MANOR COURT OF CARBONDALE
Non profit - Corporation
120 Beds
UNLIMITED DEVELOPMENT, INC.
Data: November 2025
Trust Grade
20/100
#259 of 665 in IL
Photo by Liberty Village of Carbondale
Photo by Liberty Village of Carbondale
Photo by Liberty Village of Carbondale
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Manor Court of Carbondale has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #259 out of 665 facilities in Illinois, they are in the top half, but their county rank of #1 out of 2 suggests they are the only choice for local families, which may be a concern. The facility is worsening, with the number of issues rising sharply from 5 in 2023 to 26 in 2024. Staffing is a weakness, with a rating of 2 out of 5 and a 54% turnover rate, indicating that staff may not stay long enough to build strong relationships with residents. The facility has been fined $80,971, which is a red flag for potential compliance problems. There is less RN coverage than 79% of state facilities, raising concerns about the quality of medical oversight. Specific incidents include a resident being at risk of falling due to a failure to follow their care plan for assistance during transfers, and another resident not receiving scheduled pain medication, which is concerning for their comfort and wellbeing. Overall, while there are some strengths, such as an average overall star rating, the serious issues and trends indicate that families should proceed with caution.
- Trust Score
- F
- In Illinois
- #259/665
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $80,971 in fines. Higher than 93% of Illinois facilities. Major compliance failures.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Illinois. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Top 38%
Review needed
5 → 26 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 5 issues
2024: 26 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Illinois average (2.5)
Meets federal standards, typical of most facilities
Staff Turnover: 54%
Near Illinois avg (46%)
Higher turnover may affect care consistency
Federal Fines: $80,971
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: UNLIMITED DEVELOPMENT, INC.
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 40 deficiencies on record
6 actual harm
Sept 2024
3 deficiencies
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 and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 4 of 9 residents (R3, R6, R10, and R12) review...
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Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 4 of 9 residents (R3, R6, R10, and R12) reviewed for call light response in a sample of 13.
Findings include:
1. R10's face sheet documents an admission date of 12/29/2022 with diagnoses in part; urinary tract infection, type 2 diabetes mellitus without complications, other abnormalities of gait and mobility, weakness, cognitive communication deficit, pain in right hip, pain in left hip, pain in right leg, diarrhea, nausea, urge incontinence.
R10's MDS (Minimum Data Set) dated 08/20/2024, documents in Section C-Cognitive Patterns a BIMS (Brief Interview for Mental Status) score of 10 , indicating R10 is moderately cognitively impaired. It is documented in Section GG-Functional Abilities and Goals that R10 has an impairment of upper and lower extremities on both sides. Section GG also documents that R10 is requires staff assistance for toileting hygiene, Showering/bathing, dressing, bed mobility and transfers.
R10's current care plan documents R10 is at risk for falls, with interventions including instruct resident to call for assistance before getting out of bed or transferring.
On 09/24/2024 at 01:28pm, R10 who was alert and oriented stated she feels like she always has to wait forever for staff to answer her light. Especially in the evening. R10 stated she does not receive timely incontinence care and now has a sore bottom.
A document titled, Incident list was reviewed for call light response times for 09/13/2024 through 09/17/2024. On this document there are incidents of R10's bedside call light being on over fifteen minutes. On 09/13/2024 at 02:49pm for fifteen minutes and forty-nine seconds, again at 06:06pm for fifteen minutes and forty-seven seconds, and one at 07:55pm that had a response time of one hour and forty minutes. The call light was triggered from R10's bathroom at 06:45pm with a response time of thirteen minutes and forty-nine seconds.
2. R6's face sheet documents an admission date 02/21/2024 with diagnoses in part; chronic obstructive pulmonary disease, unspecified diarrhea, other amnesia, pain, dependence on supplemental oxygen, unilateral primary osteoarthritis, unspecified knee.
R6's MDS (Minimum Data Set) dated 05/22/2024 documents in Section C-Cognitive Patterns, a BIMS (Brief Interview for Mental Status) score of 12, indicating R6 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R6 requires staff assistance with toileting hygiene, showering and bathing, dressing, personal hygiene, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R6 is incontinent of bladder and bowel.
R6's current care plan documents that R6 is at a risk for falls related to recent illness/hospitalization with interventions including, instructing resident to call for assistance before getting out of bed or transferring.
On 09/24/2024 at 01:47pm, R6 who appeared alert stated sometimes it isn't easy to get help when you need it. R6 stated she has a hard time remembering somethings, but that she recalls recently she has been left in the bathroom for an extended period of time more than once. R6 states she uses her call light often, she stated sometimes it seems like no one is going to answer it, other times they answer pretty quickly, say they will be back and then don't come back.
A document titled, Incident list was reviewed with call light response times listed on it for 09/13/2024 through 09/17/2024. On this document there are two incidents on 09/13/2024 for the call light in R6's restroom. One at 03:53pm for thirty-two minutes and forty seconds. Another one at 09:06pm for ten minutes and fifty-three seconds.
3. R3's face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, Difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified.
R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel.
R3's care plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R6 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours.
On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated sometimes they do not even have a CNA assigned to their hallway on the weekends. R3 stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not content, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't. R3 stated if she is not in bed, she will go find someone rather than use her light.
4. R12's face sheet documents an admission date of 08/23/2024 with diagnoses in part; displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, nausea, other abnormalities of gait and mobility, pain, need for assistance with personal care, chest pain, pain in left hip, muscle weakness (generalized), Weakness, acute cystitis without hematuria.
R12's MDS (Minimum Data Set) has not been completed due to being recently admitted . R12's MDS assessment summary dated 09/04/2024, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R12 is cognitively intact.
R12's care plan documents that she is at risk for falls, is incontinent of bowel and bladder and requires staff assistance with turning and repositioning and is toe touch weight bearing on her left lower extremity due to recent fracture.
On 09/24/2024 at 1:20pm, R12 who appeared alert and oriented stated the call lights in this facility are basically useless. She stated you can ring your call light and you will wait forever, someone will tell you they will be back and then they are not. R12 stated she has taken herself to the bathroom or transferred off the toilet on multiple occasions because she cannot wait any longer. R12 stated she recalls that her roommate has also experienced issues with her call light being answered timely.
On 09/19/2024 at 09:50am, V9 (Certified Nurse Aide) stated call lights rarely get answered in a timely manner on the weekends they are so short.
On 09/24/2024 at 12:00pm, V2 (Director of Nursing) stated his expectation would be that call lights were answered within 15 minutes, he stated anything over that makes him sad. V2 stated he expects bathroom call lights to be answered within 5 minutes. V2 stated he knows that it is an issue here and they are trying to work on it.
Facility policy titled Call Light with a revision date on 01/04 documents the following under procedure; Answer call light promptly. Listen to resident's request. Do not make him/her feel that you are too busy to help. Respond to request. Return to resident with prompt reply.
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
Based on interview, observation, and record review, the facility failed to provide dependent residents with showers and timely ADL (Activities of Daily Living) assistance for 4 of 9 residents (R1, R3,...
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Based on interview, observation, and record review, the facility failed to provide dependent residents with showers and timely ADL (Activities of Daily Living) assistance for 4 of 9 residents (R1, R3, R8, R10) reviewed for ADL assistance in the sample of 13.
Findings include:
1. R1's face sheet documents an admission date of 09/12/2024 and a discharge date of 09/17/2024. R1's face sheet documents the following diagnoses in part; functional urinary incontinence, unspecified, mild cognitive impairment of uncertain or unknown etiology, altered mental status, unspecified, age-related osteoporosis without current pathological fracture, cognitive communication deficit, weakness, disorientation, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R1's Face Sheet documents R1 was discharged on 09/17/2024.
R1 did not have a completed MDS due to only residing in the facility for 5 days.
R1's baseline care plan with a revision date of 09/16/2024, documents that R1 is incontinent of bladder and requires assistance with toileting/incontinence and dressing. R1's bath days are Monday, Wednesday, and Friday. R1's care plan further documents that she is at increased risk for pressure ulcers with interventions including Turning and Repositioning every two hours as tolerated. Assist with turning and repositioning. Provide incontinence care after each episode.
R1's progress notes document the following:
09/14/2024 10:36 AM . POA concerned of un neat appearance of Res. This nurse advised POA to speak to management on Monday during business hours to voice concerns. POA agreed to do so. This nurse assured POA of speaking with CNA (Certified Nursing Assistant) staff to meet the needs of Res. POA voiced thanks for this nurse's care.
09/14/2024 10:47 AM This nurse spoke to CNA staff regarding POA concerns. CNA staff voiced understanding. This nurse et (and) other nurse assessed Res room et (and) res appearance. Room in neat et (and) clean condition. Res in clean bed with clean bedding. Res wearing clean clothing. Res does not appear soiled. Res smiling , stating I am fine.
A document in R1's medical record titled Point of Care History dated 9/11/2024-9/18/2024 documents that R1 only received a shower on 09/16/2024 (Monday) at 05:52pm.
On 09/18/2024 at 09:47am, V2 (Director of Nursing/DON) stated R1 had only been in the facility for 5 days and that her family just seemed like they were nit-picking everything.
On 09/19/2024 at 09:32am, V10 (CNA) stated she was not really sure of the staffing on 09/13/2024. V10 stated she did not make it too far off her hallway that day, she was giving showers and that kept her pretty busy. V10 stated that she showered R1 on 09/13/2024 (Friday), she stated she gave her a shower just like she would anyone else and washed her hair.
On 09/19/2024 at 12:46pm, R2 who was alert to person, place and time stated she was in the same room as R1 and felt that R1 was not properly placed on their hallway, she needed a lot and could not really speak up for herself. R2 stated R1 did not really get out of bed much, but that she did not notice any undesirable odors coming from her side of the room and could not speak on whether or not she received care. R2 stated R1 had her daughters visiting often.
2. R3's face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified.
R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel.
R3's Current Care Plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R3 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours.
On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not continent, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't.
3. R8's face sheet documents an admission date of 12/04/2023 with diagnoses in part; other abnormalities of gait and mobility, unsteadiness on feet, weakness, acute respiratory failure with hypercapnia, essential (primary) hypertension, cellulitis of unspecified part of limb, depression, iron deficiency anemia, generalized anxiety disorder, Obstructive and reflux uropathy, benign prostatic hyperplasia, urinary tract infection, nausea.
R8's MDS (Minimum Data Set) dated 07/24/2024, documents a BIMS (Brief Interview for Mental Status) of 14, indicating R8 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R8 requires assistance with toileting hygiene, showering and bathing, dressing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R8 is frequently incontinent of bladder and bowel.
