right side because, she has a couple areas on her bottom that's sore, and she is trying to take pressure off it. She stated the only treatment they are doing for her bottom is to put cream on it.
On 07/26/23 at 12:05 PM, while V13 (CNA) was observed performing incontinent care on R1, an open area was observed to R1's left buttock, that did not have a dressing on it and it measured approximately 1 centimeter, (cm), x 1cm. The wound bed appeared to be red/granular, no drainage or odor noted. R1 also had an area to her gluteal fold that did not appear to be open, but appeared to be tender when V13 was cleaning the area. This area measured approximately 2.5 cm x 2 cm.
On 07/26/23 at 12:28 PM, R1 stated she didn't have any open areas on her bottom when she came to the facility. She said she had tender spots but no open areas.
R1's Face Sheet, admission date of 06/16/23 at 3:06 PM, documents, R1 diagnoses of Congestive Heart Failure, (CHF), Pain, unspecified, Hypertension, (HTN), Atrial Fibrillation, Rheumatoid Arthritis, and Acute Kidney failure.
R1's Minimum Data Set, (MDS), dated [DATE], documents R1 is cognitively intact and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, toilet use, she is always continent of bladder, frequently incontinent of bowel, is not at risk for developing pressure ulcers, currently has no wounds or other skin problems, and has a pressure reducing device for her chair and her bed.
R1's Care Plan, with a created date of 07/27/23, documents, Problem: Resident is at risk for impaired skin integrity r/t, (related to), incontinent of B&B, (bladder and bowel), and decreased mobility. Goal: Resident will have skin remain intact by next review date. Approach: Observe skin conditions with daily care. Provide incontinent care of episodes of incontinence. Report changed to M.D., (medical Doctor), and obtain treatment as ordered as indicated. Weekly body audits.
R1's Braden Scale for Predicting Pressure Sore Risk, dated 07/03/23, documents, R1 is a moderate risk for developing pressure ulcers with a score of 14.
R1's Physician's Orders, dated 06/21/23, documents, Weekly skin check 10p-6a Once a Day on Wed, (Wednesday).
R1's Skin Observation, (weekly skin observation admission/return, (after 30 days), dated 07/22/23 at 9:38 AM, documents, R1 has no skin abnormalities.
Review of R1's Electronic Medical Record, (EMR), has no other documentation of skin assessments being done.
On 07/26/23 at 2:07 PM, V2 (Director of Nursing/DON) stated that she had gone down and got measurements of the wounds.
On 07/27/23 at 2:30 PM, R1's Wound Management, documents, 07/26/2023 at 02:08 PM, Right inner thigh 0.3 cm X 0.3 cm and 07/26/23 at 2:11 PM, documents, Left buttock 1 cm X 0.5 cm.
On 07/31/23 at 12:55 PM, V1 (Administrator) stated she would expect the residents to be turned, repositioned, and incontinent care to be done every 2 hours or as needed and as it was care planned. She would expect the CNAs to report a new skin issue to the nurse immediately and report it to the Doctor, and the Power of Attorney, (POA).
On 07/31/23 at 2:10 PM, V1 (Administrator) stated the skin assessments are scheduled. They are done upon admission and then they go from there. If the person has wounds, they would be care planned and they would have the wound care Doctor to come and see them. If they are high risk weekly assessment the skin assessments are done weekly. If a resident has an order for weekly skin assessments, she expects them to be done weekly.
V1 (Administrator) stated that it could have potentially been avoided. She said R1 is known to refuse care, but that is no excuses for it to not be offered. She said she would expect for it to be offered, at least.
The Facility's Policy Repositioning of Resident, revision date, 05/02/2019, documents Purpose: The purpose of this procedure is to provide guidelines of the assessment of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chairbound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. It further documents General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. It also documents 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. It also documents Interventions/Care Strategies: Turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored, and evaluated.
1. Residents who are in bed should be on a q (every) 2 hour turning program.
2. For residents with a Stage 1 or above pressure ulcer, monitoring of skin condition should occur daily- daily skin checks with weekly documentation of skin condition.
3. If ineffective, the turning and repositioning frequency will be increased.
The Facility's Policy Wound Management Program, revision date, 01/20/2023, documents Policy: It is the policy of this facility to manage resident skin integrity though prevention, assessment, and implementation and evaluation of interviews. It also documents Procedure: 2. The facility will use the Braden Scale on each resident at admission, weekly for four weeks post admission and readmission, and quarterly thereafter to assess skin breakdown risk. It further documents 3. Residents identified at risk on the Braden scale will have this addressed on their care plan and will have interventions put in place for preventative measure. Identifier will be assigned to resident room name plate for risk assessment score. High risk or with any Stage PUI or wound identified will have skin checks daily. All others will have at least a weekly skin check assigned through the Resident Scheduler and documented by the nurse. It also documents 5. The facility will assess residents weekly for current skin conditions. A. The charge nurse for each hall will do skin assessments. A schedule will be established to identified room/bed day and shift. Refer to the Weekly Skin Assessment Sample schedule for direction. The facility is active on HER, (Electronic Health Record), they will complete the skin assessment as assigned on the TAR, (Treatment Administration 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on interview, observation, and record review, the facility failed to maintain residents' dignity by staff being on their cell phones and/or ear buds during their shift and while caring for the r...
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Based on interview, observation, and record review, the facility failed to maintain residents' dignity by staff being on their cell phones and/or ear buds during their shift and while caring for the resident's needs for 5 of 5 residents (R2, R3, R6, R7, R13) in the sample of 16, but this has the potential to affect all 103 residents in the facility.
Findings Include:
On 7/24/23 at 11:55 AM, R3 stated, The staff are always on their cell phones and will hold a conversation while they are in my room, they just don't care.
On 7/24/23 at 12:10 PM, V5 (Certified Nursing Assistant/CNA) had an ear bud in her right ear while she was caring for R3, and while talking to surveyor.
On 7/24/23 at 12:16 PM, R7 stated the staff are always on their cell phones here. They will stay on it while taking care of me. Not all of them, but most of them.
On 7/24/23 at 12:28 PM, R6 stated the staff are always on their cell phones. The CNA was cleaning me up in bed the other day, and she was talking to someone that sounded like maybe her girlfriend, on her cell phone, while she was cleaning me up.
On 7/24/23 at 12:48 PM, R2 stated that at night, when I visit the nurse's desk, they are all on their cell phones and/or playing games.
On 7/24/23 at 1:12 PM, V8 (Licensed Practical Nurse/LPN) stated the CNAs here are always on their cell phones, mainly in the halls and at the desk. They always have ear buds in and will have conversations with someone while working.
On 7/24/23 at 2:15 PM, V2 (Director of Nursing/DON) stated, We have had some problems with staff being on their cell phones, and I have personally walked a few out. We are working on that problem.
On 7/25/23 at 11:30 AM, V12 (CNA) was seen walking around the facility and caring for residents with her ear bud in her left ear and her cell phone in her pocket.
On 7/25/23 at 3:10 PM, V21 (LPN) was seen sitting at the nurse's desk going through her cell phone.
On 7/25/23 at 3:12 PM, V12 (CNA) was seen sitting at the desk on the XX-hall flipping through her cell phone.
On 7/25/23 at 3:15 PM, V5 (CNA) seen sitting in a chair around the corner, in the living area at the end of the YY-hall, while flipping through her cell phone.
On 7/25/23 at 3:20 PM, R13 stated the staff are always on their cell phones, showing each other pictures and stuff. I watched a nurse who was passing meds tell a resident, she had to get something off her med cart, went to the cart and starting texting on her cell phone.
On 7/24/23 at 2:20 PM, V2 (DON) stated, I don't think we have a policy on cell phone usage.
Reviewed Resident Council Meeting Minutes for past 3 months. On 6/27/23: Some concerns are still an issue. Call lights not answered timely. Showers, CNA lunch breaks, Cell Phone Use.
The Facility's Resident Rights Policy, dated 10/2017, documents, The resident has a right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility, including: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. The facility must protect and promote the rights of each resident. Respect and Dignity: The resident has a right to be treatment with respect and dignity.
The Facility's CMS 672, dated 7/31/23, documents there are 103 residents residing in the 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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide assistance with bathing, grooming, and hygie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide assistance with bathing, grooming, and hygiene to dependent residents for 4 of 8 residents (R2, R7, R9, R14) reviewed for ADL (Activities of Daily Living) care in the sample of 16.
Findings include:
1. R2's admission Record, undated, documents, R2 was admitted to the facility on [DATE].
R2's Electronic Medical Record, documents, R2's medical diagnosis include, Left Artificial Knee Joint, Diabetes Mellitus (DM), Phlebitis and Thrombophlebitis of Left Iliac Vein.
R2's Care Plan, dated 7/18/23, documents, I (do) have pain, Left TKR, (total knee replacement). I will have pain screening on admission, daily, and PRN, (as needed). I will receive comfort measures. I will receive pain medication per Physician/NP (Nurse Practitioner), orders and be observed or report pain medication effectiveness as appropriate or within one hour of receiving pain medication. Interventions: Percocet PRN, Ice PRN Left Knee. It continues Safety: I will need to be monitored to prevent falling in my new environment. I will need (assistance with bed/chair mobility), (assistance with transfers), (assistance with locomotion) to prevent falling or injury. I use a walker. WBAT, (weight bearing as tolerated). It continues Overall I require (limited assistance with oral care; (limited) with eating; (limited) with toileting; (limited) with dressing; (limited) with mobility. I will need (assistance) to have my personal care needs met while supporting my strengths and personal goals. S/P, (status post), left TKR.
R2's Minimum Data Set, (MDS), dated [DATE], documents, R2 is cognitively intact with a BIMS of 15. R2 needs supervision for all ADLs (Activities of Daily Living).
On 7/24/23 at 11:00 AM, V3 (R2's Sister-in-law) stated, My brother-in-law (R2) went into the facility on a Friday (7/14/23) and when I came back to visit him on the following Monday (7/17/23) around 12:00 PM, he still did not have his skin assessment, or a shower done. He basically didn't get anything done until around Wednesday (7/19/23). My sister-in-law was the one helping him walk because, they were not doing it. Every time I went there, I saw the staff just sitting either at the nurse's station or at the end of the halls. They were wearing ear buds and talking on their phones and not taking care of the residents.
On 7/24/23 at 12:48 PM, R2 stated, I have not been cleaned up or showered since I came in here (7/14/23). I'm even wearing the same clothes since I came here. I figured I would change when they clean me up. I was told I can't have a shower since I have a knee dressing. They haven't even given me anything to clean myself in my room. I have washed off my face in the sink but that's about it. My hair is so matted and in knots that you can't get a comb through it.
On 7/24/23 at 12:50 PM, R2 appeared to have long greasy and messy hair, matted on the back side and visible knots. R2 appeared unshaven.
The Facility's Resident Shower Schedule documented, that R2 is scheduled for showers on Wednesday and Saturdays Day shift.
The Facility's Shower Sheets reviewed for the months of June and July with R2 having no shower sheets completed.
2. R7's Face sheet, undated, documents, R7 was admitted to the facility on [DATE].
R7's Electronic Medical Record, documents, R7's medical diagnosis include chronic kidney disease (CKD), Arteriosclerotic Heart Disease (ASHD), Venous insufficiency, Morbid obesity, Polyosteoarthritis, Benign Prostatic Hyperplasia (BPH), and Major depressive disorder.
R7's Care Plan, dated 4/4/23, documents, Problem: Grooming/Hygiene. Interventions: Assist X 2. It continues Problem: Bathing. Interventions: Allow sufficient time to complete bathing, lay bathing items within reach and in the order, they are needed, praise resident for neat appearance. It continues Problem: Resident is limited in wheelchair mobility at present time. Resident requires total assist of staff for placement in chair and mobile r/t resident debility.
R7's MDS, dated [DATE], documents, R7 is cognitively intact with a BIMS of 15. R7 requires total dependent on one to two staff members for transfers, toilet use, personal hygiene, and bathing. R7 requires extensive assistance from one to two staff members for bed mobility, and dressing. R7 is frequently incontinent of both bowel and bladder.
On 7/24/23 at 12:16 PM, R7 stated, I have not had a shower or bed bath for the past two weeks. I'm supposed to have one on Tuesdays and Saturdays. They always have some excuse, like this past Thursday, they told me that the girl that was working my hall left early, and they had no one else to do it. They are short of help here. I might get one twice a month if I'm lucky.
On 7/25/23 at 2:42 PM, R7 appears with greasy hair and dry skin flakes in his hair, and body odor.
On 7/25/23 at 2:44 PM, R7 stated, Well, they told me they changed my shower days to Wednesdays and Saturdays instead of Tuesday and Saturdays, so I'm hoping for one tomorrow. I think it's been about 10 days or so since my last one.
On 7/26/23 at 2:38 PM, R7 lying in bed, appears with greasy hair and dry skin flakes in his hair, slight body odor remains, no shower had been given at this time.
On 7/26/23 at 2:40 PM, R7 stated, Yesterday they told me they changed my shower schedule to today. I'm supposed to get one on day shift and as of now, I still have not received one.
3. R9's Face sheet, undated, documents, R9 was admitted to the facility on [DATE].
R9's Electronic Medical Record, documents, R9's medical diagnosis include CHF, Cognitive communication deficit, COPD, Hyperlipidemia, Major depressive disorder, Type 1 DM, BPH.
R9's Care Plan, dated 5/2/23, documents, (R9) is at risk for falls. Interventions: Provide toileting assistance, keep call light in reach at all times. It continues (R9) is at risk for skin breakdown. Interventions: Assess resident for presence of risk factors, treat reduce, eliminate risk factors to extent possible, encourage physical activity, mobility, and range of motion to maximal potential.
R9's MDS, dated [DATE], documents, R9 is cognitively intact with a BIMS of 13. R9 requires extensive assistance from one to two staff members for all ADLs. R9 is occasionally incontinent of both bowel and bladder.
On 7/25/23 at 2:47 PM, R9 sitting in wheelchair in his room, with a strong body odor, dirty clothes on, very hair greasy and uncombed hair, and unshaven.
On 7/25/23 at 2:49 PM, R9 stated, It's been about six or seven days since I've changed clothes, and my last shower was about 16-17 days ago. They don't even ask me if I want one. I think they just ignore me here.
The Facility's Grievance/Concern/Complaint Forms for past 3 months was reviewed and documents R9 reported to administration that he did not get his scheduled shower on Saturday. Findings: Resident did not get scheduled shower.
Residents Shower Schedule: R9 is scheduled for showers on Monday and Thursday Nights.
4. R14's Face sheet, undated, documents, R14 was admitted to the facility on [DATE].
R14's Electronic Medical Record, documents R14's medical diagnosis include Rheumatoid Arthritis, Anemia, HTN, Type 2 DM, Hyperlipidemia, Osteoarthritis, Falls, GERD.
R14's Care Plan, dated 2/8/23, documents, R16 is on Black Box Medications: Insulin, and Pain. (R16) has scheduled steroid therapy and narcotics as needed per MD order.
R14's MDS, dated [DATE], documents, R14 is cognitively intact with a BIMS of 14. R14 requires total dependence of one staff member for bathing, extensive assistance from one to two staff members for all other ADLs. R14 is always incontinent of bladder and frequently incontinent of bowel.
On 7/26/23 at 10:10 AM, V23 (Social Worker) stated, The residents at the facility haven't been getting their showers. I feel like if I wasn't here to say something, they wouldn't follow through with getting stuff done.
On 7/26/23 at 10:50 AM, R14 was lying in her bed, appeared to have a dirty gown on, her hair appeared to be greasy and stringy, and her fingernails were long and dirty.
On 7/26/23, R14 stated I haven't had a shower since coming to the facility, but they had been giving her bed baths occasionally. The last time I got a bed bath was two weeks ago. The facility doesn't have enough staff. There was one day when they only had one person in the building, and that person had to be the Nurse and the CNA (Certified Nursing Assistant).
On 7/31/23 at 12:35 PM, V20 (CNA) stated, I don't feel like the facility has enough staff working to get tall of my daily task done. I work a 12-hour shift, and I don't think it's right that the residents must wait until later in the day to get a shower. They want to get cleaned up and dressed in clean clothes before then, and sometimes it's hard to get it done with only two staff on the hall.
On 7/25/23 at 2:49 PM, V12 (CNA) stated, We have to fill out a shower sheet every time we give a resident a shower. We document any skin conditions we see on that sheet, and we give that sheet to the nurse working.
On 7/25/23 at 3:20 PM, R13 (Resident Council President) stated, This is the general complaint at every Resident Council Meeting. The facility has a resident shower schedule here, but they never follow it. We do not get our showers here. They always give us excuses like: I don't want to break my nails (long fancy nails), and sometimes will tell us they changed our shower schedule to a different day, so they don't have to do it then.
On 7/25/23 at 3:55 PM, V2 (Director of Nursing/DON) stated, No one has the authority to change their shower schedule, and no one should be doing that. Showers should be given according to their scheduled days and times.
Reviewed Resident Council Meeting Minutes for past 3 months. On 4/25/23: Discussed last month's concerns and getting showers on shower days was still an issue. On 5/22/23: Concerns were discussed and some continue to be an issue. On 6/27/23: Some concerns are still an issue, will write up forms. Call lights not answered timely. Showers, CNA lunch breaks, Cell Phone Use.
The Facility's Bathing a Resident Policy, dated July 2014, documents It is the policy of (this facility) that residents will receive a shower/bath will be scheduled regularly and PRN.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence care for 4 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide timely and complete incontinence care for 4 of 4 residents (R1, R3, R4, R5) reviewed for incontinence care in the sample of 16.
Findings include:
1. R3's admission Record, undated, documents, R3 was admitted to the facility on [DATE].
R3's Electronic Medical Record, documents R3's Diagnosis include: Hemiplegia/Hemiparesis, HTN, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, (COPD), Type 2 DM, (Diabetes Mellitus), Cerebral Infarction, Major depressive disorder, Arteriosclerotic Heart Disease, (ASHD), Benign prostatic hyperplasia, (BPH), Peripheral Vascular Disease, (PVD), Anemia, Chronic Kidney Disease, (CKD), stage 2, Gastroesophageal Reflux Disease, (GERD), Deep Vein Thrombosis, (DVT), Dysuria, Pneumonia, Vascular Dementia, COVID-19, Pressure Ulcer buttock, Right Below Knee Amputation, (RBKA), Left Below Knee Amputation, (LBKA), Contracture left hand, Polyneuropathy.
R3's Care Plan, dated 6/21/23, documents, (R3) unable to independently change position while in bed as evidenced by not being able to turn, sit up, or move to head of bed. Interventions: Place resident in restorative nursing program. It continues (R3) is limited in physical mobility r/t, (related to), bilateral amputation, chair bound hemiplegia. Interventions: Place resident in restorative nursing program. It continues (R3) is limited in physical mobility r/t hemiplegia and amputation. (R3) utilizes electric w/c, (wheelchair), It continues (R3) is incontinent at times. Prefers to use urinal while in bed, incontinence briefs or pads. Interventions: Provide X's, (times), two assistances for toileting, apply moisture barrier to skin, provide incontinence care after each incontinent episode, use briefs while (R3) is out of bed, ensure adequate bladder and bowel elimination.
R3's Minimum Data Set, (MDS), dated [DATE], documents, R3 is cognitively intact with a BIMS of 14. A score of 13-15 indicates an Intact cognitive response, 8-12 a Moderate Impairment, and a 0-7 a Severe cognitive Impairment. R3 requires total dependence of two staff members for bed mobility, transfers, dressing, toilet use, and bathing, requires extensive assistance from one staff member for personal hygiene. R3 is always incontinent of both bowel and bladder.
On 7/24/23 at 11:15 AM, V4 (R3's Sister) stated, When I talk to my brother (R3), he would tell me that he is in bed all day and that he doesn't get washed up all the time. My complaint is that he has a stage one or two sore on his butt and his right leg and if they were taking care of him, he shouldn't be getting these. I visit him at least twice a week and every time I come in, he is always sitting in his chair, and I think he sits in his chair all day. I don't think they reposition him while he is in his chair or check him to see if he is wet/soiled.
On 7/24/23 at 12:10 PM, V5 (Certified Nursing Assistant/CNA) stated, I know (R3) stays in bed all morning and we get him up after breakfast around 11:30 and will clean him at that time. (R3) will get back in bed and cleaned up again sometime after lunch. If he wants to stay in his chair, which he does a lot, we will put him back in his chair. (R3) will usually use his call light when he needs something or will drive out his door to get someone.
On 7/24/23 at 1:50 PM, R3 remains in his wheelchair watching television. R3 stated No one has checked me or cleaned me up since the morning, when I got out of bed. I will get back in bed after dinner, and they will clean me up at that time.
On 7/26/23 at 8:43 AM, R3 stated, I was cleaned up last night when they put me to my bed. I don't think they checked me or cleaned me up after that, and I have not been cleaned up or been out of bed yet this morning. I will get up around 11:15 AM or so to my chair, and that is when they usually clean me up. I am not sure if I am wet now or not.
2. R4's Face sheet, undated, documented R4 was admitted to the facility on [DATE].
R4's Care Plan, dated 6/22/23, documents (R4) is at risk for impaired skin integrity r/t incontinent of B&B, (bowel and bladder), decreased mobility, and history of wounds. Interventions: Observe skin condition with daily care, weekly body audit, provide incontinence care for episodes of incontinence, assist with mobility and transfers. It continues (R4) is totally dependent on nursing for all aspects of care r/t limited mobility, decreased strength, and disease process. Interventions: Turn and reposition while in bed or chair for comfort, observe skin condition with daily care, provide incontinence care for episodes of incontinence, provide daily care for resident.
R4's MDS, dated [DATE], documents R4 is cognitively intact with a BIMS of 13. R4 requires total dependence on two staff members for bathing, toileting, transfers, and bed mobility. R4 requires extensive assistance from one to two staff members for personal hygiene and dressing. R4 is always incontinent of both bowel and bladder.
On 7/24/23 at 1:35 PM, R4 was lying in bed and was saturated in urine, including his gown and his incontinence pad on the bed.
On 7/24/23 at 1:38 PM, R4 stated, I was last cleaned up around 2:00 AM this morning. Now I'm soaked. I put my call light on, and someone came in and turned it off and didn't clean me. They have no staff here.
On 7/25/23 at 11:32 AM, R4 stated I was last cleaned up (incontinent care) between 3:00 and 4:00 AM this morning. I peed at that time and put my call light on, and they came and changed me, and that was the last time anyone checked me. I am wet now. I peed earlier this morning around 8:30 AM, and I put my call light on and (V12, CNA), came in and shut it off and said she would be back and has not come back in yet. I still have not gotten out of bed yet, I have asked, and they always tell me they don't have enough time or help to do it.
On 7/25/23 at 11:34 AM, V13 (Certified Nursing Assistant/CNA) stated, V12 (CNA) did go in and shut off (R4's) call light and told him she would be back after she's done with another resident. We just don't have the help. I've been doing showers this morning and (V12) has been answering lights and helping the residents.
On 7/25/23 at 12:22 PM, V12 (CNA)and V14 (Certified Nursing Assistant/CNA) entered to perform incontinent care and to get R4 out of bed. Both CNAs donned gloves with no hand hygiene performed. V12 wet a few washcloths in the restroom sink, R4's sheet was pulled off, his hospital gown removed. R4's saturated brief was unfastened and tucked between his legs. V12 used a wet washcloth sprayed with peri-wash and briefly wiped over R4's pubic area, both groins, penis, and scrotum using one washcloth. There was no drying of R4 seen. R4 was turned to his left side, and the soiled brief was pulled out. V14 wiped R4's anal area and buttocks and he was rolled to his right side. A clean incontinence brief was put on R4 and fastened, his pants were pulled up and the (full body mechanical lift) sling was placed under him, all while both CNAs used the same soiled gloves used for incontinence care. V12 doffed her gloves and went to get the full body mechanical lift device, while V14 gathered trash and soiled linen and left room with same soiled gloves on. Both CNAs returned with the full body mechanical lift and attached it to R4's sling. R4 was lifted off the bed and transferred to his wheelchair. Both CNAs doffed their gloves and left the room with no hand hygiene performed after care.
3. R5's Face sheet, undated, documents R5 was admitted to the facility on [DATE].
R5's Electronic Medical Record, documents R5's medical diagnosis include
Amyotrophic lateral sclerosis, and Anxiety disorder.
R5's Care Plan, dated 6/21/23, documents (R5) Requires (Brand name) Urine Collection System R/T Dx, (diagnosis), urinary incontinence. Interventions: Change (Brand name) Urine Collection System as ordered and PRN, (as needed). It continues (R5) requires assistance with Toileting Resident requires bedpan for BM (bowel movement) and utilizes indwelling catheter r/t urinary retention, total dependence from staff. Interventions: Total dependence. It continues (R5) is at risk for skin breakdown r/t immobility, dependent on staff for repositioning, incontinent of bowel. Interventions: Report any signs of skin breakdown (sore, tender, red, or broken areas), use moisture barrier product to perineal area and buttocks after each incont., (incontinence), episode and PRN, provide incontinence care after each incontinent episode, turn and reposition at least every two hours as resident allows and tolerates, keep clean and dry as possible, minimize skin exposure to moisture.
R5's MDS, dated [DATE], documents, R5 is cognitively intact with a BIMS of 15. R5 requires total dependence from one to two staff members for all ADLs. R5 is always incontinent of bladder and frequently incontinent of bowel.
On 7/24/23 at 1:20 PM, V9 (R5's daughter) stated, We've been having some issues here. When I come in to visit my mom, she's soaked in urine, her hospital gown and all. They are so short staffed around here. They never come in when they are supposed to take care of mom.
On 7/25/23 at 11:40 AM, V12 (CNA) and V13 (CNA) in R5's room providing incontinent care.
On 7/25/23 at 11:42 AM, V9 (R5's daughter) seen in R5's room and stated, This is the first-time mom has been cleaned up this morning. They haven't had enough help to get things done.
On 7/25/23 at 11:42 AM, V12 (CNA) and V13 (CNA) were getting ready to provide incontinence care for R5. Both CNAs donned gloves with no hand hygiene performed prior. R5's gown removed, and her incontinence brief tucked between her legs. V12 used a wet washcloth and wiped once across her pubic area, once down each groin, then using same washcloth, once down the middle of R5's vagina. R5 was turned to her left and the saturated incontinent brief was pulled out, R5's sheet was also wet under her, and feces was seen in her buttock/anal area. V13, doffed her gloves and left the room to get clean linen, then re-entered and donned gloves with no hand hygiene performed before leaving the room or upon reentering the room. R5 was turned to her left side again, and V13 wiped R5's anal area to remove feces. Using the same soiled gloves, V13 placed the clean linen on the bed. R5 was not dried at any point in this care. R5's soiled brief was tucked under her, and she was rolled to her right side and the soiled linen and brief was removed. There was no wiping of R5's buttocks before putting clean incontinence brief under her. V13 used the same soiled gloves to put cream on R5's buttocks and anal area. V12 and V13 used their same soiled gloves used for incontinent care to put a clean gown, clean linen, and pillows on and around R5. Both CNAs doffed their gloves and left the room without any hand hygiene performed during entire incontinence care.
On 7/26/23 at 10:38 AM, V24 (RN/Hospice) stated, that R5 has had some issues with getting cleaned up in a timely manner. R5 stated, she hadn't been cleaned up since yesterday at 3:00 PM. V24 stated she has been through all of this before when she talked with another surveyor, and when she talked with the ombudsman. V24 stated, it takes a long time for them to come in and clean her up. V24 stated that the agency staff will clean her up, but they don't put any ointment on her bottom after cleaning her.
On 7/31/23 at 12:35 PM, V20 (CNA) stated she doesn't feel like the facility has enough staff working to get tall of her daily task done. V20 stated, the residents should be checked for incontinence at least every two hours, and sometimes it hard to get it done with only two staff on the hall.
4. On 7/26/23 at 12:05 PM, V13 (CNA) was observed doing incontinent care on R1 at this time. No hand hygiene was performed prior to gloves being donned. V13 took several wash clothes to the bathroom and wet them after placing some peri wash on a few of the washcloths. V13 unfastened R1's incontinent brief and pushed it down between R1's legs. V13 took a wet washcloth and wiped R1's lower abdomen and under R1's abdominal fold, with the same washcloth and then wiped down each side of R1's groin area with the same washcloth. V13 then got a new wet washcloth and continued to clean R1's groin area. She then used the same washcloth and wiped down the middle, (outer labia), and the washcloth was noted to have a small amount of bowel movement, (BM), on it. V13 failed to separate the labia and clean the inner labia. V13 then assisted R1 onto her left side, (no glove change was performed). R1's incontinent brief was wet with urine and soiled with BM. V13 then took the soiled incontinent brief from between R1's legs and rolled it up and tucked it under R1, along with the incontinent pad. V13 used a clean wet washcloth to clean the BM from R1's buttocks. V13 folded the washcloth and continued to use the dirty washcloth to clean more BM from R1's buttocks. V13 then got a clean wet washcloth and wiped R1's gluteal cleft, she then folded the washcloth that had BM on it and continued to clean R1's gluteal cleft. V13 then got another clean washcloth and cleaned R1's bottom until it was clean. V13 failed to rinse and dry any of the areas of incontinence, prior to placing a clean incontinent brief on R1.
R1's Face Sheet, admission date of 06/16/23 at 3:06 PM, documents, R1 diagnoses of Congestive Heart Failure, (CHF), Pain, unspecified, Hypertension, (HTN), Atrial Fibrillation, Rheumatoid Arthritis, and Acute Kidney failure.
R1's Minimum Data Set, (MDS), dated [DATE], documents, R1 is cognitively intact and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, toilet use, she is always incontinent of bladder, and is frequently incontinent of bowel.
R1's Care Plan, with a created date of 07/27/23, documents, Problem: Resident is at risk for impaired skin integrity r/t, (related to), incontinent of B&B, (bladder and bowel), and decreased mobility. Goal: Resident will have skin remain intact by next review date. Approach: Observe skin conditions with daily care. Provide incontinent care of episodes of incontinence. Report changed to M.D. (Medical Doctor) and obtain treatment as ordered as indicated. Weekly body audits.
On 7/24/23 at 3:00 PM, R1 stated, I have been lying in my pee and poop all day. I was last cleaned up around 7:00 PM last evening. I went to the bathroom in my, (incontinent brief), around 6:00 AM this morning. I put my call light on, and someone came in and turned the light off and said, they only have one CNA (Certified Nursing Assistant), on now, and I would have to wait.