R8's current Care Plan with a revision date of 08/28/2024, documents he is at risk for pressure ulcers with interventions including providing incontinent care after each incontinent episode. Cleanse area of MASD (moisture associated skin damage) to bilateral buttocks and apply zinc twice daily.
On 09/18/2024 at 10:47am, R8 stated he did have a grievance earlier this summer about care. R8 stated he was a little sicker than he is now and was pretty dependent on staff. R8 stated he was having issues receiving timely incontinence care and assistance with personal hygiene. R8 stated it has gotten a little better and the girls do their best, there just aren't many of them to go around. R8 stated weekends are usually pretty scarce for staff and then other days they are tripping over each other. R8 stated he didn't recall having any issues this past weekend, but when he was out and about he did see the girls running all over the place. R8 stated he does have some soreness/open areas to his buttocks, and they have been treating it all summer, he stated that it has improved some. R8 stated if was able to get to the toilet or cleaned up timelier, it would probably be healed by now.
A grievance dated 06/19/2024 by R8 documents that he was having issues with the care given. The documented corrective actions taken were to CNA's on the importance of peri care and what can be caused by a delay in timely hygiene.
4. R10's face sheet documents an admission date of 12/29/2022 with diagnoses in part; urinary tract infection, type 2 diabetes mellitus without complications, other abnormalities of gait and mobility, weakness, cognitive communication deficit, pain in right hip, pain in left hip, pain in right leg, diarrhea, nausea, urge incontinence.
R10's MDS (Minimum Data Set) dated 08/20/2024, documents in Section C-Cognitive Patterns a BIMS (Brief Interview for Mental Status) score of 10, indicating R10 is moderately cognitively impaired. It is documented in Section GG-Functional Abilities and Goals that R10 has an impairment of upper and lower extremities on both sides. Section GG also documents that R10 is requires staff assistance for toileting hygiene, Showering/bathing, dressing, bed mobility and transfers.
R10's current care plan documents R10 is at risk for pressure ulcers with interventions including applying antifungal powder to groin twice daily as needed. Provide incontinent care after each incontinent episode.
On 09/24/2024 at 01:28pm, R10 who appeared alert and oriented stated she feels like she always has to wait forever for staff to answer her light, especially in the evening. R10 stated she does not receive timely incontinence care and now has a sore bottom and gets infections.
On 09/19/2024 at 09:50am, V9 (CNA) stated the incontinence care provided on the night shift could be better. V9 stated when she comes on shift and starts getting people up, you can tell that they haven't been changed for a while. V9 stated some of the more alert residents on R1's hall have also complained about it. V9 stated they are always short on weekends; this past weekend was pretty bad. V9 stated that Fridays are where it starts, they are usually short and then they have to get people ready for appointments and everything on top of the normal care that has to be provided. V9 stated that there are many times there are only 3-4 aides to 4 hallways, that are basically full right now and some of the hallways should really have 2-3 aides on them due to the needs of their residents.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a sufficient amount of staff to ensure residents receive as...
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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 a sufficient amount of staff to ensure residents receive assistance with care. This has the potential to affect all 111 residents living in the facility.
Findings include:
1. R3's Face sheet documents an admission date of 12/04/2023 with diagnoses in part; cerebral infarction, unspecified, difficulty in walking, not elsewhere classified, other reduced mobility, other lack of coordination, weakness, hemiplegia, unspecified affecting left nondominant side, local infection of the skin and subcutaneous tissue, other asthma, flaccid neuropathic bladder, not elsewhere classified, neurogenic bowel, not elsewhere classified.
R3's MDS (Minimum Data Set) dated 08/14/2024, documents a BIMS (Brief Interview for Mental Status) of 15, indicating R3 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R3 has an impairment of upper and lower extremities on one side. This section also documents that R3 requires assistance with toileting hygiene, showering and bathing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R3 is frequently incontinent of bladder and bowel.
R3's Current Care plan documents she is at a risk for falling related to history of cerebrovascular accident with left sided Hemiplegia and osteoarthritis with interventions including, instructing resident to call for assistance before getting out of bed or transferring. It also documents R6 requires staff assistance with care and that she is to be assisted with turning and repositioning and should be turned and repositioned every two hours.
On 09/19/2024, at 12:58pm, R3, who appeared alert and oriented stated there is never anyone to take her to the bathroom in a timely manner, she stated often times she is incontinent but does not receive timely incontinence care either. R3 stated she was under the understanding that everyone should be checked every 2 hours if they were not content, she stated that does not happen for her and she tries to hit her call light to get them to come in and they do not. R3 stated call light response times are all over the place, she stated sometimes they will come in and turn it off, say they will come back, and then they don't.
2. R8's Face sheet documents an admission date of 12/04/2023 with diagnoses in part; other abnormalities of gait and mobility, unsteadiness on feet, weakness, acute respiratory failure with hypercapnia, essential (primary) hypertension, cellulitis of unspecified part of limb, depression, iron deficiency anemia, generalized anxiety disorder, obstructive and reflux uropathy, benign prostatic hyperplasia, urinary tract infection, nausea.
R8's MDS dated [DATE], documents a BIMS of 14, indicating R8 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R8 requires assistance with toileting hygiene, showering and bathing, dressing, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R8 is frequently incontinent of bladder and bowel.
R8's Current care plan documents he is at risk for pressure ulcers with interventions including providing incontinent care after each incontinent episode. Cleanse area of MASD (moisture associated skin damage) to bilateral buttocks and apply zinc twice daily.
On 09/18/2024 at 10:47am, R8 stated he did have a grievance earlier this summer about care. R8 stated he was a little sicker than he is now and was pretty dependent on staff. R8 stated he was having issues receiving timely incontinence care and assistance with personal hygiene. R8 stated it has gotten a little better and the girls do their best, there just aren't many of them to go around. R8 stated weekends are usually pretty scarce for staff and then other days they are tripping over each other. R8 stated he didn't recall having any issues this past weekend, but when he was out and about, he did see the girls running all over the place. R8 stated he does have some soreness/open areas to his buttocks, and they have been treating it all summer, he stated that it has improved some. R8 stated if was able to get to the toilet or cleaned up timelier, it would probably be healed by now.
3. R10's face sheet documents an admission date of 12/29/2022 with diagnoses in part; urinary tract infection, type 2 diabetes mellitus without complications, other abnormalities of gait and mobility, weakness, cognitive communication deficit, pain in right hip, pain in left hip, pain in right leg, diarrhea, nausea, urge incontinence.
R10's MDS (Minimum Data Set) dated 08/20/2024, documents in Section C-Cognitive Patterns a BIMS (Brief Interview for Mental Status) score of 10 , indicating R10 is moderately cognitively impaired. It is documented in Section GG-Functional Abilities and Goals that R10 has an impairment of upper and lower extremities on both sides. Section GG also documents that R10 is requires staff assistance for toileting hygiene, Showering/bathing, dressing, bed mobility and transfers.
R10's current care plan documents R10 is at risk for falls, with interventions including instruct resident to call for assistance before getting out of bed or transferring.
On 09/24/2024 at 01:28pm, R10 who was alert and oriented stated she feels like she always has to wait forever for staff to answer her light. Especially in the evening. R10 stated she does not receive timely incontinence care and now has a sore bottom.
A document titled, Incident list was reviewed for call light response times for 09/13/2024 through 09/17/2024. On this document there are incidents of R10's bedside call light being on over fifteen minutes. On 09/13/2024 at 02:49pm for fifteen minutes and forty-nine seconds, again at 06:06pm for fifteen minutes and forty-seven seconds, and one at 07:55pm that had a response time of one hour and forty minutes. The call light was triggered from R10's bathroom at 06:45pm with a response time of thirteen minutes and forty-nine seconds.
4. R6's face sheet documents an admission date 02/21/2024 with diagnoses in part; chronic obstructive pulmonary disease, unspecified diarrhea, other amnesia, pain, dependence on supplemental oxygen, unilateral primary osteoarthritis, unspecified knee.
R6's MDS (Minimum Data Set) dated 05/22/2024 documents in Section C-Cognitive Patterns, a BIMS (Brief Interview for Mental Status) score of 12, indicating R6 is cognitively intact. In Section GG-Functional Abilities and Goals it documents that R6 requires staff assistance with toileting hygiene, showering and bathing, dressing, personal hygiene, bed mobility and transfers. In Section H- Bladder and Bowel, it documents that R6 is incontinent of bladder and bowel.
R6's current care plan documents that R6 is at a risk for falls related to recent illness/hospitalization with interventions including, instructing resident to call for assistance before getting out of bed or transferring.
On 09/24/2024 at 01:47pm, R6 who appeared alert stated sometimes it isn't easy to get help when you need it. R6 stated she has a hard time remembering somethings, but that she recalls recently she has been left in the bathroom for an extended period of time more than once. R6 states she uses her call light often, she stated sometimes it seems like no one is going to answer it, other times they answer pretty quickly, say they will be back and then don't come back.
A document titled, Incident list was reviewed with call light response times listed on it for 09/13/2024 through 09/17/2024. On this document there are two incidents on 09/13/2024 for the call light in R6's restroom. One at 03:53pm for thirty-two minutes and forty seconds. Another one at 09:06pm for ten minutes and fifty-three seconds.
5. R12's face sheet documents an admission date of 08/23/2024 with diagnoses in part; displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, nausea, other abnormalities of gait and mobility, pain, need for assistance with personal care, chest pain, pain in left hip, muscle weakness (generalized), weakness, acute cystitis without hematuria.
R12's MDS (Minimum Data Set) has not been completed due to being recently admitted . R12's MDS assessment summary dated 09/04/2024, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R12 is cognitively intact.
R12's care plan documents that she is at risk for falls, is incontinent of bowel and bladder and requires staff assistance with turning and repositioning and is toe touch weight bearing on her left lower extremity due to recent fracture.
On 09/24/2024 at 1:20pm, R12 who appeared alert and oriented stated the call lights in this facility are basically useless. She stated you can ring your call light and you will wait forever, someone will tell you they will be back and then they are not. R12 stated she has taken herself to the bathroom or transferred off the toilet on multiple occasions because she cannot wait any longer. R12 stated she recalls that her roommate has also experienced issues with her call light being answered timely.
6. On 09/24/2024 at 01:30pm, R13 who was alert and oriented stated that he has been here for about 8 months and his care has been okay. R13 stated you call for help and nobody comes, then they yell at you for taking yourself to the bathroom. R13 stated he has had CNA's lecture him on not toileting himself and using his call light for help, and his call light was still going off from when he tried to get some help. R13 stated that the staff always seems rushed, he stated he thinks there is not enough of them to go around. R13 stated the weekends are always pretty rough for staff.
On 09/18/2024 at 09:47am, V2 (Director of Nursing/DON) stated staffing can be a little tight on the weekends especially, but that he would be more than happy to provide documentation of anything needed to prove that staffing was covered.