On 7/25/23 at 3:00 PM, R1 stated, The last time I was cleaned up, (incontinent care), was around 4:30 AM. No one changed me or cleaned me up until, I got to the shower at 10:00 AM. I was pretty wet and accidently had a bowel movement and had to sit in it, until they got me to the shower.
On 7/31/23 at 12:55 PM, V1 (Administrator) stated that she would expect the residents to be turned, repositioned, and incontinent care to be done every two hours or as needed and as it was care planned. She would expect the CNAs to report a new skin issue to the nurse immediately and report it to the Doctor, and the Power of Attorney, (POA).
On 7/31/23 at 2:58 PM, V18 (Regional Director) stated she would expect that all areas of incontinence, be cleaned when doing incontinent care.
The Facility's Handwashing Policy, dated 4/2015, documents, It is the policy of, (this facility), that all staff thoroughly cleanse hands with friction, soap, and water to control infection and reduce transmission of organisms. Hands should be thoroughly washed before and after providing resident care. Proper hand washing techniques must be followed at all times.
The facility's Policy Perineal Care, revision date July 2017, documents, Purpose: The Purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. Equipment and Supplies The following equipment and supplies will be necessary when preforming this procedure: 1. Wash basin; 2. Towels; 3. Washcloth; 4. Soap (or other authorized cleansing agent); 5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the Procedure 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin on-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. It further documents 9. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping front to back. (1) Separate labia and wash area downward from front to back. Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing front the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to and including thighs, alternating from dis to side, and using downward strokes. Do not reuse the same washcloth or water to clean the urethra or labia. (3) Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (Note: If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) (4) Gently dry perineum. c. Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth or water to clean the labia. f. Rinse thoroughly using the same technique as described in e above. g. Dry area thoroughly. 10. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (1) Retract foreskin of the uncircumcised male. (2) Wash and rinse urethral area using a circular motion. (3) Continue to wash the perineal area including the penis, scrotum, and inner thighs. Do not reuse the same washcloth or water to clean the urethra. c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. (Note: IF the resident has an indwelling catheter, hole the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.) d. Gently dry perineum following same sequence. e. Reposition foreskin of uncircumcised male. f. Instruct to assist the resident to turn on his side with his upper leg slightly bent, if able. g. Rinse washcloth and apply soap or skin cleansing agent. h. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. i. Dry area thoroughly. It also documents 17. Wash and dry your hands thoroughly.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to administer medications in a timely manner to residents in order to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to administer medications in a timely manner to residents in order to meet their needs for 4 of 5 residents (R2, R3, R6, R16) reviewed for medication administration in the sample of 16.
Findings include:
1. R2's Face sheet, undated, documents, R2 was admitted to the facility on [DATE].
R2's Electronic Medical Record, documents, R2's Diagnosis include Left artificial knee joint, Diabetes Mellitus (DM), Phlebitis and Thrombophlebitis of left iliac vein.
R2's Care Plan, dated 7/18/23, documents, I do have pain, L (left) TKR, (Total Knee Replacement). I will have pain screening on admission, daily, and PRN, (as needed). I will receive comfort measures. I will receive pain medication per physician/NP, (Nurse Practitioner), orders and be observed or report pain medication effectiveness as appropriate or within one hour of receiving pain. Interventions: Percocet PRN, Ice PRN L Knee. It continues Safety: I will need to be monitored to prevent falling in my new environment. I will need assistance with bed/chair mobility, assistance with transfers, assistance with locomotion to prevent falling or injury. I use a walker. WBAT, (weight bearing as tolerated). It continues Overall I require limited assistance with oral care; limited with eating; limited with toileting; limited with dressing; limited with mobility. I will need assistance to have my personal care needs met while supporting my strengths and personal goals. S/P, (status post), left TKR.
R2's Minimum Data Set, (MDS), dated [DATE], documents, R2 is cognitively intact with a Basic Interview for Mental Status, (BIMS), of 15. A score of 13-15 indicates an Intact cognitive response. R2 requires supervision for all ADLs.
R2's Physician Order, dated 7/14/23, documents, Famotidine 20mg Twice a day. 8:00 AM to 10:00 AM, and 8:00 PM to 10:00 PM.
R2's Physician Order, dated 7/14/23, documents, Atorvastatin 40mg Once a day. 8:00 AM to 10:00 AM.
R2's Physician Order, dated 7/14/23, documents, Eliquis 2.5mg Twice a day. 8:00 AM to 10:00 AM, and 8:00 PM to 10:00 PM.
R2's Physician Order, dated 7/14/23, documents, Metformin 1000mg Twice a day. 8:00 AM to 10:00 AM, and 8:00 PM to 10:00 PM.
R2's Physician Order, dated 7/14/23, documents, Oxycodone-Acetaminophen 5-325mg, 1 tablet every 4 hours PRN.
R2's Physician Order, dated 7/19/23, documents, Oxycodone-Acetaminophen 5-325mg, 2 tablets every 6 hours PRN.
On 7/24/23 at 12:48 PM, R2 stated, I just got my morning medications a little while ago, around 12:15PM or so. I got a pain pill around 2:00 AM this morning and should have had another one by now with my morning meds around 8:00AM.
On 7/24/23 at 1:02 PM, V7 (Licensed Practical Nurse/LPN) stated, I came on at 7:00 AM. This hall is very heavy on medications. I start at 7:00 AM and it takes me about four hours or more to get through the morning medication pass. There are a lot of accu-checks, injections, and vitals. R2 stopped by on his way to the dining room around 11:30 AM for lunch, and was asking for his medications, specifically for his pain pill. He never asked for it before that. I asked him if he wanted it then and he said he would wait until after lunch. I went ahead and gave them to him in the dining room. I think it's like this on every hall.
2. R3's admission Record, undated, documents R3 was admitted to the facility on [DATE].
R3's Electronic Medical Record, documents R3's Diagnosis include: Hemiplegia/Hemiparesis, Hypertension (HTN), Hyperlipidemia, Chronic Obstructive Pulmonary Disease, (COPD), Type 2 DM, Cerebral Infarction, Major depressive disorder, Arteriosclerotic Heart Disease, (ASHD), Benign prostatic hyperplasia, (BPH), Peripheral Vascular Disease, (PVD), Anemia, Chronic Kidney Disease, (CKD) stage 2, Gastroesophageal Reflux Disease, (GERD), Deep Vein Thrombosis, (DVT), Dysuria, Pneumonia, Vascular Dementia, COVID-19, Pressure Ulcer buttock, Right Below Knee Amputation, (RBKA), Left Below Knee Amputation, (LBKA), Contracture left hand, Polyneuropathy.
R3's Care Plan, dated 6/21/23, documents, R3 unable to independently change position while in bed as evidenced by not being able to turn, sit up, or move to head of bed. Interventions: Place resident in restorative nursing program. It continues R3 is limited in physical mobility r/t, (related to), bilateral amputation, chair bound hemiplegia. Interventions: Place resident in restorative nursing program. It continues R3 is limited in physical mobility r/t hemiplegia and amputation. R3 utilizes electric w/c, (wheelchair), It continues R3 is incontinent at times. Prefers to use urinal while in bed, incontinence briefs or pads. Interventions: Provide X's, (times), two assistances for toileting, apply moisture barrier to skin, provide incontinence care after each incontinent episode, use briefs while (R3) is out of bed, ensure adequate bladder and bowel elimination.
R3's MDS, dated [DATE], documents, R3 is cognitively intact with a BIMS of 14. R3 requires total dependence of two staff members for bed mobility, transfers, dressing, toilet use, and bathing, requires extensive assistance from one staff member for personal hygiene. R3 is always incontinent of both bowel and bladder.
On 7/24/23 at 11:55 AM, R3 stated, I usually get my medicines earlier in the morning, but I'm still waiting for them today (7/24/23).
On 7/24/23 at 12:20 PM, V7 (LPN) was seen passing medications to R3.
3. R6's Face sheet, undated, documents, that R6 was admitted to the facility on [DATE].
R6's Electronic Medical Record, documents, R6's diagnosis include Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, Asthma, Alzheimer's Disease, Hypothyroidism, Idiopathic peripheral autonomic neuropathy, Methicillin-Resistant Staphylococcus Aureus (MRSA), Gastroesophageal Reflux Disease, Anemia, Osteoarthritis, COVID-19, Deep Vein Thrombosis (DVT), Left Lower Extremity (LLE).
R6's Care Plan, dated 7/10/23, documents, R6 requires the use of antianxiety medication r/t: covid positive dx, (diagnosis), and isolation. Interventions: Provide meds as ordered and monitor effectiveness, 1:1 visits as needed for reassurance. It continues (R6) is at risk for further skin breakdown. admitted [DATE] with stage IV pressure ulcer left buttock. 7/10/23 Doxycycline for 20 days d/t (due to) wound culture with Proteus Mirabilis., MRSA, Strep, Coag negative Staphylococcus. Interventions: Use pressure relieving chair pad for pressure reduction when resident is in chair, treatment to pressure ulcer left buttock as ordered, keep clean and dry as possible, minimize skin exposure to moisture, provide incontinence care after each incontinent episode, use pressure reduction mattress for pressure reduction when resident is in bed.
R6's MDS, dated [DATE], documents R6 is cognitively intact with a BIMS of 13. R6 requires total dependence on one to two staff members for dressing, bathing, personal hygiene, and toilet use, and extensive assistance of two staff members for bed mobility. R6 is always incontinent of both bowel and bladder.
R6's Physician Order, dated 6/8/23, documents, Tramadol 50mg Every 6 hours. Administration Time 1. 12:00 AM. 2. 6:00 AM, 3. 12:00 PM, 4. 6:00 PM.
R6's Physician Order, dated 5/29/23, documents, ASA 81mg Once a Day. 8:00 AM to 11:00 AM.
R6's Physician Order, dated 7/17/23, documents, Cyclobenzaprine 5mg Twice a Day. 8:00 AM to 10:00 AM, and 8:00 PM to 10:00 PM.
R6's Physician Order, dated 5/29/23, documents, Digoxin 125mcg Once a Day.
R6's Physician Order, dated 7/10/23, documents, Doxycycline 100mg Twice a Day. 7:00 AM to 10:00 AM, and 7:00 PM to 10:00 PM.
R6's Physician Order, dated 5/29/23, documents, Duloxetine 60mg Once a Day. 8:00 AM to 10:00 AM.
R6's Physician Order, dated 6/2/23, documents, Eliquis 5mg Twice a Day. 8:00 AM to 10:00 AM, and 4:30 PM to 6:30 PM.
On 7/24/23 at 12:28 PM, R6 stated, I still have not gotten my medications yet today. They are usually late.
On 7/24/23 at 1:12 PM, V8 (LPN) stated, I have been here since 7:00 AM doing the morning med pass and just now got done with my AM (morning) med pass on the 100-hall. This happens all the time here. Our med pass time for AM meds is 7:00 AM until 10:00 AM and for the afternoon med pass is from 12:00 PM until 2:00 PM.
4. R16's Face sheet, undated, documents, R16 was admitted to the facility on [DATE].
R16's Electronic Medical Record, documents, R16's medical diagnosis include CHF, Cellulitis, COPD, ASHD, Hypothyroidism, Anxiety disorder, CKD, HTN.
R16's Care Plan, dated 7/19/23, documents, (R16) is on Black Box Medications. It continues (R16) is at risk for falls. Interventions: Keep personal items and frequently used items within reach, keep call light in reach at all times, provide resident an environment free of clutter, provide resident with safety device/appliance Walker.
R16's MDS, dated [DATE], documents, R16 is cognitively intact with a BIMS of 15. R16 is independent for ADLs with supervision with bathing and personal hygiene. R16 is occasionally incontinent of both bowel and bladder.
R16's Physician Order, dated 5/10/23, documents, Amlodipine 10 MG Once a Day at 8:00 AM to 10:00 AM.
R16's Physician Order, dated 5/10/23, documents, ASA 81 MG Once a Day at 8:00 AM to 10:00 AM.
R16's Physician Order, dated 6/23/23, documents, Benzonatate 100 MG Three Times a Day at 8:00 AM to 10:00 AM, 12:00 PM to 2:00 PM, and 8:00 PM to 10:00 PM.
R16's Physician Order, dated 5/10/23, documents, Buspirone 5 MG Three Times a Day at 8:00 AM to 10:00 AM, 12:00 PM to 2:00 PM, and 8:00 PM to 10:00 PM.
R16's Physician Order, dated 5/10/23, documents, Carvedilol 12.5 MG Twice a Day at 8:00 AM to 10:00 AM, and at 8:00 PM to 10:00 PM.
R16's Physician Order, dated 6/24/23, documents, Clonidine 0.1 MG (half tab) Twice a Day at 8:00 AM to 10:00 AM, 8:00 PM to 10:00 PM.
R16's Physician Order, dated 7/6/23, documents, Lasix 40 MG Twice a Day at 6:00 AM to 8:00 AM, and at 12:00 PM to 2:00 PM.
R16's Physician Order, dated 5/10/23, documents, Isosorbide 30 MG Once a Day at 8:00 AM to 10:00 AM.
R16's Physician Order, dated 5/10/23, documents, Losartan 100 MG Once a Day at 8:00 AM to 10:00 AM.
On 7/30/23 at 11:15 AM, V29 (Registered Nurse/RN) stated, I don't feel like the facility has enough help and that is why I don't pick up very many days here. It is just crazy here. I am responsible for 25 resident's meds and for all the dressing changes on the 400-hall and I am running behind right now. I have a hard time trying to find the residents meds on the med carts.
On 7/30/23 at 11:21, V29 (RN) was seen passing R16's 8:00 to 10:00 AM medications. V29 had the AM medications pulled up on the computer.
On 7/31/23 at 12:55 PM, V1 (Administrator) stated, The nurses should be administering the residents' medications within the scheduled time frame.
On 7/31/23 at 2:05 PM, R16 stated, I usually get my medicines late in the morning. My Doctor or Nurse Practitioner told me that I should get my Lasix at 6:00 AM and again at 2:00 PM so I am not up all night using the restroom, otherwise, I am up and down all night. I would like my medicines changed, but I don't like to complain. I would tell the nurse, but there is a different one every day.
V1 (Administrator) produced a list of the facility's medication pass times. Times are Medications Once a day should be given from 8:00 AM to 10:00 AM. Medications twice-a-day, should be given from 8:00 to 10:00 AM and from 4:30 to 6:30 PM. Medications three-times-a-day should be given 8:00 to 10:00 AM, 12:00 to 2:00 PM, and 8:00 to 10:00 PM. Then medications given four times-a-day should be given 8:00 to 10:00 AM, 12:00 to 2:00 PM, 4:00 to 6:00 PM, and 8:00 to 10:00 PM.
The Facility's General Dose Preparation and Medication Administration Policy, dated 1/1/2013, documents 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.4: Administer medications within timeframes specified by facility policy.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to have sufficient staff in the facility in order to maintain the resident's cleanliness, including incontinent care, and the as...
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Based on observation, interview, and record review, the facility failed to have sufficient staff in the facility in order to maintain the resident's cleanliness, including incontinent care, and the assistance with ADLs (Activities of Daily Living). This deficiency has the potential to affect all 103 residents living in the facility.
Findings include:
On 7/24/23 at 9:30 AM, The staff working on Monday 7/24/23: 100-hall had one Licensed Practical Nurse, (LPN), and one Certified Nursing Assistant, (CNA), (the other CNA scheduled quit and left). The 200-hall has one LPN and two CNAs. The 300 and 500-halls share staff and had one RN and two CNAs. The 400-hall has one LPN and two CNAs.