On 09/19/2024 at 09:50am V9 (Certified Nursing Assistant/CNA) stated the incontinence care provided on the night shift could be better. V9 stated when she comes on shift and starts getting people up, you can tell that they haven't been changed for a while. V9 stated some of the more alert residents have also complained about it. V9 stated they are always short on weekends; this past weekend was pretty bad. V9 stated that Fridays are where it starts, they are usually short and then they have to get people ready for appointments and everything on top of the normal care that has to be provided. V9 stated that there are many times there are only 3-4 aides to 4 hallways, that are basically full right now and some of the hallways should really have 2-3 aides on them due to the needs of their residents. V9 stated no matter how short they are no one floats from the memory care unit; they are basically their own entity and scheduled separately. V9 stated the only staff that will assist the CNA's in the main part of the building, is sometimes the kitchen staff, they will help where they can when they see we are drowning. V9 stated that the staff all try to work together and the aides from the lighter halls will pitch in where they can. But there are only so many of us to go around. V9 stated call lights rarely get answered in a timely manner on the weekends they are so short.
On 09/19/2024 at 02:50pm, V11 (CNA) stated the weekends are always a mess when it comes to staffing. He recalled the weekend before he had worked on 09/13/24 and he was sure there were residents waiting longer than they should for assistance, because staffing was not good.
On 09/24/2024 at 02:37pm, V2 (DON) stated if he is trying to determine what staffing was like for previous shifts, he will reference a couple of things. He has a text thread with the other administrative staff and the CNA supervisors where they discuss call ins and schedule changes. V2 stated he will also compare the scheduling template and employee timecards. V2 stated the scheduling template and assignments provided were excluding the memory care unit.
During the course of this investigation, several requests for a working CNA schedule for 09/12/24-09/17/24 were made from V1 (Administrator) and V2 (DON). On 09/19/2024 a copy of the scheduling template for CNA's and a spreadsheet that was identified by V1 as the time clock punches were produced. On 09/20/2024 a handwritten copy of the CNA assignment schedule and CNA time cards were produced. These documents were reviewed, none of these documents correlate the same information. The facility was not able to provide any reproducible evidence that there was sufficient staffing for CNA's on the dates requested.
The facility Resident Bed List Report dated 9/18/24 documents there are currently 111 residents living in the facility.
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide documentation by a physician regarding the basis of a reside...
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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 documentation by a physician regarding the basis of a resident's involuntary transfer/discharge, the specific resident needs that cannot be met, facility attempts to meet the resident needs, the service available at the receiving facility to meet the resident's needs and failed to allow a resident to return to the facility pending the appeal process for 1 (R8) of 4 residents reviewed for Involuntary Discharge in a sample of 8.
Findings include:
R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders, altered mental status, unspecified psychosis not due to a substance or know physiological condition.
R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily.
R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he (R8) displays verbal/ physical behaviors during reflection of care (refusing showers, ADLs (Activities of Daily Living), changing clothes), when others enter his room, when redirecting, while experiencing visual hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of . Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes, and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include: Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will have a reduction in physical/ threatening behaviors directed toward others by next review . with a target date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or approaches regarding R8's diagnosis of Alzheimer's disease or dementia.
R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed toward others occurred 10 times during this time period. Documented interventions attempted include redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The section easily altered after each documented behavior and intervention documents and answer of no. The sections effect on resident and effect on others after each documented behavior and intervention is left blank.
On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19 said she woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding. V19 said she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her around the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over R8's bed and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff reentered R8's room and finished cleaning R8 up and changing his bedding. V19 said R8 would have physical behaviors in his room with staff, but would have physical behaviors anywhere in the facility. V19 said there was no plan on what staff should do when R8 became agitated. V19 said she had spoken with V17 (Memory Care Unit Coordinator) about staff needing a plan on what to do when R8 became agitated or R8 needing his medications changed.
R8's Behavior and Mood Event dated 7/6/24 documented R8 had a physical behavior toward staff with possible contributing factors of ADL (Activities of Daily Living) care. R8's 7/6/24 Behavior and Mood Event documented a 2:00 AM progress note documenting in part . Resident displayed physical behavior towards staff member while performing care. Resident has been redirected and is currently in his bed resting .
R8's Behavior and Mood Events dated 7/8/24 documented a physical behavior directed toward staff with possible contributing factors of ADL care documenting in part . punched staff in abdomen during shower assistance .
On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21 said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not able to be redirected when staff were providing care in his room or in the shower room. V21 said the only thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to try to finish care.
R8's Behavior and Mood Event dated 7/21/24 documented a physical behavior directed towards others and rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a physical behavior toward staff when staff was attempting to assist resident with changing soiled (disposable undergarment) and soiled clothing resident was redirected safety of peers and staff secured resident is resting in bed at this time [sic] .
R8's 7/22/24 Progress Note at 8:30 AM documented in part . Resident refusing care from staff d/t (due to) delusional behaviors (believing that they just want to see him naked). Multipule attempts were made. Still unsuccessful .
R8's 7/22/24 Progress Note at 10:16 AM documented in part . Resident displayed physical behaviors during episodes of rejection of care. Task was stopped at this time and will re-approach .
On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less behaviors with female staff and R8's behaviors were worse at night.
On 9/5/24 at 11:59 AM, V17 (Memory Care Unit Director) said R8 was very difficult. V17 said when R8 was first admitted to the facility R8 was seen by the psychiatric provider and had less behaviors and suddenly had an increase in severity of physical behaviors. V17 said R8 would get mad if anyone went into his room because he thought people were trying to steal from him. V17 said R8 would become violently aggressive very quickly when staff were trying to assist him with care. V17 said R8's Electronic Medical Record (EMR) documented when R8 had physical behaviors toward others but did not contain details of the physical behaviors in the progress notes because other facilities are unlikely to accept the resident if the facility wanted to transfer the resident.
On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he was unsure how the resident's care plan would be updated.
On 9/4/24 at 10:26 AM, V14 (Hospital Social Worker) said R8 had been discharged to the hospital from the facility due to R8 being combative and the facility not being able to meet R8's needs. V14 said during R8's hospital stay R8 did not exhibit any combative behaviors.
On 9/10/24 at 2:43 PM, V14 said she had spoken with V2 at the facility on 7/24/24 and was told R8 would not be allowed to return to the facility.
On 9/10/24 at 2:15 PM, V15 (Ombudsman) said she had spoken with V14 when V14 was told R8 would not be allowed to return to the facility. V15 said she had contacted V16 (Family Member) to ask if V16 would like to appeal the involuntary discharge of R8 from the facility. V14 said she had filed for an appeal of the involuntary discharge. V14 said the facility had not let R8 return to the facility during the involuntary discharge appeal process.
On 9/12/24 at 10:30 AM, V1 (Administrator) said R8 had an incident of violent physical behaviors on 7/6/24, 7/7/24, and 7/21/24. V1 said R8 was involuntarily discharged to the hospital acute psychiatric unit with the intention that R8 was not going to be permitted to return to the facility.
On 9/12/24 at 10:37 AM, V2 (Director of Nursing) said when he called to give the hospital report on R8 V2 had expressed to the hospital R8 would not be permitted to return to the facility and would be arriving with the involuntary discharge documents. V2 said if the hospital acute psychiatric unit had called the facility after R8 had been treated and report R8 was not having any behaviors R8 would not have been permitted to return to the facility.
R8's 7/22/24 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documented R8 had been emergency transferred or discharged from the facility due to the safety of individuals in the facility being endangered.
R8's Illinois Department of Public Health State of Illinois Proof of Service documented in part . The undersigned certifies that true and correct copies of the attached Notice of prehearing conference and hearing were sent via email and/or Certified mail to: (R8), (V16), (V14), (V15), and (the facility's attorney). That said documents were sent from the Illinois Department of Public Health Office in [NAME], Illinois on the (8th) day of August 2024 .
On 9/10/24 at 9:59 AM, V24 (Psychiatric Nurse Practitioner) said R8's physically aggressive behaviors had worsened and R8 needed an inpatient acute psychiatric care stay. V24 said she had adjusted R8's psychiatric medications to the best of her abilities but increasing R8's medications would have been worrisome of chemical restraint. V24 said she was aware of R8 being involuntarily discharged from the facility. V24 said it was the responsibility of the Medical Director to document why the facility was not able to meet the resident's needs and what the receiving facility would need to meet the resident's needs.
On 9/10/24 at 10:46 AM and 9/12/24 at 2:35 PM, messages were left with V25's (Physician) office with no return phone call from V25.
On 9/10/24 at 10:32 AM, V2 said R8's EMR did not contain any documentation by V25 (Physician) pertaining to why the facility could not meet R8's needs and what the receiving facility would need to do to meet R8's needs.
R8's 7/1/24 through 7/31/24 Physician Order Report documented the following medication orders: 7/17/24 - 7/20/24 Depakote Sprinkles 125 mg (milligrams) 2 capsules by mouth 3 times daily, 7/21/24 - open ended Depakote Sprinkles 125 mg 1 capsule by mouth 3 times daily, 7/10/24 clonazepam 0.5 mg 1 tablet by mouth at bedtime, 5/2/24 Risperdal 12.5 mg intramuscular once a day on Wednesday every other week. R8's Physician Order Report did not document an order from V25 or V24 to discharge R8 or to refer R8 to inpatient psychiatric treatment.
R8's hospital Medication Administration Record (MAR) documented an 8/8/24 order to start Remeron 15 mg by mouth at bedtime and an 8/11/24 order to start Zoloft 50 mg by mouth daily.
R8's hospital record documented an 8/3/24 progress note documenting in part . (R8) is going to medical due to low response with spoken with, lack of caloric intake and hydration. (R8) appears to be experiencing failure to thrive. Poor (oral) intake staff is encouraging (R8) to sip water, juice, ice chips through straw with no success. (R8's) vital signs are within normal limits. (R8) skin tents on back of hand and lips and gums are furled. (R8's) hue is a pale ashen hue .
The facility policy titled Skilled Special Care Unit Care and Treatment (revised 4/7/21) documents in part . Our Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed on perceiving any behaviors as a means of communication by a resident and determining the trigger . The resident will be assessed through observations geared toward analysis of the resident's activity interests, cognitive and behavioral status . The care plan is accessible to all (Memory Care Unit) staff and shall be utilized as a directive for all cares provided . As a resident requires more assistance, staff will communicate these needs with the Director of Memory Care to ensure changes are made to the resident's plan of care as needed
The facility policy titled Transfer of a Resident (revised 1/11/23) documents in part . 5. Involuntary Discharge . Involuntary transfers will be initiated for reasons as specified by the Resident Contract.