On 7/26/23 at 10:50 AM, R14 was lying in bed. Her gown was dirty, hair appeared to be greasy and stringy, fingernails were long, dirty and unkept.
On 7/26/23 at 10:52 AM, R14 stated, I haven't had a shower since coming to the facility, but they had been giving me an occasional bed bath. The last time I got a bed bath was two weeks ago. The facility doesn't have enough staff. There was one day when they only had one person in the building and that person had to be the Nurse and the CNA.
On 7/24/23 at 11:55 AM, R3 stated, They don't have enough staff here. They are always on their cell phones and will hold a conversation while in my room, they just don't care.
On 7/26/23 at 12:00 PM, V13 (CNA) stated, I feel like the 100-hall needs another CNA working on it. I don't feel like two CNAs is enough. The front half of the hallway is all, (full body mechanical lift), residents and it's hard to take care of. I feel like there isn't enough staff to get my daily tasks done like I am supposed to.
On 7/24/23 at 12:16 PM, R7 stated, I have not had a shower or bed bath for the past two weeks. I'm supposed to have one on Tuesdays and Saturdays. They always have some excuse, like this past Thursday, they told me that the girl that was working my hall left early, and they had no one else to do it. I might get one twice a month if I'm lucky. They are short of help here. They don't really mess with me much here. The staff are always on their cell phones here. They will stay on it while taking care of me. Not all of them, but most of them.
On 7/25/23 at 2:42 PM, R7 stated, Well, they told me they changed my shower date to Wednesdays and Saturdays, instead of Tuesday and Saturdays, so I'm hoping for one tomorrow.
On 7/26/23 at 2:40 PM, R7 stated, I've pooped my pants a couple of hours ago. I put my call light on and told them, and someone shut it off and said, they would be back, and no one came. Yesterday they told me they changed my shower schedule to today. I'm supposed to get one on Day shift and as of now, I still have not received one. I don't think they have the staff to do it.
On 7/24/23 at 12:28 PM, R6 stated, They are very short staffed here. There are times that I have had to wait a long time to get someone to help me.
On 7/24/23 at 12:48 PM, R2 stated, I put my light on and the CNA will answer it and will say that she will go tell the nurse, but no one ever shows up. They are extremely short staffed here. Every time when I visit the nurse's desk, they are all on their cell phones and/or playing games.
On 7/24/23 at 1:12 PM, V8 (LPN) stated, They need more nurses and aids. I just had the aid that I was supposed to work with today walk out and leave. The CNAs here are always on their cell phones, mainly in the halls and at the desk. They always have ear buds in and will have conversations with someone while working. I think the residents are not getting turned and repositioned or good incontinent care like they should because, we don't have the staff.
On 7/24/23 at 1:20 PM, V9 (R5's daughter) stated, We've been having some issues here. When I come in to visit my mom, she was soaked in urine, her hospital gown and all. They are so short staffed around here. They never come in when they are supposed to take care of mom.
On 7/24/23 at 1:25 PM, V10 (CNA) stated, I worked yesterday from 1:00 PM until 11:00 PM. A nurse came in with only one other nurse here. She came in from another facility, but she left at 3:00 PM. Then another nurse came in and made the second nurse again. We had no RN on duty. The night shift nurse came in at 11:00 PM to help. The 100-hall was not getting their meds and care needed. I think after I left at 11:00 PM, there was only three CNAs in the building. When I came in this morning at 7:00 AM, majority of the residents were drenched in urine from their knees up.
On 7/24/23 at 1:35 PM, R4 stated, I was last cleaned up around 2:00 AM this morning. Now I'm soaked. I put my call light on, and someone came in and turned it off and didn't clean me. They have no staff here.
On 7/24/23 at 2:10 PM, V2 (Director of Nursing/DON) stated, Let me tell you what happened this past weekend. My ADON, was on her regular scheduled Friday shift and decided at 10:15 PM that she was resigning, and she was the manager on call for the weekend. We had call offs on Sunday, (7/23/23), we were short staffed until we could get other people in here. Last night the staffing went to four CNAs and three nurses. One CNA had to leave because, his wife went into labor, so that dropped us to three CNAs in the building until early this morning. I had one nurse come in and helped as a CNA also. One CNA did come from another facility, she works at two different facilities, and worked from 4:00PM to 11:00PM for us.
On 7/24/23 at 3:00 PM, R1 stated, I have been lying in my pee and poop all day. I was last cleaned up around 7:00 PM last evening. I went to the bathroom in my, (incontinent brief), around 6:00 AM this morning. I put my call light on, and someone came in and turned light off and said, they only have one CNA on now and that I would have to wait. I usually get out of bed every morning to my wheelchair, and no one has gotten me up today yet.
On 7/25/23 at 11:20 AM, V2 (DON) stated, Our normal staffing matrix that we use is that for Days we have three to four Nurses and nine CNAs, for Nights we have two Nurses, with a third scheduled from 7:00 PM until 12:00 AM to help with meds/bedtime; and then five to six CNAs. Employees always think they are short staffed.
On 7/25/23 at 11:32 AM, R4 stated I was last cleaned up, (incontinent care), around 3:00 to 4:00 AM this morning. I peed at that time, put my call light on and they came and changed me, that was the last time anyone checked me. I am wet now. I peed earlier this morning around 8:30 AM, I put my call light on and (V12, CNA) came in and shut it off and said, she would be back and has not come back in yet. I still have not gotten out of bed yet, I have asked, and they always tell me they don't have enough time or help to do it.
On 7/25/23 at 11:34 AM, V13 (CNA) stated, (V12, CNA) did go in and shut off R4's call light and told him she would be back after she's done with another resident. We just don't have the help. I've been doing showers this morning and V12 has been answering lights and helping the residents.
On 7/25/23 at 11:40 AM, V12 (CNA) and V13 (CNA) in R5's room to clean her up. V9 (R5's daughter) was in the room and stated This is the first-time mom has been cleaned up this morning. They haven't had enough help to get things done.
On 7/25/23 at 3:20 PM, Resident Council Meeting was being held in the dining room with eight residents in attendance. The general complaint from the residents were staffing issues.
On 7/25/23 at 3:25 PM, R12 stated, in the Resident Council Meeting, They keep telling us they don't have the staff to take care of our needs. They have got to do something.
On 7/25/23 at 3:45 PM, R13 (President of the Resident Council) stated, This is the general complaint at every meeting, that there is not enough staff to help us. They have a shower schedule here, but they never follow it. We do not get our showers here. They always give us excuses like: I don't want to break my nails (long fancy nails), and sometimes will tell us they changed our shower schedule to a different day, so they don't have to do it then. The other issue we have is the staff always on their cell phones. They are always on their phones, showing each other pictures. I watched a nurse who was passing meds tell a resident she had to get something off her med cart, went to the cart and starting texting on her cell phone. Another issue is that the evening staff all take a dinner break together. They will decide when and where to meet and all meet to have dinner, meanwhile, call lights are going off and not getting answered.
On 7/26/23 at 11:20 AM, V18 (Regional Director) stated, We did have a staffing issue over this past weekend but, that is not our normal.
On 7/26/23 at 2:39 PM, V20 (CNA) stated, We are too short staffed to give showers and to provide the care residents need. We address this in every staff meeting and have suggested to hire a shower aid, but nothing happens. It's even worse on the weekends.
On 7/30/23 at 11:00 AM, V13 (CNA) stated, We had three agency people scheduled to work the 100-hall, but one was a no-call, no-show, and the other two CNAs left because, they said the hall was too hard to work with just two CNAs, as it needs three. There are three CNAs on the 200-hall until 11:00 AM, then we will have two CNAs. There are two agency CNAs on the 300-hall, there was supposed to be three CNAs on the 400-hall, but one of them was a no-call, no-show (agency). All the CNAs have been covering the 100-hall to help out. I have a hard time getting all of my daily task done because, the facility doesn't have enough help working.
The Facility's Staffing Policy, dated 11/2021, documents, The Facility provides adequate staffing to meet needed care and services for our resident population and according to regulatory staffing requirements (CMS, IDPH). 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met and schedules adequate staff to meet or exceed individual state requirements. 2. Licensed Registered Nursing and Licensed Nursing staff are available to provide and monitor the delivery of resident care services. The facility will schedule a Registered Nurse for eight consecutive hours each day or as required by individual state regulations. 3. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.
The Facility's CMS 672, dated 7/31/23, documents there are 103 residents residing in the facility.
Jul 2023
9 deficiencies
1 Harm
SERIOUS
(G)
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 interview and record review, the facility failed to perform safe transfers for 1 of 10 residents (R86) reviewed for fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to perform safe transfers for 1 of 10 residents (R86) reviewed for falls in the sample of 45. This failure resulted in R86 sustaining a head laceration that required five staples in the emergency room (ER).
Findings include:
R86's Face Sheet documents diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypo-osmolality and hyponatremia, nonspecific low blood-pressure reading, dysarthria following cerebral infarction, long term (current) use of anticoagulants, anxiety disorder, and pain.
R86's Minimum Data Set (MDS) dated [DATE] documented R86 was moderately cognitively impaired and required limited one-person physical assistance with bed mobility, transfer, and toileting.
R86's Care Plan starting 7/22/2022 documents, Resident at risk for falls r/t, (related to), recent RCVA, (right sided stroke). Care Plan revision dated 2/26/23 documents, Requires assistance with Toileting and Potential for bleeding or decrease in blood coagulation R/T use of anticoagulant for blood clot prophylaxis (prophylaxis).
R86's Orders printed 7/13/2023 document open ended order dated 12/29/22 for the anticoagulant Eliquis (Apixaban) tablet; 2.5 mg (milligram); 1 tab; oral; twice a day.
R86's Fall Risk Assessment Tool dated 5/8/2023 documented resident was at moderate fall risk.
R86's Progress Note dated 7/8/2023 at 5:43 AM by V12 (Licensed Practical Nurse/LPN) documents, Resident was heard calling out for help, this writer went into resident's room and observed resident on floor in front of toilet. Resident had blood all over face, this writer assisted resident into wc (wheelchair), after cleaning with NS (Normal Saline), there was a 3-5 (inch), laceration to top of head, resident A&Ox3-4 WNL, (alert and oriented x 3-4 within normal limits), vitals T(Temperature)-97, P(Pulse)-84, BP(Blood Pressure)127/74, R(Respiration)-18, O2(Oxygen)-99% , RA (Room Air), stated, I fell asleep while sitting on the toilet and hit my head on the board on the wall this writer held pressure, site was still actively bleeding when resident left building, resident is on Eliquis, EMS, (Emergency Medical Services), collected resident via ambulance and transferred resident to (Local Hospital).
R86's Fall and Investigation dated 7/8/2023 documents, R86 was observed on the bathroom floor in front of the toilet. The fall was not witnessed, and R86 had a laceration to the top of her head. First Aid and pressure to wound were applied before sending R86 to the Emergency Room, (ER). The intervention was to educate R86 to use call light and request assistance with toileting (R86 is moderately cognitively impaired).
R86's After Visit Summary dated 7/8/2023 documents, What You Need to Know: Staples are often used to close a wound.
R86's Progress Note dated 7/8/2023 at 12:28 PM by V23 (Licensed Practical Nurse/LPN) documents, Resident returned to facility via car with daughter. Resident arrived with 5 staples located on the top of her head.
On 7/13/2023 at 8:15 AM and 1:02 PM, V12 (LPN)) caring for R86 during the shift R86 fell, was unavailable by telephone. V13 (Certified Nursing Aid/CNA), caring for R86 during the shift R86 fell, was employed by a staffing agency, and contact information was not available.
On 7/13/2023 at 2:55 PM, V2 (Director of Nursing/DON) stated, (R86) tries to transfer herself at times, but I expect staff to be assisting her with toileting.
On 7/13/2023 at 10:37 AM, V17 (Nurse Practitioner/NP) stated that she was informed of R86's fall on 7/8/23. She stated, she would have expected someone to be with her in the bathroom, and if they had been with her the fall probably could have been prevented.
The Facility's Falls Management Policy revised July 2017 documents, It is the policy of (Facility) to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions.
The Facility's Safe Patient Handling Program Policy revised January 2017 documents, Purpose: To identify, assess, and develop strategies to control the risk of injury to residents, nurses and other health care workers associated with lifting, transferring, repositioning, or movement of a resident. All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's Care Plan. All residents will be assessed by the Care Plan team about the need for assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements. All employees shall also receive training at the time of hire, at least annually and retraining whenever necessary. The training provided will emphasize: Resident Transfer criteria including the facility's communication system for transfer status (care plan, transfer assessment, E.H.R. (Electronic Health Record), change in status); Types of approved resident transfers (1 person, 2 person). Restorative/CNAs are responsible to: Using at least as much assistance to transfer residents as the transfer assessment indicates. CNAs may always choose to use more assistance, but never less than the assessment indicates.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report a resident-to-resident altercation for 1 of 5 residents (R52)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report a resident-to-resident altercation for 1 of 5 residents (R52) reviewed for resident-to-resident altercations in the sample of 45.
Findings include:
R52's MDS dated [DATE] documents, R52 has moderately impaired cognitive skills for daily decision making.
R52's Care Plan dated 6/13/23 documents, resident is considered at risk for abuse/neglect due to history of sexual abuse as a child.
R74 Nurses Note dated 7/2/23 documents, the resident (R74) was going into another resident's (R52) room. She entered R52's room and began hitting him. The resident (R52) was yelling stop hitting me and get out before I slap you back. The CNA (Certified Nursing Assistant) went to get her out and direct her to her room. I encouraged her to stay in her own room.
On 7/14/23 at 10:00 AM, V1 (Administrator) stated, An investigation was not done for this.
On 7/14/23 at 12:00 PM, V2 (Director of Nursing/DON) stated it was never reported to me.
The facility policy entitled Abuse Prevention Program dated September 29,2022 documents employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely tube feedings for one of one resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide timely tube feedings for one of one resident (R45) reviewed for tube feedings in the sample of 45.
Findings Include:
R45 Care Plan dated 4/19/23 (R45) requires nutrition through g-tube. NPO, (Nothing by Mouth). Receives Tube feeding as ordered. Tube placement checks per auscultation before meals. All medications given through g-tube per order. H2O (water) flush as recommended 1/5/22 enteral feeding per MD (Medical Doctor) order for 15hrs daily.
R45's Minimum Data Set, dated [DATE] documents, R45 is cognitively intact.
R45's Physician Order Sheet dated 5/16/23 documents, tube feeding Nutren 1.5 80 ml (milliliters), per hour from 3 PM to 6 AM.
On 7/13/23 at 3:00 PM, there was a bag of clear liquid hanging on a tube feeding pole labeled 7/13 at 8 AM. No enteral feeding product was hanging. R45 stated, They don't always do it. You know that. At 4:00 PM, the enteral feeding was still not hung.
07/14/23 08:08 AM, V2 (Director of Nursing/DON) stated, Yes, I expect them to hang the tube feeding. Our dietician usually checks on that.
The facility policy entitled Monitoring Enteral Feeding-Tubes dated July 2014, enteral feeding-tubes will be monitored to ensure that feedings are delivered per Physicians Orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to establish an infection prevention and control program that include antibiotic use protocols in 2 of 2 residents (R17, R94) reviewed for ant...
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Based on interview and record review, the facility failed to establish an infection prevention and control program that include antibiotic use protocols in 2 of 2 residents (R17, R94) reviewed for antibiotic stewardship in the sample of 45.
Findings include:
1. R17's Physician Order Sheets dated 5/19/2023 documents, Macrobid capsule 100mg twice daily. End date 5/26/2023. R17's May's Medication Administration Record (MAR), documents, R17 received doses of Macrobid on 5/19/23 through 5/26/2023. No culture documented. R17's Physician Order Sheet dated 6/26/2023 documents, Augmentin 875mg by mouth twice daily for Urinary Tract Infection (UTI). End date 7/6/2023. R17's June's MARs document R17 received doses of Augmentin on 6/26/2023 through 7/6/2023. No culture documented.
2. R94's Physician Order Sheet dated 7/4/2023 documents, Cephalexin capsule 250mg once daily open ended. Long term use of antibiotic with no culture documented. R94's MAR documents, R94 received doses of Cephalexin on 7/4/2023-7/13/2023.
Facility Policy dated 8/2018 states, It is the appropriate authorized practitioner's responsibility to prescribe appropriate antibiotics and to establish the indication for use of specific medication. As part of the medication regimen review, the Consultant Pharmacist can assist with oversight by identifying antibiotics prescribed for resistant organisms for situations when questionable indications and report to the appropriate individuals. Prudent antibiotic use is an important step to development of MDRO. This facility will assess for infections using the McGear criteria.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to prevent resident-to-resident abuse for 6 of 6 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to prevent resident-to-resident abuse for 6 of 6 residents (R6, R18, R20, R52, R74, R79) reviewed for resident-to-resident abuse in the sample of 45.
Findings include:
1. R74's Minimum Data Set, dated [DATE] documents, R74 has moderately impaired cognitive skills for decision making.
R74's Behavior Care Plan dated 7/12/23 documents, resident has episodes of yelling and screaming, refusing and resisting care, agitation and angry outbursts, combative with staff, requires PRN, (as needed), administration of Haldol, 2/23/22 residents behaviors have decreased, PRN medications DC, (discontinued), remains a potential problem 6/14/22 resident has increased anxiety, arguing with other resident and running into other residents with her w/c, (wheelchair), purposefully 6/24/22 Res, (resident), erratic behaviors with aggression toward staff and threatening to other residents. continue UA, (urine analysis), ordered with labs per MD, (Medical Doctor), order. On 7/3/22 resident with aggressive behaviors towards staff and other residents, going into other residents' rooms, resident getting OOB, (out of bed), and w/c consistently, when attempts to place back to chair or bed (R74) becomes very aggressive. 1x med order given to calm behavior. On 7/18/22 resident behaviors continue, with aggressiveness towards other residents and staff. DON, (Director of Nursing), met with Res POA suggested interventions in place. 1/12/23 resident involved in resident-to-resident altercation with verbal and physical abuse to another resident. R74's goal is resident will not hurt self or others during episodes of aggressive behavior and will receive adequate care by next review date.
R74's Nurses Note dated 6/30/23 documents, resident daughter is here visiting with her this morning. When they were going outside to sit this resident started to rub her arm saying that her arm was really hurting. She continued to have these c/o, (complaints of). Therefore, this writer did look at her arm. Upon further assessment it is noted that she has bruise to her right elbow. The area is purple and light green. She has a hematoma. Her (R74) ROM (Range of Motion) is within normal limits, DON made aware. This writer was then made aware of this resident had taken the bedrail off her bed, this is how she got bruise to her hand and forearm, MD made aware. Waiting on return call from MD, she called with no voice concerns.
R74's Nurses Noted dated 6/25/23 documents, staff reported that resident had taken side rail off bed and was swinging it around in her room. Resident was agreeable and handed the side rail over to CNA (Certified Nursing Assistant), new bruises noted to top of Right hand and Right thumb. Photos sent on (Company), compliant-communication platform for physicians and healthcare workers, to notify MD.
On 7/12/23 at 1:00 PM R74 was sleeping in her bed. On 7/13/23 at 11:00 AM R74 was asleep.
2. R74's Nurses Note dated 6/1/23 documents, the resident (R74) was walking down the hall and stopped to hit (R6) on the shoulder. The resident (R6) hit her back across the arm and grabbed her shirt. Neither resident was in pain or distress. The residents were separated, they will continue to monitor, and the POA were notified.
R6 and R74 Long Term Care Facility Serious Injury Incident Report, dated 6/1/23 documents R74 had a disagreement with R6 and hit her on the arm.
R6 MDS dated [DATE] documents, R6 is moderately cognitively impaired.
R6's Care Plan dated 2/27/23 documents, R6 is considered at risk for abuse/neglect due to wandering and communication barrier being weak and confusion and disorientation.
3. R18's Long Term Care Facility Serious Injury Incident Report dated 6/7/23 documents, R74 hit R18 in the head, they were separated.
R18's MDS, dated [DATE] documents, R18 is severely cognitively impaired.
R18 Care Plan dated 5/22/23 documents, resident is considered at risk for abuse/neglect, due to past Psychiatric history exhibiting confusion requiring total care and communication barrier.
4. R74 Nurses Note dated 7/2/23 documents, the R74 was going into another resident's (R52) room. She entered R52's room and began hitting him. R52 was yelling stop hitting me and get out before I slap you back. The CNA went to get her out and direct her to her room.
R52's MDS dated [DATE] documents, R52 has moderately impaired cognitive skills for daily decision making.
R52's Care Plan dated 6/13/23 documents, resident is considered at risk for abuse/neglect, due to history of sexual abuse as a child.
5. R79's Long Term Care Facility Serious Injury Incident Report dated 12/21/22 documents, at approximately at 6:50 PM an allegation of resident to resident was made upon investigation nursing staff found both residents throwing a shoe at each other, and R79 reached out and grabbed R74's arm.
R74's Nurses Note 6/4/23 for R74 noted she was wandering the halls into another resident's room. She went into R79's room, and when the CNA went into the room to get her out of R79's room, he stuck his nails in her skin.
R79's MDS dated [DATE] documents, is severely cognitively impaired.
R79's Care Plan dated 3/29/23 documents, resident is considered at risk abuse/neglect due to diagnosis of Dementia.
6. R74's Nurses Note dated 6/20/23 documents, the resident was walking down the hall and walked up to R20 and started hitting him. R20 grabbed her arm and pushed her down. She (R74) fell on her butt.
R20's MDS dated [DATE] documents, R20 is moderately cognitively impaired.
R20's Care Plan, dated 2/26/23, documents that R20 is considered at risk for abuse/neglect related to Dementia, history of combative behaviors resident is exhibiting harmful behavior as seen by altercation with remote and hitting him with the wheelchair leg.
On 7/13/23 at 8:00 AM, V19 (Licensed Practical Nurse/LPN) stated, she R20 has sundowner and sleeps most of the day.
On 7/13/23 at 3:00 PM, V2 (Director of Nursing/DON) stated she (R20) is not that bad. They call me, and I come in and walk her around the facility and give her something to eat or drink.
The facility policy entitled Abuse Prevention Program dated September 29, 2022, residents who allegedly mistreated another resident will be removed the situation and will have limited contact with the targeted individual during the course of investigation. The accused resident's condition shall be immediately evaluated to determine most suitably therapy, care approaches, and placement, considering his/her safety, as well as the safety of other residents and employees of the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 7 of 7 (R86...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers to residents on a twice weekly basis for 7 of 7 (R86, R33, R303, R31, R70, R41, R21) residents in the sample of 45.
Findings include:
R86's Face Sheet documents diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; hypo-osmolality and hyponatremia; nonspecific low blood-pressure reading; dysarthria following cerebral infarction; long term (current) use of anticoagulants; anxiety disorder, unspecified; and pain, unspecified.
R86's Minimum Data Set, MDS, dated [DATE] documented R86 was moderately cognitively impaired and required total dependence with bathing.
R86's Care Plan dated 2/26/23 documents, Resident will bathe with required assistance.
On 7/12/23 at 8:15 AM, V18 (R86's Family Member) stated, (R86) has not gotten showers for 3 weeks at a time. They told me R86 was refusing, but R86 told me she never refuses.
The Facility provided R86's Bath/Shower Sheets for the past month. These document R86 had a shower on 6/22/23 and was not showered again until seven days later on 6/29/23. R86's next shower was twelve days later on 7/11/23.
The Facility's Grievance/Concern/Complaint Form for R33 on 11/7/2022 documents, (R33) has not been shaved. He looks terrible, like he lives in the woods. Has he been getting showers.
R33's MDS dated [DATE] documents R33 is severely cognitively impaired.
The Facility's Grievance/Concern/Complaint Form for R303 on 11/28/22 documents, Daughter believes the resident has not been showered or given a bed bath in the past two weeks.
R303's MDS dated [DATE] documents R303 is severely cognitively impaired.
The Facility's Grievance/Concern/Complaint Form dated 12/15/22 documents, Several residents complained of shower schedule over the past couple of weeks.
The Facility's Resident Council Meeting Minutes dated 4/25/23 document, 2/11 residents concerned about showers under Issues/Concerns.
The Facility's Grievance/Concern/Complaint Form for R31 dated 5/16/23 documents, Resident reported to admin (administrator) that he did not get his scheduled shower on Saturday.
R31's MDS dated [DATE] documents R31 has no cognitive impairments.
The Facility's Grievance/Concern/Complaint Form for R70 on 6/5/23 documents, Resident has not received a shower in over a week.
R70's MDS dated [DATE] documents R70 has no cognitive impairments.
The Facility's Resident Council Meeting Minutes dated 6/27/23 document, Showers under Issues/Concerns.
On 7/13/23 at 9:15 AM, V24 (Ombudsman) stated showers have been an issue at the facility. She has spoken to the administration about it, but nothing has changed.
On 7/11/2023 at 10:00AM, R41 stated, I've been here a month and have not gotten a shower at all. I've only gotten bed baths, and I want a shower.
R41's MDS dated [DATE] documents R41 has no cognitive impairments.
On 7/11/23 at 11:05 AM, R70 stated that she has not gotten a shower in 2 weeks.
On 7/12/2023 at 9:00AM, R21 stated, I have been here a year and maybe had 3 showers. I have to wash up in the bathroom.
R21's MDS dated [DATE] documents R21 has no cognitive impairments.
On 7/13/2023 at 3:00PM, V2 (Director of Nursing/DON) stated she expects showers to be done twice weekly.
Facility Bathing policy with a revision date of 7/2014 documents It is the policy of the facility that residents will receive a shower/bath that will be scheduled regularly and prn.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents with limited range of motion (R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents with limited range of motion (ROM) receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 4 out of 4 (R10, R45, R66, R81) residents in a sample of 45 investigated for contractures.
Findings include:
1. R10's Physician Order dated 02/11/19 documents, contracture, left hand.
R10's Physician Order dated 02/24/22 documents, Restorative Therapy Program for AROM (Active Range of Motion), q (every) shift 6-7x/wk.(week), and Restorative Therapy Program for bed mobility q shift 6-7 x/wk.
R10's Care plan dated 08/06/13 documents, Problem: Requires total care with all ADLs (Activities of Daily Living) d/t (due to) dx, (diagnoses) of CVA, (cerebrovascular accident), w/(L) left, hemiparesis, Aphagia, Dysphagia, CAD, (coronary artery disease), MI (myocardial infarction), HTN (hypertension), Dyslipidemia, NIDDM (non-insulin-dependent diabetes mellitus). DJD (degenerative joint disease), Depression and Debility secondary to CVA. Uses mechanical 2 assist with bed mobility.
R10's Care Plan 09/04/19 documents, Problem: R10 is limited in physical mobility R/T (related to) hemiplegia and amputation. Res utilizes electric W/C, (wheelchair), 1/27/23 Res electric w/c seat belt damaged.
R10's MDS (Minimum Data Set), dated 03/10/23 documents, a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that R10 requires extensive assistance of two plus persons for bed mobility, transfer, and dressing. R10 is independent with setup only for locomotion on unit and locomotion off unit. R10 requires supervision of one person for eating. Resident requires extensive assistance of one person for toilet use and personal hygiene. R10 is not steady, only able to stabilize with staff assistance. Functional limitation in ROM documents impairment on one side of the upper extremity and impairment on both sides of the lower extremity.
R10's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents, that R10 is total dependence of two plus person for bed mobility, transfer, dressing, and toilet use. R10 is independent with setup help only for locomotion on unit and locomotion off unit. Resident requires supervision of one person for eating. R10 requires extensive assistance of one person for personal hygiene. R10 is not steady, only able to stabilize with staff assistance. Functional Limitation in ROM documents impairment on one side of the upper extremity and impairment on both sides of the lower extremity.
On 07/13/23 at 9:03 AM, observed resident's left hand is contracted in a fist, and there was no hand roll noted.
2. R45's Physician Order dated 04/19/20 documents, quadriplegia, unspecified.
R45's Physician Order dated 10/26/20 documents, Restorative Therapy Program for Bed Mobility 6-7x/wk.
R45's Care Plan 10/11/19 documents, Problem: Requires Therapy services, Restorative Program PT, OT, and SLP.
R45's MDS dated [DATE] documents a BIMS score of 10 out of 15. The MDS documents that R45 is in total dependence on two plus persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. R45 is in total dependence of one person for eating. R45 is not steady, only able to stabilize with staff assistance. R45 functional limitation in ROM resident has impairment on both side of the upper extremity and impairment on both sides of the lower extremity.
R45's MDS dated [DATE] documents, a BIMS score of 14 out of 15. The MDS documents that R45 is total dependence of two plus persons for bed mobility and toilet use. R45 is total dependence of one person for dressing, eating, and personal hygiene. Resident is not steady, only able to stabilize with staff assistance. The MDS documents R45 functional limitation in ROM resident has impairment on both sides of the upper extremity and impairment on both sides of the lower extremity.
On 07/13/23 at 2:45 PM, observation of R45 has contracted bilateral arms and bilateral legs.
3. R66's Physician Order dated 02/24/22 documents, Restorative Therapy Program for AROM q shift 6-7x/wk., Restorative Therapy Program for Bed Mobility q shift 6-7x/wk. and Restorative Therapy Program for Dressing q shift 6-7x/wk.
R66's Care Plan dated 07/11/23 documents, Problem: Resident is limited in physical mobility R/T weakness, chronic low back pain decreases mobility BLE.
R66's MDS dated [DATE] documents, a BIMS score of 15 out of 15. The MDS documents that R66 requires extensive assistance of two plus persons for bed mobility, transfer, dressing, and toilet use. R66 requires extensive assistance of one person for personal hygiene. R66 requires supervision of one person for locomotion on unit, locomotion off unit, and eating. R66 is not steady, only able to stabilize. MDS documents that R66 functional limitation in ROM impairment on both side of the lower extremity.
R66's MDS dated [DATE] documents, a BIMS score of 15 out of 15. The MDS documents that R66 requires extensive assistance of two plus persons for bed mobility, dressing, and toilet use. R66 is total dependence of two plus persons for transfer. R66 requires supervision of one person for eating. R66 requires extensive assistance of one person for personal hygiene. R66 is not steady, only able to stabilize with staff assistance. MDS documents, that R66 functional limitation in ROM impairment on both sides of the lower extremity.
On 07/14/23 at 9:20 AM, observation of R66's contracted bilateral legs.
4. R81's Physician Order dated 04/13/22 documents, hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage affecting left non-dominant side.
R81's Physician Order dated Physician Order dated 08/23/22 documents, Restorative Therapy Program for AROM q shift 6-7x/wk., Restorative Therapy Program for Bed Mobility q shift 6-7x/wk., and Restorative Therapy Program for PROM to LUE q shift 6-7x/wk.