R8's admission Agreement dated 1/31/23 documents in section Q. Discharge The Facility may terminate the contract and discharge the Resident with a 30 day notice for any of the following reasons: The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility .The safety of individuals in the Facility is endangered. The health of individuals in the Facility would otherwise be endangered .
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 interview, observation, and record review the facility failed to provide showers for dependent residents for 1 (R2) of ...
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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 showers for dependent residents for 1 (R2) of 3 residents reviewed for Activities of Daily Living in a sample of 8.
The findings include:
R2's Resident Face Sheet documents an admission date of 6/17/24 with diagnoses including acute respiratory failure with hypoxia, acute myocardial infarction, unspecified, Chronic Obstructive Pulmonary Disease, unspecified, unspecified open wound, left knee, initial encounter, systemic lupus erythematosus, unspecified, and Rheumatoid arthritis, unspecified.
R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 15 which indicates R2 is cognitively intact. The same MDS documents that for shower/baths, R2 requires substantial/maximum assistance-helper lifts or holds trunk or limbs and provides more than half the effort.
R2's Care Plan documents a problem area of Resident Care Information dated 6/17/24. Documented approaches include bathing type: shower/whirlpool and bath days of Monday, Wednesday and Friday.
On 9/5/24 at 10:00 am, R2's hair appeared to be greasy and to have not been washed. R2 said her hair had not been washed in a week or so and it really needs it. R2 said she has not had a shower in a while, said she has received mostly bed baths with moistened bath wipes. R2 said she would really like her hair washed.
On 9/10/24 at 10:45 am, V1 (Administrator) said the CNA's (Certified Nurse Assistants) does the whirlpools baths.
On 9/5/24 at 11:00 am, V2 (DON/Director of Nurses) said that the facility policy is that a resident receives one shower/bath a week, and they do schedule residents for 2 a week. V2 said it is his expectation that if a resident refuses a shower/bath, staff will go back and attempt again.
R2's document labeled CNA Duties List dated 8/13/24 document that R2 received a shower on 8/27/24 and notes BB which indicates a bed bath. R2's Point of Care History in the electronic Health Record document that R2 refused a shower on 8/17/24. This indicates that R2 went 14 days without a shower/ bath. R2's Point of Care History documents R2's next shower/bath as 9/4/24 which indicates R2 went from 8/25/24 to 9/4/24 which indicates 9 days without a shower/bath.
The facility's Personal Care of Residents policy (revised 12/02) documents Each Resident shall have at least one (1) complete bath and hair wash weekly and as many additional baths and hair washes as necessary for satisfactory personal hygiene.
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
Based on interview and record review, the facility failed to re-assess and implement progressive individualized interventions for increased occurrences of combative behaviors for 1 (R8) of 3 residents...
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Based on interview and record review, the facility failed to re-assess and implement progressive individualized interventions for increased occurrences of combative behaviors for 1 (R8) of 3 residents reviewed for dementia care in the sample of 8.
Findings include:
R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders, altered mental status, unspecified psychosis not due to a substance or known physiological condition.
R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily.
R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he (R8) displays verbal/ physical behaviors during refection of care (refusing showers, ADLs (Activities of Daily Living), changing clothes), when others enter his room, when redirecting, while experiencing visual hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of . Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes, and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include: Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will have a reduction in physical/ threatening behaviors directed toward others by next review . with a target date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or approaches regarding R8's diagnosis of Alzheimer's disease or dementia.
R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed toward others occurred 10 times during this time period. Documented interventions attempted include redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The section easily altered after each documented behavior and intervention documents and answer of no. The sections effect on resident and effect on others after each documented behavior and intervention is left blank.
On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19 said she woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding. V19 said she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her around the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over R8's bed and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff reentered R8's room and finished cleaning R8 up and changing his bedding. V19 said R8 would have physical behaviors in his room with staff, but would have physical behaviors anywhere in the facility. V19 said there was no plan on what staff should do when R8 became agitated. V19 said she had spoken with V17 (Memory Care Unit Coordinator) about staff needing a plan on what to do when R8 became agitated or R8 needing his medications changed.
R8's 7/6/24 Behavior and Mood Event documented R8 had a physical behavior toward staff with possible contributing factors of ADL care. R8's 7/6/24 Behavior and Mood Event documented a 2:00 AM progress note documenting in part . Resident displayed physical behavior towards staff member while preforming care. Resident has been redirected and is currently in his bed resting .
R8's 7/8/24 Behavior and Mood Event documented a physical behavior directed toward staff with possible contributing factors of ADL care documenting in part . punched staff in abdomen during shower assistance .
On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21 said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not able to be redirected when staff were providing care in his room or in the shower room. V21 said the only thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to try to finish care.
R8's 7/21/24 Behavior and Mood Event documented a physical behavior directed towards others and rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a physical behavior toward staff when staff was attempting to assist resident with changing soiled depends and soiled clothing resident was redirected safety of peers and staff secured resident is resting in bed at this time [sic] .
R8's 7/22/24 progress note at 8:30 AM documented in part . Resident refusing care from staff d/t (due to) delusional behaviors (believing that they just want to see him naked). Multipule attempts were made. Still unsuccessful .
R8's 7/22/24 progress note at 10:16 AM documented in part . Resident displayed physical behaviors during episodes of rejection of care. Task was stopped at this time and will re-approach .
On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less behaviors with female staff and R8's behaviors were worse at night.
On 9/5/24 at 11:59 AM, V17 said R8 was very difficult. V17 said when R8 was first admitted to the facility R8 was seen by psychiatric provider and had less behaviors and suddenly had an increase in severity of physical behaviors. V17 said R8 would get mad if anyone went into his room because he thought people were trying to steal from him. V17 said R8 would become violently aggressive very quickly when staff were trying to assist him with care. V17 said that R8's Electronic Medical Record (EMR) documented when R8 had physical behaviors toward others but did not contain details of the physical behaviors in the progress notes because other facilities are unlikely to accept the resident if the facility wanted to transfer the resident.
On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he was unsure how the resident's care plan would be updated.
The facility's revised 4/7/21 Skilled Special Care Unit Care and Treatment policy documented in part . Our Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed on perceiving any behaviors as a means of communication be a resident and determining the trigger . The resident will be assessed through observations geared toward analysis of the residents activity interests, cognitive and behavioral status . The care plan is accessible to all (Memory Care Unit) staff and shall be utilized as a directive for all cares provided . As a resident requires more assistance, staff will communicate these needs with the Director of Memory Care to ensure changes are made to the resident's plan of care as needed
Aug 2024
5 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Resident Rights
(Tag F0550)
A resident was harmed · This affected 1 resident
Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 of 3 residents (R1) reviewed for dignity in ...
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Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 of 3 residents (R1) reviewed for dignity in a sample of 7. This failure resulted in R1 having feelings of desertion, fear, frustration and embarrassment.
Findings include:
1. R1's face sheet documents an admission date of 6/1/2024. Diagnoses upon admission included Multiple Sclerosis, cellulites of left lower limb, edema, weakness, difficulty walking, foot drop of right foot, pain, depression, anxiety disorder. R1's MDS (Minimum Data Set) dated 6/14/2024 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. Section GG Functional abilities and goals) indicates R1 requires substantial/maximal assistance with toileting, hygiene, also indicates R1 is dependent for walking, sit to stand, chair to bed and toilet transfers.
R1's Care plan dated 6/20/2024 indicates, problem of resident at risk for falling related to recent illness/hospitalization and new environment with approach dated 6/1/2024 to instruct resident to use call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Problem start date of 6/1/2024 section named Resident Care Information with approach dated 6/1/2024 indicates bowel and bladder: incontinent, incontinent products, small pull ups.
On 8/13/2024 at 3:45 PM, R1 was observed sitting outside on the front porch of the facility visiting with a friend. R1 was alert and oriented. R1 was sitting in wheelchair which she was able to propel around in independently. R1 stated, I did live alone just a few months ago but I had a fall transferring myself, so I landed in the hospital and then was transferred here for therapy. R1 stated, My hopes are to get my strength back and go back home. R1 stated, My diagnosis is a tough one to stay ahead of but with my determination I believe I can stay at home a few more years and stay self-sufficient which isn't the normal for most people, but I have learned to adjust. She said she doesn't want to get anyone in trouble, and she knows how short staffed they are around here, but the care is just not very good. R1 stated the weekends are the worst but last Sunday was horrible. R1 stated she was on her call light asking for help for hours but there was nobody to help her. R1 stated the Occupational therapist was there and she is the one who finally came and helped me get cleaned up and was soaked in urine. My family came and took me home for the day.
On 8/14/2024 at 9:14 AM, R1 was asked to explain what occurred on Sunday 8/11/2024. R1 stated, I was on my call light for hours needing assistance as I needed to use the bathroom. R1 stated she does have episodes of incontinence but for the most part she is able to feel the urge and get to the bathroom with assistance in time. R1 stated, I am really OCD (obsessive compulsive disorder) about continence. I use liners and I do not like being wet so I try to ask for assistance at the first feeling of urgency so I can stay dry. R1 stated, 'Sunday felt like the longest day of my life. There was nobody here to help us and I felt deserted. R1 stated she could hear all the lights ringing nonstop but there was just no help. R1 stated, I was totally soaked through my clothes, and I had to lay like that for hours. R1 stated, I started asking for help before 6 AM and it was after 10 AM before anyone was able to help me. The one that helped me was the OT (Occupational Therapist). R1 was asked how this made her feel and she stated, I was crying so much, I felt deserted, and I was frustrated, embarrassed, and fearful. R1 stated, I fear this will happen again and I know it will because they do not have enough staff to take care of us especially on the weekend. I know it is not their fault and some of the staff go above and beyond but they can't work every day of the week, and they can't do it all either. I was supposed to go to my daughter's house, and I did get to go but we were 2 hours behind leaving because I wasn't ready, nobody could help me get ready.
On 8/14/2024 at 11:15 AM, V8 COTA (Certified Occupational Therapist Assistant) stated, I work Sunday through Thursday at the facility. V8 stated, I worked this past Sunday. V8 was asked if there was anything unusual about Sunday 8/11/2024, V8 stated the weekends are always bad, but this past Sunday was bad. V8 stated, I was trying to help by changing resident and getting them up, as I was seeing resident for their therapy. V8 was asked if she cared for R1 and V8 stated yes, I noticed in between my patients that I was treating that (R1's) call light had been on for a long, long time, approximately 45 minutes. She said she went into R1's room to check on her and when she entered the room the smell of urine was very strong as soon as she walked into the room. (R1) was lying in bed crying and was very upset. She said she felt bad for her as (R1) was so soaked with urine, it was so bad. V8 stated (R1) was so embarrassed and just kept apologizing to me for being in such bad shape, it was so sad. V8 stated (R1) is totally dependent with walking so she can't get up by herself. V8 stated, I just started getting her cleaned up. R1 was soaked through the pad, depends, night clothes, bed pad and sheet down to the mattress. the mattress was even wet. V8 stated R1 was even wet all the way up her entire back. V8 said (R1's) family member came in just as she was finishing, and the family member said R1 had been texting her since early that AM stating she needed help.