R81's Care Plan dated 04/13/22 documents, Problem: Requires Therapy services Restorative Program PT, OT, & SLP.
R81's MDS dated [DATE] documents, a BIMs score of 10 out of 15. The MDS documents that R81 requires extensive assistance of two plus persons for bed mobility and transfer. R81 requires supervision with setup help only for locomotion on unit and locomotion off unit. R81 requires extensive assistance of one person for dressing and toilet use. R81 requires supervision of one person for eating and personal hygiene. R81 is not steady, only able to stabilize with staff assistance. The MDS documents, that R81 functional limitation in ROM impairment on one side of the upper extremity and impairment on one side of the lower extremity.
R81's MDS dated [DATE] documents, a BIMS score of 14 out of 15. The MDS documents that R81 requires extensive assistance of two plus persons for bed mobility and transfer. R81 requires supervision with setup help only for locomotion on unit, locomotion off unit, and eating. R81 requires extensive assistance of one person for dressing and personal hygiene. R81 is total dependence of two plus persons for toilet use. R81 is not steady, only able to stabilize with staff assistance. The MDS documents that R81 functional limitation in ROM is impairment on one side of upper extremity and impairment on one side of lower extremity.
On 07/12/23 at 9:25 AM, observation of R81 contracted left arm and left leg.
On 07/3/23 at 8:26 AM, V2 (Director of Nursing/DON) stated the facility does not have a restorative nurse.
Rehabilitative Nursing Care policy revised February 2012 documents Rehabilitative nursing care is provided for each resident admitted .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to properly store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect al...
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Based on observation, interview, and record review, the facility failed to properly store, prepare, and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 97 residents living in the facility.
Findings include:
On 7/11/23 at 8:03 AM, in the dry storage room there was a 48-ounce jar of grape jelly, that was previously opened and half empty with smears of a light brown creamy substance inside. The jar was not refrigerated or dated upon opening. There was a bag of powdered sugar that had been opened and resealed but was not dated. There was a bag of chicken gravy mix that was previously opened and resealed, but not dated. There was a bottle of liquid thickener directly on the floor underneath the shelf.
On 7/11/23 at 8:05 AM, underneath the preparation table in the main kitchen area, there were six clear containers of dry cereal that were not labeled or dated and were sticky to the touch.
On 7/11/23 at 8:09 AM, there were ice crystals in the deep freeze next to the tray line, approximately one inch thick. There was no thermometer inside the deep freeze.
On 7/11/23 at 8:12 AM, there was a layer of dust on the pipes behind the convection oven, approximately ¼ of an inch deep. There was an area of dust and dirt circling a pipe on the wall above the pots and pans that was approximately six inches in diameter. On the shelf directly below, there was a pot that was stored upright, potentially allowing the dirt and dust to fall inside.
On 7/11/23 at 8:16 AM, on a shelf below the steam table, there was a clear tub containing metal lids, sheets of wax paper and disposable containers. There was no lid on the tub, and there were food crumbs scattered inside.
On 7/11/23 at 8:31 AM after the last resident tray was served, the scrambled eggs on the steam table measured 86 degrees Fahrenheit, (F), with metal calibrated thermometer. The gravy measured 116 degrees F. V6, Cook, stated, I think it's supposed to be 155, (degrees F).
On 7/11/23 at 8:47 AM, V5 (Dietary Manager/DM) looked in the deep freeze and was unable to find a thermometer. V5 stated, I can get one for it.
On 7/11/23 at 9:54 AM in the Diet Kitchen freezer on the 400 hallway there were 3 opened bottles of water that were not labeled, and a nutritional supplement dated 3/28. There was a half-empty pint of orange sherbet that was not labeled or dated. In the refrigerator, there was a half-empty nutritional supplement no label or date.
On 7/13/23 at 2:55 PM, V1 (Administrator) stated she expects the facility staff to follow their food service policies, including labeling, dating, and maintaining proper serving temperatures.
The Facility's Food and Supply Storage Policy revised January 2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Food services will maintain clean food storage areas. Acceptable storage area temperatures: Dry storage 50º F to 70º F; Refrigerator 41º or below; Freezer 0º or below. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated. Refrigerators and freezers will be equipped with an internal thermometer and monitored. Food items will be dated as it is placed on the shelves.
The Facility's Food from Outside Sources Policy revised December 2016 documents, Food(s) brought to a resident by a family/visitor will be permitted. Any food brought in is checked by nursing or food service. Food stored must be labeled with the resident's name and dated.
The Facility's Cooking Foods - Internal Temperatures Policy revised January 2012 documents, Meal temperatures shall be monitored by the Dietary Manager and the Cooks on a daily basis. Hot food shall be cooked or heated to a temperature above 165º F. The [NAME] shall take temperatures of food (as appropriate) during meal preparation to ensure food is cooked or chilled to the appropriate temperature. Temperatures shall also be taken once food is placed on the steam table prior to the start of meal service. Temperature Guidelines: Food - Hot on Steam table - 165 degrees or higher on steam table. Food - Hot at Point of Service - 120 degrees or higher.
The Resident Census and Condition of Residents Form (CMS 672) dated 7/11/23 documents there are 97 residents living in the Facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to develop an ongoing infection control surveillance program. This has the potential to affect all 97 residents living in the facility.
Findin...
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Based on interview and record review, the facility failed to develop an ongoing infection control surveillance program. This has the potential to affect all 97 residents living in the facility.
Findings include:
The Facility's Infection Tracker does not document an organism causing R21's 7/11/23 urinary infection. The log documents R21 was treated with the antibiotic Doxycycline Monohydrate.
The Facility's Infection Tracker does not document an organism causing R28's 6/26/23 urinary infection. The log documents, R28 was treated with the antibiotic Sulfamethoxazole-Trimethoprim.
The Facility's Infection Tracker does not document an organism causing R61's urinary infection. The log does not document any antibiotic treatment for R61's urinary infection.
The Facility's Infection Tracker does not document an organism causing R68's urinary infection. The log does not document any antibiotic treatment for R68's urinary infection.
On 7/14/23 at 8:26 AM, V2 (Director of Nursing/DON) stated that she expects the facility to get an organism for every urinary infection. She stated, sometimes it takes time to get them from the hospital, but she would expect them to be obtained.
The Facility's Infection Control Policy revised July 2017 documents, It is the policy of (Facility) to make every effort to prevent the spread of infection in the facility. To identify true infections, track and trend infection data, the facility will utilize the Infection Criteria Checklist form and the Infection Control log. Laboratory reports will be utilized to identify infectious organisms.
The Facility's Infection Prevention and Control Program Policies and Procedures: General Statement revised August 2018 documents, The organization has made a commitment to prudent infection prevention and control measures by promoting the concept of compassionate, common-sense resident and patient care, with an emphasis on cleanliness and infection prevention strategies. This organization has an established infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The infection prevention and control program: Investigates, controls, and prevents infection in the organization.
The Facility's Resident Census and Condition of Residents Form (CMS 672) dated 7/11/23 documents there are 97 residents living in the Facility.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered insulin for 1, (R2) of 4 residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review, the facility failed to administer ordered insulin for 1, (R2) of 4 residents (R1, R2, R3, R7), in the sample of 9.
Findings include:
R2's Face sheet documents, an admission date of 6/21/2023 at 1:36PM. Diagnosis includes fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, unspecified atrial fibrillation, essential primary hypertension, diabetes mellitus.
R2's MDS, Minimum Data Set, dated [DATE] documented, R2 required extensive 2+ person assistance with bed mobility and transfer and walking did not occur. BIMS, Brief Interview for Mental Status, 15.
R2's Care Plan, does not show any documentation as R2 was new admit.
R2's Post-Acute Transfer Report, dated 6/21/2023 at 10:09AM documents, Insulin Glargine 100u/ml (3ml) pen for injection. 14units subcutaneous nightly.
R2's Medication Administration Records, dated In House 6/21/2023-6/23/2023 documents, Insulin Glargine insulin pen 100units/ml (3ml) Amount to Administer 14Units; subcutaneous at 9:00PM. No documentation that insulin was administered on 6/21/2023 at 9:00PM.
On 7/7/23 at 8:55 AM, V20, Pharmacist, stated, It is normal to pull first doses out of the Omnicell. If the med was not available, a stat order is placed. The Glargine may have been given in the hospital. If there is not a time on the order, it was most likely given in the hospital.
On 7/7/23 at 9:00 AM, V2, Director of Nursing, DON, stated, R2 was admitted without any prescriptions and orders, so the nurse contacted me. Then I contacted V24, Nurse Practitioner, NP. V24 reviewed R2's records, then sent over a script. We cannot get into the Omnicell until we have a script, so that is what we were waiting for.
Facility policy dated 12/1/2007 documents Prior to administration of medications facility staff should take all measures required by the facility policy and applicable law, including, but not limited to the following: Verify each time a medication is administered that it is the correct medications, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident, as set forth in Appendix 17: Facility Medication Administration Times Schedule. Confirm that the MAR reflects the most recent medications order.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly assess and monitor weights for a resident who is at nutr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly assess and monitor weights for a resident who is at nutritional risk for 1 of 9 residents (R2) reviewed for weight loss in the sample of 9.
Findings include:
R2's Face Sheet documents she was admitted to the facility on [DATE] with the diagnoses of Pneumonia, Encephalopathy, Atrial Fibrillation, and Type 2 Diabetes Mellitus.
R2's Minimum Data Set (MDS) dated [DATE] documents she is moderately cognitively impaired, requires set up and supervision for eating, and she is 65 inches tall and weighs 110 pounds.
R2's Care Plan dated 11/11/22 documents: Problem: Dietary Risks: Risk for weight loss r/t (related to) Resident dementia and cannot stay focused on talk of feeding herself often needs cueing and Hand over Hand direction resident current weight is 109lb (pounds). There is no intervention on the care plan to monitor R2's weights.
R2's Electronic Medical Record (EMR) does not include any documentation of an admission weight or any subsequent weights under the Vital Signs.
R2's Physician Order Report dated 11/11/22 through 1/27/23 documents the following orders:
11/11/22: Weekly weights x 4 weeks.
11/23/22: Please obtain resident's weight and document under vitals.
R2's admission Nutrition assessment dated [DATE] at 10:44 AM documents, weight and height pending. There is no ideal body weight, Body Mass Index (BMI) or assessment of R2's required caloric intake, protein needs, or fluid requirements calculated due to no available weight.
On 2/1/23 at 1:05 PM, V2 (Director of Nursing/DON), confirmed R2 was not weighed while she resided in the facility. V2 stated R2 should have been weighed on the day she was admitted and then weekly for the next three weeks as this is the facility's protocol, and these weights should have been documented under vitals in her EMR. V2 stated an accurate weight is needed for the physician's and dietician's initial assessment of the resident. V2 confirmed the weight used for R2's MDS was the weight taken from her hospital records when she was admitted . V2 stated without an initial weight on admission and then subsequent weights after that, there is no way to determine if she had any weight loss while she was a resident in the facility.
The facility's policy, Weight Management Program revised July 2014 documents, It is the policy of (facility) to manage resident weight through prevention, assessment, and implementation and evaluation of interventions. Procedure: 1. Upon Admission/Re-admission, Quarterly and with a Significant Change. 2. On the first through the fifth days of the month, the CNA (Certified Nursing Assistant) will take the weights for all monthly weights. Weekly weights will be obtained for any resident determined by the Weekly PAR committee.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for 1 of 9 residents (R1) reviewed for abuse in the s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for 1 of 9 residents (R1) reviewed for abuse in the sample of 9.
Findings include:
On 12/29/22 at 11:40 AM, R1 stated V15 (Certified Nursing Assistant/CNA) had told him she did not want to take care of him and threw a package of pop tarts at him when he asked for a snack. R1 stated he felt fearful towards V15 and felt vulnerable because he is blind. He stated he told his son about the incident and his son told V1 (Administrator). R1 stated that he does not talk too much anymore because he is apprehensive since the incident with V15.
R1's Serious Injury Incident Report-final, dated 12/7/22, documents, At approximately 8:45 AM (Initial report was dated 12/2/22) an allegation of abuse was made. Administrator, Director of Nursing (DON), and physician was notified. The final report further documents, At approximately 8:45 AM, resident's POA (Power of Attorney) came to the facility and stated that the resident had called him with concerns regarding CNA. Investigation was initiated and CNA was immediately suspended. Resident, staff, and alert and oriented residents interviewed. It was stated by the resident that CNA told him she would not be able to care for him, and when he asked her for a snack, she tossed a bag of snacks at him and exited the room. The resident is vision impaired (legally blind) and BIMS is 15 (indicates he is alert and oriented). CNA has previously been educated regarding customer service. The abuse is substantiated. CNA will be terminated.
The facility's abuse investigation of R1's allegation of abuse on 12/2/22 includes V1's handwritten interview of R1 regarding the incident, dated 12/2/22, which documents, If I put you to bed you are staying in bed. He told them, No, he wanted to go out and smoke. Nurse came, time for meds. Nurse asked if that was him smelling like that. Next day V15 yelling, If you don't want me to work for you then, just say it. I can't take it no more. I don't even want to be around him. When he came here, he walked in/could see/walk. Gets a feeling every time she comes in the room. Asked her to get pop tarts and she threw the pop tart at his chest along with a whole bag of pop tarts, and a cereal box in a paper bag and it startled him. Every fear of being blind with no legs-she is the epitome of that.
On 12/29/22 at 1:44 PM, V2 (Director of Nursing/DON) offered clarification of the above interview as, V1 interviewed R1 in his room. R1 told us V15 had come into his room and told him if she put him to bed, she would not be able to get him back up, but he wanted to be up so he could go out and smoke. V2 stated R1 reported V15 told him if he went to the bathroom in his pants, she would not be able to change him. R1 told V1 and V2 that he had asked V15 to get him a pop tart out of his cabinet where he keeps a bag of snacks, and she threw the entire paper bag, including pop tarts and a box of cereal, at his chest, and it startled him because he is blind and did not see it coming. V2 stated, I guess he had a bowel movement and V15 did not change him, and he did not get changed until the next shift. V2 stated R1 told them V15 was the epitome of fear for someone who is blind without legs. She stated they did not know the exact date when the abuse occurred, but they thought it was the weekend before R1's son reported it. V2 stated she immediately suspended V15 pending the investigation and asked V15 to come into V1's office and give a statement. V2 stated at first V15 refused to come in, but then did come in the next day and the only thing she said was, I didn't do that. V2 stated she terminated V15 on that day for abuse.
R1's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses to include Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with other skin complications, Acquired Absence of Right Leg Above the Knee, and Acute Angle-Closure Glaucoma, Left Eye.
R1's Minimum Data Set (MDS) dated [DATE] documents he is alert and oriented and requires extensive assist with transfers, bed mobility, and toileting, and is dependent for locomotion on and off the unit. The MDS further documents R1 is always incontinent of bowel and bladder.
R1's Care Plan dated 7/12/22 documents, Category: Psychosocial Well-Being: The resident is considered to be at risk for abuse/neglect (per assessment) due to: past substance abuse, isolation, chronic pain, requiring total care, and blindness. The goal for this care plan is: The resident will be free from harm secondary to abuse/neglect through the next review period of 1/20/23.