On 8/14/2024 at 2:10 PM, via phone interview, V26, R1's family member stated on Sunday 8/11/2024, R1 called her crying that morning and so she went out to the facility. V26 stated R1 was in a very depressed state. V26 stated she got there just as they were cleaning her up and staff had to change everything as she was soaked in urine. V26 stated weekends are low staff, the ones that show up are good but there are too many residents for just a few staff to care for. V26 stated, Something needs to be done because (R1) was distraught on Sunday and not in a good place when I got here on Sunday. None of the residents deserve this kind of care.
On 8/15/2024 at 2:50 PM, V21 (Certified Nurse Assistant/CNA) stated she takes care of R1 frequently. V21 stated R1 is continent of bowel and bladder. V21 stated R1 lets the staff know when she has the urge to use the bathroom and they take her to the bathroom. V21 states R1 still wears a depends (adult brief) because she is always afraid, she may have an accident and that would embarrass R1 as she is very conscious of her hygiene.
On 8/14/2024 a call light log provided by V2 was reviewed. The document contained room numbers, time the call light was started and the time the call light was ended. The call light log recorded R1's room for 8/11/2024 as start time 8:24:49 am and end time 9:26 :31am with duration of 1:01:42.
On 8/13/2024 at 4:00 PM, V2 was asked if he was aware of call lights not being answered in a timely manner and residents had long wait times for care, V2 stated he was not aware of any real issues. V2 was presented with the document (unnamed) that V2 provided, a log with room numbers, when call lights were triggered with hour, minutes, and seconds, (start time) and call light end time and dates. A specific date was presented to V2 of 8/11/2024 for R1's call light, start time was 8:24:49 am and end time was 9:26 :31am with duration of 1:01:42. V2 was asked to interpret the duration time and V2 stated that is 1 hour, 1 minute and 42 seconds and I missed seeing that when I gave you the call light usage report. V2 was asked if this was acceptable practice and V2 stated, No not at all. V2 was asked what the expectation was for the duration time of call lights being activated, V2 stated, 15 minutes or less. V2 was asked if he knows why this was an issue on 8/11/2024, V2 stated, because of staffing, it was bad. V2 was asked if care was provided adequately to the residents on 8/11/2024 during the day shift, V2 stated, evidently not. V2 was asked if the grievances pertaining to the past weekend were reviewed and V2 stated 'yes they were.
On 8/14/2024 at 1:25 PM V19 CNA (Certified Nurse Aid/CNA Supervisor) stated she worked on 8/11/2024. V19 stated the weekends are always bad due to younger staff and they call in all the time or don't show up. V19 stated it is a real struggle but this past Sunday 8/11/2024 was the worse she has ever seen it. V19 stated it has been bad for last 6 months on the weekends. V19 stated trying to get staff. V19 said breakfast was late as well V19 stated R1 is normally continent of bowel and bladder and was made aware that V8 was able to get to her and get her cleaned up. V19 stated this is not acceptable care at all, the care was not good due to staffing. V19 stated I did the best I could but with only me it wasn't enough. Call lights were on too long.
On 8/14/2024 at 8:45AM, V6 (Licensed Practical Nurse/LPN) stated he worked on 8/11/2024 and he stated they were very short on CNA's. V6 said it wasn't the idea situation, but we tried our best to take care of the residents. V6 stated he worked on 200 halls and was able to help change some residents and answer lights sometimes.
On 8/15/2024 at 7:40 PM, V17 (LPN) was asked if she worked on 8/11/2024 dayshift, V17 stated, Yes and we only had 4 CNAs and there was only 1 CNA on the hall I was working on which was 100 hall. V17 said the care was really delayed that day.
On 8/15/2024 at 8:45 AM, V13 (CNA) stated on Sunday 8/11/2024 the staffing was very short. V13 stated, The call lights were on longer than usual because normally we have 2-3 CNAs on that particular hall which is 300 hall, but Sunday there but she was the only one on the hall . V12 stated I wish it could have been better but I did the best I could do. V13 stated V15 CNA came in at around 11:30 AM and helped with lunch and left at 2:00 PM. The nurse on my hall could not help due to restrictions.
On 8/14/2024 at 3:55 PM, V1 (Administrator) was asked if she was aware of there only being 4 CNAs in the facility on 8/11/2024. V1 stated, I received a text at 6AM but I didn't see it until I woke up at 7:45 AM and at that time I started calling people. V1 was asked if 4 CNAs for the 4 halls acceptable staffing numbers and she responded it is not preferred. V1 was asked if she was aware of the issues with care such as residents being left wet and call lights not being answered for long periods of time and she stated yes and had received grievances and had addressed the issues.
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 F0697
(Tag F0697)
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 administer pain medication as ordered and develop interventions to m...
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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 pain medication as ordered and develop interventions to manage pain for 1 of 5 residents (R2) reviewed for medication administration in the sample of 7. This failure resulted in R2 experiencing increased pain due to missing 4 doses of ordered pain medication on 8/10/24, 8/11/24, and 8/12/24.
The findings include:
R2's Face sheet documents an admission date of 6/24/2024 and includes diagnoses of encephalopathy, end stage renal disease, weakness, low back pain, malignant neoplasm of left kidney except renal pelvis, weakness and hemodialysis.
R2's Minimum Data Set (MDS) dated [DATE], section C, Cognitive Patterns, documents a Brief Interview for Metal Status (BIMS) score of 15 indicating R2 is cognitively intact. Section GG, Functional Abilities and Goals, documents R2 requires substantial/maximal assistance with toileting hygiene and shower/bathing, lower body dressing and putting on and taking off footwear, and partial/moderate assist with upper body dressing. Section J, Health Conditions, documents under Pain Management, within the last 5 days (of assessment 7/26/2024) Received scheduled pain medication regimen? with a documented answer of no. The same section documents the questions within the last 5 days, received PRN (as needed) pain medication or was offered and declined? and received non-medication intervention for pain? with documented answers of yes. Under the section titled Pain Assessment Interview of section J of the same MDS dated [DATE], documents the answer of No to the question of have you had pain or hurting at any time in the last 5 days? R2's Care Plan dated 7/25/2024 does not contain problem or focus area regarding pain and does not include any interventions or approaches to manage R2's pain.
R2's Pain Management Observation completed on admission dated 6/24/24, documents the answer yes to the question Have you had pain or hurting at any time in the last 5 days? and documents the pain site of back pain. The onset of pain is documented as mid morning and afternoon, duration of pain as comes and goes, and other expressions of pain as crying/whining, grimacing/clenched teeth, and bracing/guarding/ rubbing affected area.
On 8/13/2024 at 2:38 PM, R2 is an alert and oriented male resident observed lying in bed in the fetal position. R2 stated I am in bad pain R2 explained he had a fall the other day when he tried to get up and open his door, he stated he took one step and fell. R2 stated I have bruises to my right butt. R2 stated I am asking for pain medicine now; I usually get my pain medicine, but I had to wait last night, and I was hurting bad. R2 stated he usually gets it around 7 PM but last night (8/12/24) he had to wait until 10 PM because the nurse went on break before she gave him his pain medicine and he was hurting bad for 3 hours. R2 stated they are very particular about pain medications, I ask for it and it takes a long time, I have been asking for a while right now, my back is hurting bad. While in the room with R2, V9 (Licensed Practical Nurse/LPN) came in with pain medication stated to be Hydrocodone-acetaminophen 5/325mg. R2 was given Hydrocodone-acetaminophen 5/325mg by mouth. V9 stated I am trying to get R2's pain under control as R2 is having bad back pain that has increased since the fall. V9 stated R2 is getting Tylenol in between pain meds to help with breakthrough pain. R2 stated The Tylenol is not helping me very much. V9 stated R2's pain medication is now every 6 hours and the next dose will be due at 8:00 PM. V9 offered R2 a warm compress to R2's back to help with the pain and R2 accepted and stated, I will try anything because this pain is bad. V9 stated R2's pain medication is scheduled at 8AM, 2 PM, 8 PM and 2 AM. R2 stated it takes about an hour for the pain medication to start easing the pain. V9 asked R2 to rate his pain and R2 responded it is a 8-9 on a 10 point pain scale. V9 stated she had given Tylenol around 10 AM and R2 stated that didn't help anything.
R2's Physician's Order Report dated 6/24/2024 -8/15/2024 documents the following orders: Hydrocodone-acetaminophen 5/325 mg (milligrams) every 6 hours as needed dated 6/24/2024 and a discontinuation date of 7/25/2024, hydrocodone- acetaminophen 5/325mg twice daily dated 7/25/24 and a discontinuation date of 7/30/2024, hydrocodone- acetaminophen 5/325mg three times a day dated 7/30/24 and a discontinuation date of 8/12/2024, hydrocodone- acetaminophen 5/325mg every 6 hours dated 8/12/24 and a discontinuation date of 8/13/2024, and a current order of hydrocodone- acetaminophen 5/325mg dated 8/13/2024 every 4 hours. All hydrocodone- acetaminophen 5/325mg orders have a documented diagnosis of low back pain. The same Physician's Order Report documents a current order dated 6/24/24 for Lidocaine adhesive 5% patch, 1 patch topical once a day for low back pain and an order dated 6/25/24 for acetaminophen 325 mg 2 tablets every 6 hours as needed for low back pain.
R2's Medication Administration Record (MAR) with a date range of 8/1/24 through 8/20/24, documents that Hydrocodone-acetaminophen 5-325 MG tablet was Not Administered: Drug/Item unavailable on the following dates and administration times: 8/10/24 at 5:00 PM, 8/11/24 at 5:00 PM, 8/12/24 at 7:00 AM, and 8/12/24 at 2:00 PM. The same MAR documents an order of Assess pain Q (every) shift using the 0-10 pain scale or verbal descriptor scale. R2's pain is documented as a 6 on shift 2 (6PM to 6AM) on 8/10/24, as 9/10 on shift 1 (6AM to 6PM) on 5 on shift 2 on 8/11/24, as 8/10 on shift 1 and 7/10 on shift 2 on 8/12/24.
R 2's Progress Note dated 8/12/2024 at 6:03 AM, documents resident gets hydrocodone5-325mg three times a day with PRN (as needed) Tylenol (acetaminophen) throughout the night as needed. Resident is still very much in pain and states that it is generalized, and the pain pills are not controlling his pain and moans in pain. NP (Nurse Practitioner) on call and notified for further orders.
R2's Progress Notes dated 8/12/2024 at 11:53 AM by V2 documents, (V14 Nurse Practitioner) gives updated order to increase Norco (Hydrocodone-acetaminophen) to QID (4 times a day/every 6 hours). One time order for Tramadol 50 mg now related to pain prior to appointment.
On 8/13/2024 at 4:00 PM, V2 (Director of Nursing) stated I know R2 ran out of pain medications on Sunday 8/11/2024 and just gave him Tylenol for his back pain. V2 stated R2 has chronic back pain and hurts most of the time. V2 stated R2 was on pain medications 3 times a day and V2 got orders to increase the frequency to 4 times a day which is every 6 hours to help with the increased pain since the fall.
On 8/202/2024 at 8:33 PM, V28 (Licensed Practical Nurse) was asked if she had to get medications out of the Stat Safe Machine (emergency medication kit) for R2, she stated she has had to get his pain medications out of there but there was a time recently when there were no more Hydrocodone-acetaminophen 5-325 mg in the Stat Safe Machine so there were none available to administer to R2. V28 stated R2 had bad back pain and as of recently the pain medications kept getting increased to help control the pain as the pain was bad.
On 8/20/24 at 10:14 AM, V14 (Nurse Practitioner) said she was called about increase pain so she increased R2's pain medications. V14 was asked if she was aware R2 went without pain medications at times and she stated I know they do run out of medications but they know they should always notify me or the on call (physician) because we will always give orders for available medications from the emergency kit, even though it may not be exactly what was ordered originally but we can substitute until the original medications is delivered. V14 stated Nobody should go without medications, there is a ton of options in the emergency kits. V14 stated she had met with R2's family member in late July and they discussed how R2's pain was getting worse and they had even discussed palliative care in the future. V14 stated R2's family member is very realistic and stated (R2) is miserable with his pain. V14 stated R2 was also kind of hit and miss with his dialysis as well and some of it has to do with his pain. V14 stated R2 didn't always want to participate in therapy or get up. V14 aid R2 wanted to stay on his side with his knees bent up for comfort. That was his position that helped with the pain. V14 stated that it is very sad because R2 was such a kind man and he was very alert and oriented.
The facility policy titled Pain Management Policy with revision date of 3/3/2022 documents The facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy. Purpose: To identify residents experiencing pain to establish control of pain to the resident's satisfaction and to relieve related symptoms . Procedures: 5. An individualized care plan will be developed and implemented.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview, and record review the facility failed provide timely toileting assistance to 3 of 7 residents (R1, R3, and R5) reviewed for ADL (Activities of Daily Living) care in the sample of 7...
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Based on interview, and record review the facility failed provide timely toileting assistance to 3 of 7 residents (R1, R3, and R5) reviewed for ADL (Activities of Daily Living) care in the sample of 7.
Findings include:
1. R1's face sheet documents an admission date of 6/1/2024. Diagnoses upon admission included Multiple Sclerosis, cellulites of left lower limb, edema, weakness, difficulty walking, foot drop of right foot, pain, depression, anxiety disorder. MDS (Minimum Data Set) dated 6/14/2024 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitively intact under Section C. Section GG (Functional abilities and goals) indicates R1 requires substantial/maximal assistance with toileting hygiene, also indicates R1 is dependent for walking, sit to stand, chair to bed and toilet transfers.
R1's Care plan dated 6/20/2024 indicates, problem of resident at risk for falling related to recent illness/hospitalization and new environment with approach dated 6/1/2024 to instruct resident to use call for assist before getting out of bed or transferring. Encourage resident to stand slowly. Problem start date of 6/1/2024 section named Resident Care Information with approach dated 6/1/2024 indicates bowel and bladder: incontinent, incontinent products, small pull ups.
On 8/13/2024 at 3:45 PM, R1 was observed sitting outside on the front porch of the facility visiting with a friend. R1 was alert and oriented. R1 stated the weekends are the worst but last Sunday was horrible, the staffing was low, call lights weren't getting answered, incontinence episode happened, and a therapy person helped me get cleaned up.
On 8/14/2024 at 9:14 AM, R1 was asked to explain what occurred on Sunday 8/11/2024. R1 stated, I was on my call light for hours needing assistance as I needed to use the bathroom. R1 stated she does have episodes of incontinence but for the most part she is able to feel the urge and get to the bathroom with assistance in time. R1 stated, I am really OCD (obsessive compulsive disorder) about continence. I use liners and I do not like being wet so I try to ask for assistance at the first feeling of urgency so I can stay dry. R1 stated, 'Sunday felt like the longest day of my life. There was nobody here to help us and I felt deserted. She stated she could hear call lights going off for a long time. She stated she was incontinent and soaked in urine and she laid in urine for hours. R1 stated, I started asking for help before 6 AM and it was after 10 AM before anyone was able to help me. She said the one that helped me was the OT (Occupational Therapist).
On 8/14/2024 11:15 AM, V8 COTA (Certified Occupational Therapist Assistant) stated, I work Sunday through Thursday at the facility. V8 stated, I worked this past Sunday. V8 was asked if there was anything unusual about Sunday 8/11/2024, V8 stated the weekends are always bad, but this past Sunday was really bad. V8 stated, I was trying to help by changing resident and getting them up, as I was seeing resident for their therapy. V8 was asked if she cared for R1 and V8 stated yes, I noticed in between my patients that I was treating that R1's call light had been on for a long, long time, approximately 45 minutes. She said she went into R1's room to check on her and when she entered the room the smell of urine was very strong as soon as she walked into the room. V8 stated (R1) was so soaked with urine, it was so bad. V8 stated (R1) is totally dependent with walking so she can't get up by herself. V8 stated, I just started getting her cleaned up. R1 was soaked through the pad, depends, night clothes, bed pad and sheet down to the mattress. the mattress was even wet. V8 stated R1 was even wet all the way up her entire back. V8 said (R1's) family member came in just as she was finishing, and the family member said R1 had been texting her since early that AM stating she needed help.
On 8/14/2024 at 2:10 PM via phone interview, V26 (R1's) family member stated Sunday 8/11/2024, (R1) called her crying that morning and so she went out to the facility. She said when she arrived R1 was getting changed and everything was soaked in urine. V26 said weekends are low staff, the ones that show up are good but there are too many residents for just a few staff to provide care for.
On 8/13/2024 at 4:00 PM, V2 was asked if he was aware of call lights not being answered in a timely manner and residents had long wait times for care, V2 stated he was not aware of any real issues. V2 was presented with the document (unnamed) that V2 provided, a log with room numbers, when call lights were triggered with hour, minutes, and seconds, (start time) and call light end time and dates. A specific date was presented to V2 of 8/11/2024 for R1's call light, start time was 8:24:49 am and end time was 9:26 :31am with duration of 1:01:42. V2 was asked to interpret the duration time and V2 stated that is 1 hour, 1 minute and 42 seconds and I missed seeing that when I gave you the call light usage report. V2 was asked if this was acceptable practice and V2 stated, No not at all. V2 was asked what the expectation was for the duration time of call lights being activated, V2 stated, 15 minutes or less. V2 was asked if he knows why this was an issue on 8/11/2024, V2 stated, because of staffing, it was bad. V2 was asked if care was provided adequately to the residents on 8/11/2024 during the day shift, V2 stated, evidently not. V2 was asked if the grievances pertaining to the past weekend were reviewed and V2 stated 'yes they were.
On 8/15/2024 at 2:50 PM, V21 (Certified Nurse Assistant/CNA) stated she takes care of R1 frequently. V21 stated R1 is continent of bowel and bladder. V21 stated R1 lets the staff know when she has the urge to use the bathroom and they take her to the bathroom. V21 states R1 still wears a depends (adult brief) because she is always afraid, she may have an accident and that would embarrass R1 as she is very conscious of her hygiene.
2. R3's Face sheet indicates R3 was admitted to facility on 6/23/2022, diagnosis included Type 2 diabetes mellitus, hyperlipidemia, hypothyroidism chronic atrial fibrillation. MDS (Minimum Data Set) dated 6/26/2024, section C contains a BIMS (Brief Interview for Mental Status) score of 15 indicating R3 is cognitively intact. Section GG of MDS indicates requires partial/moderate assistance for toileting hygiene. Section H, Bladder and Bowel indicates occasionally incontinent of bladder and frequently incontinent of bowels.
R3's Care plan dated 6/27/2024 documents under section Resident care information bowel and bladder incontinence urinal/bedpan, incontinence products stand brief.
On 8/13/2024 at 1:35 PM, R3 was alert and oriented sitting in his recliner in his room. R3 stated the care is usually pretty good but the weekends are usually worse. R3 stated this past Sunday was the worst. R3 stated, I know they had several workers call in, so we just had one CNA working our hall and she is very pregnant. She did her best, but it was bad. R3 stated he is always incontinent, and they try to keep him cleaned up but Sunday he had to sit in a wet depends for a while due to not enough staff. R3 stated it took a while to get to the call lights too. R3 said he didn't put his call light on because there were already a lot of lights on, and he knew they would get to him when they could as they always get him up and ready for breakfast. R3 stated the meals were running late too.
3. R5's face sheet documents an admission date of 3/18/2024, which includes diagnoses of Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries. Aphasia, weakness, malnutrition. MDS (Minimum Data Set) dated 6/19/2024 includes a BIMS (Brief Interview for Mental Status) score of 8, which indicates a severe cognitive impairment. Section GG of the MDS indicates R1 is dependent for toileting, showers dressing and personal hygiene.
R5's Care plan dated 7/3/2024, documents under resident care information R5 has a colostomy, and incontinent of bladder, bathroom as tolerated, incontinent products standard briefs.
On 8/14/2024 at 12:08PM, V27 (R5's family member) stated he filled out a grievance on 8/12/24 because something must be done with the staffing issues at the facility. V27 stated, I was sick of finding R5 laying in puddles of urine, R5 doesn't deserve that at all. V27 stated, I have had to hire private sitters to be with R5 to give me a rest in the mornings. V27 stated, CNAs in the facility are so few and some of them don't even need to be working anywhere as they don't do anything. V27 stated, 1 CNA on that hall is no way right and the resident 's deserve so much better than that, but that is not an unusual occurrence there. V27 stated, I am old too, but I will do all I can to care for R5 and assure R5 is taken care of.
Grievance form dated 8/12/24 by V27 regarding R5 documents, the husband states he has some concerns regarding personal care throughout the weekend and concerns with resident just lying in bed. The same grievance form indicates grievance was substantiated and signed by V1.