The facility's policy, Abuse Prevention Program, revised 9/29/22 documents, 'Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, mean the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
Nov 2022
2 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
Based on observation, interview and record review, the facility failed to implement safety measures for falls for one of three residents (R4) reviewed for falls in the sample of nine.
Findings Include...
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Based on observation, interview and record review, the facility failed to implement safety measures for falls for one of three residents (R4) reviewed for falls in the sample of nine.
Findings Include:
R4's Care Plan, dated 10/23/22 documents, R4 is limited in physical mobility. R4 is unable to independently change position, while in bed as evidenced by not being able to turn, sit up, or move to the head of the bed. R4 is at risk for falls related to mobility.
R4's Fall Risk Assessment, dated 10/20/22, documents she is at high risk for falls.
R4's Nurses Note from Event Report, dated 10/19/22 at 4:49 PM, documents that resident (R4) had witnessed fall out of bed, V6 (Certified Nursing Assistant/CNA) was changing her, and resident, R4, rolled out of bed and fell to the floor hitting her head. Resident, R4, was sent to a (local hospital), POA (Power of Attorney), and MD (Medical Doctor) was notified. VS (vital signs), prior to leaving 97.8, 93, 18, 132/77, 94%.
R4's Nurses Note, from Event Report, dated 10/19/22 11:09 PM, documents Resident, R4, returned from a (local hospital), ER (Emergency Room), with 11 sutures in-tact to forehead with bruising noted to both eyes. Resident, R4, transferred to bed with assist x (times) 4. Bed rails up and call light within reach, resident, R4, denies pain at this time.
R4's Nurse Practitioner Note, dated 10/20/22, documents patient, R4, was seen today for readmission. Patient, R4, had a fall out of bed on 10/19/2022, that resulted in an ED, (Emergency Department) visit, and 11 sutures into the middle of the forehead. Bruising noted around both eyes. Patient, R4, is alert and awake. Patient states she is having a little bit of pain all over, Tylenol as needed, made nursing aware. Records requested from ED visit. Not available for review at this time.
On 11/2/22 at 1:13 PM, R4 refused to be transferred or gotten out of bed. R4 did have bed rails on her bed.
On 11/3/22 at 8:32 AM, V6 (CNA) stated, her (R4) bed didn't have bed rails, and she needed cleaning up. I went to turn her, R4, and she kept rolling and rolled off the bed onto the floor. It was a regular bed with a remote. She, R4, was a two-assist, but I tried to do her myself.
On 11/3/22 8:40 AM, V7 (Licensed Practical Nurse/LPN) stated, this was a week or two ago. Well, she rolled out of the bed and fell. I had to send her out to the hospital, she hit her head. Her room was recently changed when she came back from the hospital. The rails were on order for her bed.
On 11/3/22 1:42 PM, V18 (Nurse Practitioner/NP), stated R4, fell from the bed. It could have been easily prevented with side rails on the bed. She was placed in a new bed without side rails.
The policy, entitled Falls Management, dated 7/2017, documents It is the policy of facility to assess and manage resident falls through prevention, investigation, and implementation and evaluation of interventions. The definition of a fall refers to unintentionally coming to rest on the ground, floor, or other lower level.
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 F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record interview, the facility failed to provide resident and family members the opportunity to particip...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record interview, the facility failed to provide resident and family members the opportunity to participate and make decisions or changes in treatments and/or interventions in care, in residents Care Planning process, in 5 of 5 residents (R1, R3, R7, R8, R9) reviewed for Care Plan intervenes in the sample of 9.
Findings include:
1. R1's Minimum Data Set, (MDS), dated [DATE] documents, R1 is severely cognitively impaired; it is very important to her to have family or close friend involved in discussion about R1's care.
R1s Face Sheet, undated documents R1's diagnoses as Malignant neoplasm of endometrium, Acute embolism and thrombosis of deep veins of unspecified upper extremity.
R1's Case Conference Report, dated 8/15/22, documents R1 and V4(Registered Nurse/RN Care Planner) present for Care conference.
R1's Case Conference Report, dated 5/24/22 documents, R1 and V4 present for Care conference,
R1's Care Plan, dated 1/23/22, documents Care Areas with Interventions of Falls, Behavioral Symptoms, Mood State, Psychotropic Drug Use, Disease Process, Bed Mobility, Feeding Tube, Advance Directive, Urinary Incontinence, ADL Functional/ Rehabilitation (e.g., R1, requires assistance with toileting, grooming /hygiene, equipment needs, eating assistance with set up only, bed mobility, assistance with bathing, limited in wheelchair mobility, related to generalized weakness, deconditioning and debility, etc.) Potential Return to Community Referral, Pressure Ulcers, Nutritional Status, Psychosocial Well-Being, Dehydration/ Fluid Maintenance, Communication, Visual Function and Activities with Interventions.
2.R3's Minimum Data Set, (MDS), dated [DATE], documents R3 is cognitively intact, and it is very important to her to have family or close friend involved in discussion about R3'scare.
R3's Face Sheet undated documents R3's diagnoses as Parkinson's Disease End Stage Renal Disease, Unspecified Severe Protein-Calorie Malnutrition, Pain, unspecified.
R3's Case Conference Report, dated 3/14/22, documents R3 and V4 present for Care conference.
R3's Case Conference Report, dated 4/11/22, documents R3 and V4 present for Care conference,
R3's Case Conference Report, dated 8/10/22, documents only V4 present for Care conference.
R3's Care Plan, dated 1/23/22 documents Care Areas with Interventions of Falls, Behavioral Symptoms, Mood State, Psychotropic Drug Use, Disease Process, Bed Mobility, Feeding Tube, Advance Directive, Urinary Incontinence, ADL Functional/ Rehabilitation (e.g. R3 requires dialysis related to End Stage Renal Disease, {ESRD}, requires assistance with toileting, grooming /hygiene, equipment needs, eating assistance, bed mobility, assistance with bathing, limited in wheelchair mobility related to generalized weakness, deconditioning and debility, etc.) Potential Return to Community Referral, Pressure Ulcers, Nutritional Status, Psychosocial Well-Being, Dehydration/ Fluid Maintenance, Communication, Visual Function and Activities with Interventions.
3. R7's MDS, dated [DATE], documents R7 has moderate cognitive impairment, it is important to R7 to have family, or a close friend involved in discussions about his care.
R7''s Face Sheet, undated, documents R7's diagnoses as unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Type 2 diabetes mellitus with diabetic neuropathy, Unspecified Atherosclerotic heart disease of native coronary artery without angina pectoris.
R7's Care Conference Report, dated 6/28/22, documents R7 and V4 were present for case conference.
R7's Case Conference Report, dated 9/29/22, documents that R7 and V4 were present for case conference.
R7's Care Plan dated 9/29/22, documents R7's care areas as ADL/ Functional Rehabilitation (e.g., R7 had paraplegia related to history of [NAME] Nile Disease, R7 has the potential for weakness, fatigue, confusion, chest pain, dizziness, syncopal episodes and palpations, related to cardiac dysrhythmias. R7 has the potential for diminished range of motion), Urinary Incontinence Nutritional status, Disease Process and Dehydration/Fluid Maintenance, Return to Community Referral, Falls, Pressure Ulcers and Communication with Interventions.
4. R8's MDS, dated [DATE] documents, R8 is cognitively intact; it is very important to have family and close friends involved in discussions about her care.
R8's Face Sheet, undated documents, some diagnoses as Chronic combined systolic (congestive) and diastolic (congestive) heart failure, Anemia, unspecified, Embolism and thrombosis of superficial veins of right lower extremity, Unspecified Atrial Fibrillation, Transient alteration of awareness, Age-related cognitive decline, Major Depressive Disorder, etc.
R8's Care Plan documents, R8's last Care conference as 10/11/22. There were no documented Case Conferences for the year 2022. The last documented Case conference was in 2019.
R8's Care Plan, dated 10/11/22 documents, R8's care areas as Psychotropic Drug Use, ADL/Functional/Rehabilitation (e.g., R8 is at risk for heart damage related to heart damage/injury, for complications due to edema,
R8 had a decline in ADL, function, R8 has limited ability to walk in corridor, related to arthritis, limited physical mobility, requires therapy services-Restorative Program, R8 has Potential for Weakness, fatigue, confusion, chest pain, dizziness, syncopal episodes and palpitations related to cardiac dysrhythmias), Dehydration/Fluid Maintenance, Pressure Ulcers, Psychosocial Well-being, Behavioral Symptoms, Urinary Incontinence with Interventions.
5. R9's MDS, dated [DATE], documents R9 is cognitively intact; it is very important to have family or a close friend involved in discussion about care conference.
R9's Face sheet, undated documents R9's diagnoses as Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Hypertensive heart and [NAME] kidney disease with heart failure and Stage 1 through 4 chronic kidney disease, or Unspecified Chronic Kidney Disease, Unspecified combined Systolic (congestive) and Diastolic (Congestive) heart failure, Type 2 Diabetes Mellitus with diabetic chronic kidney disease, Dysphagia, oropharyngeal phase. etc.
R9's Care Conference Report, dated 4/6/22, documents the Interdisciplinary Team, (IDT), met, reviewed R9's current Plan of Care (POC), updates and changes made. The Care Conference Report document identifies those present as IDT and R9.
R9's Care Conference Report dated 7/5/22 documents the IDT met with R9.
R9 Care Plan, dated 7/5/22, documents R9's Care areas as Bed mobility, ADL Functional/ Rehabilitation Potential (e.g., R9 has limited ability to change position in bed, needs assistance to walk, requires assistance with toileting, grooming/hygiene, equipment needs, eating assistance, bathing, limited ability to walk in room requires assistance) R9 at risk for adverse effect due to use of medication with black box warning, Communication, Falls, Nutritional Status, Visual Function, R9 at risk for complications due to Diabetes diagnosis, R9 has diagnosis of Congestive Heart Failure (CHF), R9 has pain/risk for pain, Dehydration/Fluid Maintenance, Pressure Ulcers, Psychosocial Well-being, Behavioral Symptoms, Urinary Incontinence with Interventions.
On 11/4/22 at 10:26 AM, V2 (Director of Nursing/DON), states, the role of the Care Plan person is to notify the family/POA in writing of the upcoming Care Plan Meeting; notify the resident of the upcoming care plan meeting as well. The expectations are that the care plan meetings are held quarterly, and that family and residents are notified of the meeting in a timely manner. We also, expect residents and families/POA's to receive a Care Plan Summary of the meeting.
On 11/4/22 at 10:23 AM, V4 (RN/Care Plan Coordinator) stated, she, (V4), obtains a list of residents for review/revision of Care Plan. Letters or calls are placed to families one week in advance. I normally go to the residents' rooms to inform them of the care plan meeting. Some days we have to change the day to accommodate everyone's schedule. I contact the families one week before the meeting and one week after the meeting. After the meeting, I send a Care Plan meeting summary out to the family and give one to the residents. In preparation for the Care Plan meeting, I review the chart for any change in conditions and review the nurses' notes, any falls and Doctors Orders. If a resident request something that is contradictory to his well-being. We, (the team), discusses it. If the resident is nonverbal, the facility has templates for verbal and nonverbal residents. In terms of who is present for the care planning meeting, sometimes it is just me and the resident.
On 11/3/22 at 12:48 PM, V13 (R7's son) states, he has not received notification of Care Planning meeting for his father, R7. V13 states he has never received notification since his father's admission and has not received a summary of the Care Plan Conference.
On 11/3/22 at 12:27 PM, V14 (R8's brother) states that his sister, (R8), notifies him of what occurred during the Care Planning meeting, and he has attended meetings in the past. However, he is uncertain of the last time he received notification of Care Plan Meetings. V14 has not received a summary of the Care Plan Conference.
On 11/3/22 at 11:46 AM, V15, (R9's brother) states that he has not gotten a letter or telephone call in a while. V15 states he used to get letters and calls, but has not gotten either in a while, V15 could not be specific in the last time he received a letter or call regarding a Care Plan Meetings. V15 has not received a summary of the Care Plan Conference.
On 11/3/22 at 11:34 AM, V16 (R3's daughter) states, I have not been involved in Care Planning since my mothers' admission, (1/21/22). I was contacted yesterday for Care Planning Meeting, 2 weeks from now due to my work schedule.
On 11/4/22 at 9:30 AM, R7 states no one has met with him regarding Care Plan. I have not seen a summary of any Care Plan Meetings.
On 11/4/22 at 9:48 AM, R8 states she has not had a Care Plan Meeting in quite a while, and she normally receives a 2-day advance warning of the meeting. The facility has, on occasion, called her brother. R8 does not recall receiving a Care Plan Summary of the Care Plan Meeting.
On 11/4/22 at 9:35 AM, R9 states, Ain't nobody talked to me about anything.
The facility's undated Policy, included in Resident Rights Handbook, Planning and Implementing Care documents: The resident has the right to be informed or, and participate in, his or her treatment, including; The resident has the right to be fully informed, in a language he or she can understand, of his or her total health status including, but not limited to, his or her medical condition. The resident has the right to participate in the planning process, The planning process must-Facilitate the inclusion of the resident and/or including the right to identify individuals or roles to be included the planning process, the right to request meetings and the right to request revisions to the person-centered Plan of Care.
The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must- facilitate the inclusion of the resident and/or resident representative.
Sept 2022
2 deficiencies
CONCERN
(D)
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 observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls for 3 of 9 residents (R69, R74, R78) reviewed for falls in the sample of 51.
Findings include:
1.R69's Physician Orders dated 05/20/22 documents generalized muscle weakness and other lack of coordination.
R69's MDS, (Minimum Data Sets), dated 08/03/22 documents that the resident has no cognitive impairment. Resident requires extensive assistance of one-person for bed mobility. Resident is total dependence of two plus persons for transfer and toilet use. Resident is total dependence of one-person for locomotion on unit, locomotion off unit, dressing, personal hygiene, and bathing. Resident is independent with setup help only for eating. Resident is not steady, only able to stabilize with staff assistance. Resident uses wheelchair for mobility.
R69's Care Plan dated 07/07/21 documents Problem: Resident at risk for falls decline in ADLs, (Activities of Daily Living), r/t, (related to), old CVA, (Cerebral Vascular Accident). Fall 9/28/21, 2 new falls 10/04/21; 11/8/21; 01/7/22; 01/11/22; 05/02/22.
R69 had falls on 01/07/22, 01/11/22, 03/22/22, 03/23/22, and 2 falls on 05/02/22. R69 only had an intervention dated 05/06/22.
R69's Nursing Notes dated 01/07/22 at 8:52 PM documents called to room AA, noted resident to be on back on floor between bed and wall, head by footboard. Noted resident to be holding on to side rail with R, (right), hand. Bed in lowest position and mattress on floor on other side of bed. Resident stated, I fell out of bed. denies hitting head. PERL, (pupils equal and reactive to light). MD, (Medical Doctor), made aware via (physician notification system), sister aware.
R69's Nursing Notes dated 01/11/22 at 2:02 AM documents resident was found on mat on floor with blood and blood clot surrounding resident all over the floor, linens and mat. Wound dressing changed 2x. This writer applied pressure to wound on foot with no stop to the bleeding. Resident sent to (local hospital), ER, (emergency room) via ambulance. Resident returned to facility via ambulance after tx, (treatment), to wound. POA, (Power of Attorney), and DR., (doctor), made aware.