On 8/15/2024 at 10:05AM, R5 was noted to be sitting in wheelchair and was getting hair done by V24 (private sitter). R5 was alert but non interviewable due to aphasia. V24 said she was hired as a private sitter due to low staff and to make sure R5 is cared for right. V24 stated the number of staff is hit and miss but usually very low staffing. We feel like we must have someone with R5 to assure she gets changed and fed. V24 stated we had to push hard to get showers done but that is better now. R5 is getting therapy right now and our hopes are to take her home so we can care for her there.
On 8/14/2024 at 1:25 PM, V19 (Certified Nurse Aid/CNA Supervisor) stated she worked on 8/11/2024. V19 stated the weekends are always bad due to younger staff and they call in all the time or don't show up. V19 stated it is a real struggle but this past Sunday 8/11/2024 was the worse she has ever seen it. V19 stated it has been bad for last 6 months on the weekends. V19 stated trying to get staff. V19 said breakfast was late as well V19 stated R1 is normally continent of bowel and bladder and was made aware that V8 was able to get to her and get her cleaned up. V19 stated this is not acceptable care at all, the care was not good due to staffing. V19 stated, I did the best I could but with only me it wasn't enough. Call lights were on too long.
On 8/14/2024 at 8:45AM, V6 (Licensed Practical Nurse/LPN) stated he worked on 8/11/2024 and he stated they were very short on CNA's. V6 said it wasn't the ideal situation, but we tried our best to take care of the residents. V6 stated he worked on 200 halls and was able to help change some residents and answer lights sometimes.
On 8/15/2024 at 7:40 PM, V17 (LPN) was asked if she worked on 8/11/2024 dayshift, V17 stated, Yes and we only had 4 CNAs and there was only 1 CNA on the hall I was working on which was 100 hall. V17 said the care was really delayed that day.
On 8/15/2024 at 8:45 AM, V13 (CNA) stated on Sunday 8/11/2024 the staffing was very short. V13 stated, The call lights were on longer than usual because normally we have 2-3 CNAs on that particular hall which is 300 hall, but Sunday she was the only one on the hall . V12 stated I wish it could have been better but I did the best I could do. V13 stated V15 CNA came in at around 11:30 AM and helped with lunch and left at 2:00 PM. The nurse on my hall could not help due to restrictions.
On 8/14/2024 at 3:55 PM, V1 (Administrator) was asked if she was aware of there only being 4 CNAs in the facility on 8/11/2024. V1 stated, I received a text at 6AM but I didn't see it until I woke up at 7:45 AM and at that time I started calling people. V1 was asked if 4 CNAs for the 4 halls acceptable staffing numbers and she responded it is not preferred. V1 was asked if she was aware of the issues with care such as residents being left wet and call lights not being answered for long periods of time and she stated yes and had received grievances and had addressed the issues.
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 acquire medication refills timely resulting in missed ...
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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 acquire medication refills timely resulting in missed doses of medications for 3 of 5 residents (R1, R2, and R3) reviewed for medication administration in a sample of 7.
The findings include:
1. R1's face sheet documents an admission date of 6/1/2024, documented diagnoses upon admission included Multiple Sclerosis, cellulites of left lower limb, edema, weakness, difficulty walking, foot drop of right foot, pain, depression, anxiety disorder. R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 indicating R1 is cognitively intact.
R1's Physician Order Report dated 6/1/2024 through 8/15/2024 documents and order dated 6/1/24 for Dextroamphetamine-amphetamine (Adderall) - Schedule II, 10 mg once a day, diagnosis Generalized Anxiety Disorder.
R1's Medication Administration Record (MAR) dated 7/14/2024 through 8-13-2024 documented on 8/11/2024 and 8/12/2024 Dextroamphetamine-amphetamine (Adderall) was not administered and documented drug /item unavailable.
On 8/13/2024 at 3:45 PM, R1 stated they have not been giving me my meds correctly and was out of some of medications especially my anxiety medication. My anxiety medication is just as needed but when I needed it last week, they told me I was out, and they would have to wait to get it in from pharmacy. I also asked for my Vicodin, but they said they were out of that medication too. R1 said I don't know what is going on, but I need my medications
On 8/14/2024 at 2:10 PM, spoke with V26 (R1's family member) via phone. V26 stated another issue is that they always run out of R1's medications and I know because she has asked for them when I am here and the nurses say, 'we are out of this medication or that medication and we have to order them.'
On 8/14/2024 at 2:40PM, V5 (Licensed Practical Nurse/LPN) was asked to check supply of Xanax for R1. 30 pills were observed in the card and there were no other cards for this medication for R1. V5 stated the card arrived last night and is marked on the label that the medication was processed on 8/12/2024. That means it was delivered last night 8/13/2024.
On 8/13/2024 at 4:00 PM, V2 (Director of Nursing/DON) was asked if he was aware of resident's running out of medications and having to go without some of their medications, V2 stated yes I know of some medications that were out and not given due to being out. V2 was asked to explain, V2 stated R1 was out of Adderall Sunday (8/11/24) and Monday (8/12/24). V2 stated said that there was a clerical error with V14's (Nurse Practitioner/NP) DEA (Drug Enforcement Agency) number, so they had to send scripts to V29 (Physician/MD), and it ended up being a mess. V2 stated if the drugs were schedule III, IV, or V, I could have taken care of those as I am an agent for V29 but I cannot reorder schedule II drugs.
On 8/14/2024 at 3:05 PM, V14 was asked if there were issues with her DEA number that prohibited her from being able to address new prescriptions or refills for scheduled drugs, V14 stated she did have a little issue but it didn't cause an issue because she would contact V29 and all the background work was done by them and should not have caused any issues or delays for the facility. V14 stated there is however an issue here at the facility with letting the providers know when a prescription is about to expire or refills that require a providers authorization. V14 stated there needs to be a way to flag those medications so resident's get their medications refilled before they totally run out. V14 stated, we have had a discussion about running out of medications, we are working on that, and we have on call available 24 hours a day.
R1's Progress Notes dated 8/11/2024 at 3:29 PM, authored by V17 (Licensed Practical Nurse) documents in part .Amphetamine/Dexro (Adderall) 10mg is o/s (out of stock). Pharmacy communicated to avail the order on Monday 8/12/2024.
R1's Progress Note dated 8/12/2024 at 2:52 PM, authored by V2, documents (name of contracted pharmacy) contacted regarding alprazolam (Xanax). Medication will be delivered tonight per (V20 Pharmacist). New scripts for Norco and Adderall sent to (name of provider) for signature.
The pharmacy invoice pharmacy with a delivery date of delivery 8/13/2024 at 1:30 AM, indicated medications for R1 including Hydrocodone 5/325 mg 30 tabs, Alprazolam 1 mg 30 tablets, and Dextroamphetamine-Amphetamine 10mg 30 tabs.
2. R2's face sheet documents an admission date of 6/24/2024, with documented diagnoses including Encephalopathy, end stage renal disease, weakness, low back pain, malignant neoplasm of left kidney except renal pelvis, weakness. R2's MDS dated [DATE], section C, documents a BIMS score of 15 indicating R2 is cognitively intact.
R2's Physician's Order Report dated 6/24/2024 -8/15/2024 documents the following orders: Hydrocodone- acetaminophen 5/325mg three times a day dated 7/30/24 and a discontinuation date of 8/12/2024, hydrocodone- acetaminophen 5/325mg every 6 hours dated 8/12/24 and a discontinuation date of 8/13/2024, and a current order of hydrocodone- acetaminophen 5/325mg dated 8/13/2024 every 4 hours.
R2's Medication Administration Record (MAR) with a date range of 8/1/24 through 8/20/24, documents that Hydrocodone-acetaminophen 5-325 MG tablet was Not Administered: Drug/Item unavailable on the following dates and administration times: 8/10/24 at 5:00 PM, 8/11/24 at 5:00 PM, 8/12/24 at 7:00 AM, and 8/12/24 at 2:00 PM. The same MAR documents and order of Assess pain Q (every) shift using the 0-10 pain scale or verbal descriptor scale. R2's pain is documented as a 6 on shift 2 (6PM to 6AM) on 8/10/24, as 9/10 on shift 1 (6AM to 6PM) on 5 on shift 2 on 8/11/24, as 8/10 on shift 1 and 7/10 on shift 2 on 8/12/24.
An inventory/ sign out sheet for the Statsafe machine (emergency medication kit) with a date range of 8/10/24 to 8/13/24, documents that 2 tablets were signed out on 8/11/24 at 5:42 AM, 4 tablets signed out on 8/12/24 at 4:54 PM, and 1 tablet on 8/13/24 at 4:45 PM of Hydrocodone/APAP 5-325mg for R2.
On 8/13/2024 2:38 PM, R2 is an alert and oriented male resident observed lying in bed lying in the fetal position. R2 stated I am in bad pain. R2 stated I am asking for pain medicine now; I usually get my pain medicine, but I had to wait last night, and I was hurting bad. R2 stated he usually gets it around 7 PM but last night he had to wait until 10 PM because the nurse went on break before she gave him his pain medicine and he was hurting bad for 3 hours. R2 stated they are very particular about pain medications, I ask for it and it takes a long time, I have been asking for a while right now, my back is hurting so bad. While in the room with R2, V9 (Licensed Practical Nurse) came in with pain medication and stated it was Hydrocodone-acetaminophen 5/325mg. V9 asked R2 to rate his pain on a pain scale of 0-10, and R2 responded it is an 8-9. V9 was observed administering Hydrocodone-acetaminophen 5/325mg by mouth to R2 at this time.
On 8/13/2024 at 4:00 PM, V2 (Director of Nursing) stated I know R2 ran out of pain medications on Sunday 8/11/2024 and we just gave him Tylenol for his back pain. V2 stated (R2) has chronic back pain and hurts most of the time. V2 stated R2 was on pain medications 3 times a day and V2 got orders to increase the frequency to 4 times a day which is every 6 hours to help with the increased pain since the fall.
3. R3's face Sheet documents that R3 was admitted to the facility 6/23/2022, with diagnoses including Type 2 diabetes mellitus, hyperlipidemia, hypothyroidism, and chronic atrial fibrillation. R3's MDS dated [DATE], section C, documents a BIMS score of 15, indicting R3 is cognitively intact.
R3's Physician Order Report dated 8/1/2024 - 8/20/2024 documents an order dated 5/1/24 for Accu-checks twice a day, and an order dated 5/1/24 and a discontinuation date of 8/20/24 for Trulicity (dulaglutide) 1.5mg/0.5ml; amount: 0.75mg subcutaneous once a week on Wednesdays, 6:00 PM-12:00AM.
R3's Medication Administration Record dated 8/1/2024-8/15/2024 documents the order for the Trulicity injection once a day on Wednesday, with the last documented dose administered on 8/7/2024. The next dose was due on 8/14/2024 and documents Not Administered: Drug/item unavailable.