R69's Nursing Notes dated 03/22/22 at 2:44 PM documents resident was found by CAN, (Certified Nurses Aide), in his room on the floor laying on mattress, resident turned over on the floor from his bed. Resident was observed and had blood coming from his foot wound, drsg, (dressing), was changed and vitals were T (temperature) 98.4; R (respiration) 18; BP(blood pressure) 120/70 ; HR (heart rate) 98; O2 (oxygen saturation) 99% (percent). Resident resting in bed. Resident is resting in bed with call light within reach, no distress noted. Will cont. (continue) to monitor.
R69's Nursing Notes dated 03/23/22 at 6:04 PM documents resident was found on the floor by CNA at 6PM. I asked resident what happened, the resident stated, That's where he wanted to be, he rather be on the floor. The resident was transferred to the chair with assistance. Vitals are BP 118/68, 98.2 T, O2 98%, RR 18, HR 100.
R69's Nursing Notes dated 05/02/22 at 6:24 PM documents resident observed laying on mat beside bed, small amount of bleeding and hematoma noted to R side of head, first aid applied, and resident assisted to bed, ice applied to hematoma and neuro WNL, (within normal limits), DON, (Director of Nursing), Physician and POA notified of incident. Resident frequently puts self on floor to lay. Resident states, when asked I wanted to lay on the floor, will continue to monitor.
R69's Nursing Notes dated 05/02/22 at 8:22 PM documents staff summoned this writer to room, resident observed in floor on mattress with blood all over the linens and skin, cleaned skin to find golf ball sized hematoma to back of right side of head with open area across top of hematoma, held pressure to area with no success of clotting, resident stated, It's because of my blood thinner, area too saturated for (brand name) sterile reinforced wound closure dressings, (local ambulance service), ambulance called, resident taken by EMS, (Emergency Medical System), to (local hospital), will follow up with hospital for updates.
On 09/29/22 at 10:38 AM, observation of floor mat next to R69's bed.
2. R74's Physician Order dated 04/25/22 documents History of falling.
R74's Physician Order dated 05/20/22 documents other abnormalities of gait and mobility.
R74's Physician Order dated 05/23/22 documents muscle weakness (generalized).
R74's MDS dated [DATE] documents that resident has no cognitive impairment. Resident requires extensive assistance of one-person for bed mobility and personal hygiene. Resident requires limited assistance of one-person for transfer, dressing, and toilet use. Resident is independent with setup only for eating. Resident is total dependence of one-person for bathing. Resident is not steady, only able to stabilize with staff assistance. Resident uses walker and wheelchair for mobility.
R74 had a fall on 04/26/22, 05/26/22, 05/27/22, 06/19/22, 06/23/22, 06/24/22, twice on 07/13/22, 09/05/22, 09/13/22, and 09/17/22. No interventions for the falls on 05/27/22, 06/19/22, 06/23/22, 06/24/22, and 07/13/22.
R74's Nursing Notes dated 04/26/22 at 4:01 AM documents This nurse was notified of resident on the floor by CNA. Upon assessment resident was sitting on bottom next to his bed resident stated he was trying to straighten out his pads on his bed. Resident educated on the use of call light to ask for help, resident voiced understanding. No injuries noted res. denies any pain or discomfort at this time. Able to move all extremities within normal limits. Wife made aware. MD made aware via (physician notification system). Will continue to monitor call light and fluids within reach.
R74's Nursing Notes dated 05/26/22 at 11:31 AM documents Resident had a fall that was unwitnessed. Resident states, he stood to use his urinal lost his balance and fell, no injuries noted vitals WNL. Resident was educated to use call light and not to get up without assistance from staff. Doc, (Doctor) and POA notified resident to be sent to local hospital ED for evaluation as resident is on Coumadin. Resident in bed, call light in reach. (local ambulance service), ambulance called, awaiting for their arrival.
R74's Nursing Notes dated 05/27/22 at 7:02 AM documents Resident found on floor near his bed by XX-hall CNA. Resident states he can't remember what he was trying to do. Resident assessed small skin tear on R elbow, PERRLA (pupil equal round, reactive to light, accommodation) = (equal) hand grasp, ROM WNL. Resident denies pain at this time. Resident educated on the use of his call light and to ask for help. POA and MD contacted. Neuros (neurological checks) in place, VS (vital signs) WNL.
R74's Nursing Notes dated 06/19/22 at 5:08 PM documents Res (resident) observed on the floor. Res stated, that he was trying to go to the bathroom tripped and fell on to his bathroom floor landing on his butt. Res denies hitting his head. Res denies any pain or discomfort. res has laceration to bottom crease of pinky toe will (sic) is length on entire pinky and few centimeters deep, unable to measure depth, will need sutures, cleaned applied dry drsg, (dressing). Res on blood thinners. Does not want to go to the ER. Notified POA, (wife), voiced understanding. Awaiting (local ambulance service) for transport to (local hospital). MD notified. MOD, (manager on duty), notified, will cont. to monitor.
R74's Nursing Notes dated 06/23/22 at 7:12 AM documents CNA notified this nurse that resident was on the floor. Upon entry resident was sitting on his bottom stated, he was trying to transfer from bed to W/C, (wheelchair). Able to move all extremities within normal limits. Neuro checks, (neurological checks), started. Notified MD via (physician notification system). Will continue to monitor call light and fluids within reach. DON made aware, phone wife, no answer.
R74's Nursing Notes dated 06/24/22 at 8:15 AM documents CNA notified nurse that resident was on floor in bathroom. Resident stated he was trying to get from toilet to wheelchair. Resident stated, He knew it was shift change, so he didn't want to bother anyone. Resident was educated on how to use call light and wait on help before trying to transfer. Resident stated he understood. Resident denies hitting head and having any pain. Resident body was observed, no new bruises were noted. Resident vitals were BP103/65, 119 P, 19 RR, 97.3 T, 98% o2 on RA (room air) and 0-10 pain. Resident's POA, MD and DON notified. Will cont to monitor. Neuros in check.
R74's Nursing Notes dated 07/13/22 at 12:42 AM documents this nurse was called into resident room noted resident sitting on the floor in front of wheelchair. Resident stated, his legs gave out on him and he slid to the floor. VS 97.4, 63, 109/74, 96%RA, (room air), BS (blood sugar) 174. ROM (range of motion) within normal limits, no new bruising, bleeding, skin tears noted. Resident stated, he is in no pain just want to be back in bed so he can rest. PCP, (Primary Care Physician), and DON notified.
R74's Nursing Notes dated 07/13/22 at 4:14 PM documents this nurse was called into room a second time this time resident noted on the L, (left), side of bed lying face down positioned halfway under the bed, this nurse noted blood coming from R elbow this nurse rolled resident to his back. Completed ROM, which was within normal limits. Resident VS, 97.8, 63, 16, 124/76, 94%RA, BS=124. This nurse completed head to toe assessment. Resident experiencing increase confusion as well as bleeding to the elbow. Resident has a 2x2 skin tear to the R elbow. Resident was placed back into bed with the assistance of 2 CNAs. (Local ambulance service) called EMS, (Emergency Medical Service), arrive 15 min later resident transported to (local hospital) by two EMS drivers, resident's wife was left a voicemail to call back to receive an update.
R74's Nursing Notes dated 09/05/22 at 2:44 PM documents resident had unwitnessed fall in room. States, he was straightening up his bed linen and lost balance. Denies hitting his head or experiencing pain. Vital signs O2 96% RA, BP 120/78, Pulse 64, R 18, 97.4 T, 254 BS, skin assessment completed. Found skin tear to (R) elbow. Resident states, tear is an old one that has re-opened. Educated resident to use call light for assistance when straightening up in bed or transferring. MD notified. Neuro checks ordered x72 hrs. Will cont. to monitor.
R74's Nursing Notes dated 09/13/22 at 4:40 PM documents Resident had a fall at 4pm when asked resident said, was trying to get in bed. Resident was educated on asking for help and pushing the call light to get help. Resident vitals were BP 146/76, 82 P, 97% RA, 19 RR, 97.4 T, 0-10 pain, denies hitting head, no bruising/open areas. Resident POA notified, neuro checks started.
R74's Nursing Note dated 09/17/22 at 12:00 AM documents CNAs informed that resident was on the floor in the bathroom. Went to assess resident & resident was sitting on his buttocks on the bathroom floor facing the toilet. There was blood on the floor & the wall. Resident stated, that he was just standing & lost his balance. Denies hitting his head, neck, or back, no complaints of pain. Bleeding from his L forearm & elbow, two skin tears were found & both had clotted off & stopped bleeding. Vital signs stable, 97.6, 80, 18, 96/77, 96%, BS 229, resident AO (Alert and Orientated) x4 with normal neuro checks. MD notified via (physician notification system). Informed CNAs that resident was not to be left unattended while out of bed any longer due to frequent falls & increased risk for injury. Resident verbalized understanding that he was not to stand up without CNA assist. Informed resident's nurse of the fall.
R74's Nursing Note dated 09/25/22 at 2:40 PM documents Pt. roommate placed call light on, this writer went to answer pt. call light and noted pt. sitting on floor next to bed. This writer asked pt. what happened, and pt. stated, I was trying to get into my wheelchair. VS-104/85, 97% on RA, 80, 18, 86. Pt. stated, I fell on my left hip, but I am not going to the hospital, I don't care what happens. AROM to all four extremities with no c/o pain at this time, provider made aware, Will notify pt.'s spouse, and make her aware. Neuro checks initiated; neuro checks WNL. Pt. educated on call light use and use of non-skid socks. Pt. stated understanding, will cont. to monitor pt. for any changes noted.
On 09/29/22 at 1:00 PM, observation of R74's bed in low position, floor mat next to his bed.
3. R78's Face Sheet dated 8/13/22 documents R78 has a diagnosis of Abnormalities of Gait and Mobility.
R78's John Hopkins Fall Risk Assessment Tool dated 9/22/22 documents R78 is high risk for falls.
R78's Minimum Data Set (MDS) dated [DATE] documents for transfer and bed mobility R78 are limited assistance of 2 staff members.
R78's Fall Investigation dated 9/19/22 documents an unwitnessed fall in her room, while attempting to transfer from bed to chair.
R78's Fall Investigation dated 9/16/22 documents the resident (R78) was observed on the floor next to the bed on her buttocks.
R78's Fall Investigation dated 8/24/22 documents R78 had a fall in room onto buttocks, while attempting to transfer self.
R78's Fall Investigation dated 8/23/22 documents residents was transferring self independently and did not have on proper foot wear. The resident (R78) was found sitting on floor between bedside commode and bed.
R78's Care Plan dated 9/29/22 documents R78 is at risk for falls due to unsteady gait and weakness. R78 has fall interventions for the falls of 9/19/22 and 9/16/22. The Care Plan did not document fall interventions for the falls of 8/23/22 and 8/24/22.
R78's 9/29/22 at 2:00 PM , V2 (Director of Nursing/DON) stated, we have interventions for all of our residents. We will print them out.
The Facility Policy Falls Management dated 7/2017 documents it is the policy to assess and manage residents falls through prevention, investigation and Implementation, and evaluation of interventions.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to store and distribute food in a manner to prevent foodborne illness. This has the potential to affect all 103 residents living...
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Based on observation, interview, and record review, the facility failed to store and distribute food in a manner to prevent foodborne illness. This has the potential to affect all 103 residents living in the Facility.
Findings include:
On 9/27/22 at 7:50 AM, in the walk-in refrigerator, there was a tray containing 18 individual containers of green gelatin, which were not covered, labeled, or dated.
There was also a clear tub containing approximately one quart of a thick, creamy, yellow substance that was covered in plastic wrap, but was not labeled or dated.
On 9/27/22 at 7:55 AM, in the walk-in freezer, there were two trays containing approximately 50 biscuits that were covered in wax paper, but not labeled or dated.
On 9/27/22 at 8:00 AM, in the storage room, there was a 1-gallon container of teriyaki sauce and a 1-gallon container of balsamic vinegar which had both been opened and used but were not dated.
On 9/27/22 at 8:04 AM, across from the stovetop, there was a clear tub full of steam table lids and serving utensils. The tub was not covered, and three of the lids had dried food and grease on them. Behind the stovetop, there was a moderate amount of grease on the hood. There were grease splatters down the side of the stove and on the wall behind. There were pieces of dried food on the stovetop following breakfast preparation. There was dirt in the crease where the floor meets the wall all along the perimeter of the wall behind the stove.
On 9/27/22 at 8:02 AM, V8 (Cook), pulled down his mask with gloved hands to introduce himself, then pulled the mask back up over nose. V8 did not change gloves and resumed plating food from the steam table.
On 9/27/22 at 8:10 AM, there was a thick layer of dust that was approximately 12 inches in diameter above a shelf of pots and pans. V7 (Dietary Manager) stated, We are going to hit that today or tomorrow. V7 pointed toward tub and stated, That is storage for lids, and we aren't using it. We will get a cover on it when we are done cleaning.
On 9/27/22 at 8:25 AM, there was a beverage cooler next to the steam table containing an open carton of mildly thick cranberry cocktail with 8/29 written on it in black marker. There was also an open carton of thickened orange juice labeled 4/4 in black marker and an open carton of thickened water dated 7/18 in black marker. These three open cartons had the following manufacturer's instructions: After opening, may be kept up to 7 days under refrigeration.
On 9/27/22 at 8:27 AM, V6 (Dishwasher) stated, The date (written in black marker) is when they came in. I don't see when they were opened.
On 9/27/22 at 8:50 AM, V7 (Dietary Manager) stated, The writing in black marker on the cartons is the date it was received here. Staff should be putting the open date on the cartons.
The Facility's Food and Supply Storage Policy with revision date of January 2012 documents, Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated.
The Facility's Resident Census and Conditions of Residents Form (CMS 672) dated 9/27/22 documents there are 103 residents living in the Facility.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 6 harm violation(s), $58,910 in fines, Payment denial on record. Review inspection reports carefully.
- • 57 deficiencies on record, including 6 serious (caused harm) violations. Ask about corrective actions taken.
- • $58,910 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Helia Southbelt Healthcare's CMS Rating?
CMS assigns HELIA SOUTHBELT HEALTHCARE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, 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 Helia Southbelt Healthcare Staffed?
CMS rates HELIA SOUTHBELT HEALTHCARE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 54%, compared to the Illinois average of 46%.
What Have Inspectors Found at Helia Southbelt Healthcare?
State health inspectors documented 57 deficiencies at HELIA SOUTHBELT HEALTHCARE during 2022 to 2025. These included: 6 that caused actual resident harm and 51 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Helia Southbelt Healthcare?
HELIA SOUTHBELT HEALTHCARE 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 HELIA HEALTHCARE, a chain that manages multiple nursing homes. With 156 certified beds and approximately 100 residents (about 64% occupancy), it is a mid-sized facility located in BELLEVILLE, Illinois.
How Does Helia Southbelt Healthcare Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, HELIA SOUTHBELT HEALTHCARE's overall rating (1 stars) is below the state average of 2.5, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Helia Southbelt Healthcare?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the below-average staffing rating.
Is Helia Southbelt Healthcare Safe?
Based on CMS inspection data, HELIA SOUTHBELT HEALTHCARE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Helia Southbelt Healthcare Stick Around?
HELIA SOUTHBELT HEALTHCARE has a staff turnover rate of 54%, which is 8 percentage points above the Illinois average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Helia Southbelt Healthcare Ever Fined?
HELIA SOUTHBELT HEALTHCARE has been fined $58,910 across 2 penalty actions. This is above the Illinois average of $33,668. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Helia Southbelt Healthcare on Any Federal Watch List?
HELIA SOUTHBELT HEALTHCARE 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.