On 8/15/2024 at 12:45 AM, R3 stated you had asked me the other day about my medications, well last night I was due to have my Trulicity injection, the medication nurse came in and told me the box was empty and the medication is not available at this time, but she would reorder it. R3 stated I am supposed to have it every Wednesday but did not get it this week. R3 stated I told you the other day that I do not have any issues with my medications, and I usually don't, maybe a few times, but this is my diabetic medication, and it is important.
On 8/15/2024 at 12:45 PM, V18 (Licensed Practical Nurse) was asked to look for R3's Trulicity injection. V18 looked through the medication cart and noted the Trulicity was not on the cart. V18 was observed entering the medication room and look through the refrigerator for R3's Trulicity and noted the medication was not there.
On 8/15/2024 at 1:06 PM, V20 (Pharmacist) was asked if he has received a request for a refill for R3's Trulicity, V20 stated yes last night. V20 stated R3's last Trulicity was filled on July 12th, 2024, and is a 28-day supply. V20 was asked if the nurses must request refill or does it get refilled automatically as it is evidence that it is outside of the 28-day supply, V20 stated they can reorder electronically. V20 was asked when the missed dose was due and V20 stated on Wednesday 8/ 14/2024. V20 stated it will not hurt R3 if it is a few days late as it is a weekly medication. V20 stated it will arrive 8/16/2024 on the midnight delivery.
On 8/202/2024 at 8:33 PM, spoke with V28 (Licensed Practical Nurse) was asked if she has ever known resident's being out of medications, V28 stated yes, and I come into many meds that need reordered. I try to keep up with this, but I only work 3 nights a week. V28 stated they have had issues with running out of medications because V14 (Nurse Practitioner) had issues with her DEA number being suspended. V28 said that V14 is the one that would pick up the prescriptions needed and take them with her, and they were not taken care of, and we ran out of narcotics. V14's DEA number is fixed now, and she can sign scripts again, so things are getting back on track.
The (name of pharmacy) Policy and Procedural Manual (revision date 6/24), under General Pharmacy Information documents Refills: Monday-Friday by 3pm, Saturday by 1pm. Refills after above time will be sent with the next day's delivery unless the nurse calls the pharmacy to request it that day. For facilities with electronic integration, refills are to be communicated electronically through the interface. For facilities without electronic integration, refills are to be requested via fax using the refill sheet and barcoded stickers. [NAME] the section titled Administration of Medication step A documents 1. PRN (as needed) medication cards are to be ordered as needed (not necessarily on a monthly basis}. Do not wait until the card is empty to notify the pharmacy of a needed refill. The section titled Stat Safe Machine documents under step E, The use of the Stat Safe Machine is to be for starter doses only. Normal ordering procedures should follow to ensure the resident receives a full quantity of the ordered medications.
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 interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to effect all 102 residents...
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Based on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to effect all 102 residents residing in the facility.
The findings include:
On 8/13/2024 at 3:45 PM, R1 was observed sitting outside on the front porch of the facility visiting with a friend. R1 is an alert and oriented to person place and time. R1 stated I don't want to get anyone in trouble, and I know how short staffed they are around here, but the care is just not very good. R1 stated the weekends are the worst but last Sunday was horrible. R1 stated she was on her call light asking for help for hours but there was nobody to help her. R1 stated the Occupational therapist was there and she is the one who finally came and helped me get cleaned up. I was soaked in urine. My family came and took me home for the day.
On 8/13/2024 at 1:35 PM, R3 was observed sitting in his recliner. R3 is alert and oriented. R3 stated the care is usually pretty good but the weekends are usually worse. R3 stated this past Sunday (8/11/24) was the worst. R3 stated I know they had several workers call in, so we just had one CNA (Certified Nursing Assistant) working our hall and she is very pregnant. She did her best, but it was bad. R3 stated he is always incontinent, and they try to keep him cleaned up but Sunday he had to sit in a wet depends for a while due to not enough staff. R3 stated it took a while to get to the call lights too. R3 stated the meals were running late too.
On 8/13/2024 at 1:59 PM, R4 was observed lying in bed reading a book. R4 is alert and oriented. R4 stated I would be better if I could walk by myself. R4 stated she has been in the facility about a year and a half. R4 stated as far as getting my call light answered, it varies, sometimes it gets answered quickly and other times it never gets answered. R4 stated They have staffing issues here, sometimes staff don't even show up for work, they call in, and I believe it is the pay. R4 stated this last Sunday (8/11/24) there was only one CNA for this whole hall. R4 stated there was only one CNA working for many hours on Sunday. R4 states she is continent of bowel and bladder but requires assistance to the bathroom. R4 stated she was able to hold her urine until they could get to her on Sunday. R4 stated Sunday was a rough day for everyone and the staff did the best they could do.
On 8/14/2024 at 12:08PM, V27 (R5's family member) stated he filled out a grievance because something has to be done with the staffing issues at the facility. V27 stated I was sick of finding (R5) laying in puddles of urine, (R5) doesn't deserve that at all. V27 stated I have had to hire private sitters to be with (R5) to give me a rest in the mornings. V27 stated CNA's in the facility are so few and some of them don't even need to be working anywhere as they don't do anything. V27 stated 1 CNA on that hall is no way right and the resident 's deserve so much better than that, but that is not an unusual occurrence there. V27 stated I am old, too, but I will do all I can to care for (R5) and assure (R5) is taken care of.
A Grievance form dated 8/12/24 by V27 (family member) regarding R5 documents, the husband states he has some concerns regarding personal care throughout the weekend and concerns with resident just lying in bed. The same grievance form indicates grievance was substantiated and signed by V1 (Administrator).
On 8/15/2024 at 10:05AM, R5 was observed sitting in a wheelchair and was getting hair done by V24 (private sitter). R5 is non interviewable. V24stated, (V27) has hired a private sitter due to low staff and to make sure (R5) is cared for right. V27 stated the amount of staff is hit and miss but usually very low staffing. We feel like we must have someone with (R5) to assure she gets changed and fed. V27 stated we had to push hard to get showers done but that is better now. (R5) is getting therapy right now and our hopes are to take her home where we can all take care of her at home.
On 8/15/2024 at 10:00 AM, R6 is observed sitting in her room in her wheelchair. R6 is alert and oriented. R6 stated care is alright here but night shift is the worse. R6 stated the staff does not come in and check on me or my roommate very often through the night. R6 stated on this last Sunday (8/11/24) the day shift was very short staffed and we had to wait on care, and it took a while to get our call light answered. R6 stated she is usually continent but does have episode of incontinence. R6 stated she was incontinent on Sunday but that is not unusual at times. R6 stated they just didn't have enough workers.
On 8/13/2024 at 1:44 PM, R7 was observed sitting in her wheelchair eating a snack. R7 is alert and oriented. R7 stated her care is normally good and they answer my call light a quick as they can. R7 stated they are short on staff here and they do the best they can, but it does sometimes take them a while to answer the call lights, I have had to wait up to 15 minutes but that was on the night shift. I can't really say which shift is worse though.
On 8/13/2024 at 2:19 PM, V4 (CNA) stated staffing is doing ok and we usually have 4 CNA's on our hall. So, with 4 we are able to answer call lights quickly and care of the residents very good. Weekends are a bit challenging, but we do the best we can do.
On 8/13/2024 at 3:31 PM, V7 (CNA) stated I work 6AM-6:30PM, lately staffing has been fine except the weekends. V7 stated Weekends are the worst, usually we have 10-11 CNA's over here scheduled, meaning all halls except the memory hall, but that doesn't mean that is how many shows up for work. V7 stated we already don't have enough scheduled for this coming Saturday. V7 stated I am sometimes by myself on a hall and when I am by myself, I have trouble answering call lights quickly and providing good care but I try my best.
The call light log report provided by V2 documents room numbers, time the call lights were started and the time the call light was ended. On 8/11/24, the call light log recorded R1's call light start time was 8:24:49 am and end time was 9:26 :31am with duration of 1:01:42.
On 8/13/2024 at 4:00 PM, V2 (Director of Nursing) was asked about staffing on Sunday 8/11/2024, V2 stated we were a bit short on Sunday. V2 stated we normally run 8-10 on the weekends but we had 5 this weekend. V2 stated we had 2 CNA's and a nurse on one hall and 1 CNA and a nurse on the other halls except on the memory hall. V2 was asked if he was aware of call lights not being answered in a timely manner and residents had long wait times for care, V2 stated he was not aware of any real issues. V2 was asked to interpret the duration time documented on the call light log report for R1's call light wait time on 8/11/24 and V2 stated that is 1 hour, 1 minute and 42 seconds. V2 said he missed seeing that when he reviewed the call light log report. V2 was asked if this was acceptable practice and V2 stated No not at all and I seen some call light times with a duration of 30 minutes and I thought that was bad. V2 was asked what the expectation was for the duration time of call lights being activated, V2 stated 15 minutes or less. V2 was asked if he knows why this was an issue on 8/11/2024, V2 stated because of staffing, it was bad. V2 was asked if care was provided adequately to the residents on 8/11/2024 during the day shift, V2 stated evidently not. V2 was asked if the grievances pertaining to the past weekend was reviewed and V2 stated yes they were.
On 8/14/2024 at 2:44PM, V2 was asked when V2 was made aware of the staffing issues on 8/11/2024, V2 checked his phone and replied 8:31 AM is when I was notified via text. V2 stated I then called the on-call nurse V11 (Licensed Practical Nurse) and told her to go into the facility and help. V2 stated this would have made 5 working the floor. V2 stated I then sent a text to V19 (Certified Nurse Assistant/CNA Supervisor) and let her know V11 was heading in to help. V2 was asked if he knew what time V11 arrived at the facility and V2 stated not sure. V2 stated 4 CNA's is not the ideal situation for sure. V2 stated this is not the normal standard, but I feel the residents were tended to. V2 was asked if the CNA's or Nurses that work Memory Lane ever come over to the other halls to help out, V2 stated No they have their own supervisor that does their own staffing, so they only work that side of the building. They don't count on the other halls.
On 8/14/2024 at 11:15 AM, V8 (Certified Occupational Therapist Assistant/ COTA) stated I work Sunday through Thursday at the facility. V8 stated I worked this past Sunday. V8 was asked if there was anything unusual about Sunday 8/11/2024, V8 stated well the weekends are always bad, but this past Sunday was really bad. V8 stated I was trying to help as I was seeing resident like changing them or getting them up.
On 8/14/2024 at 1:20 PM, V11 (Licensed Practical Nurse/LPN) stated she was the on-call nurse for 8/11/2024 so she was called in to help due to only 4 CNA's showed up to work. V11 stated she arrived about 10:00AM and worked until 2:30 PM. V11 stated she just floated between halls to help where she could. V11 stated there was only 1 CNA on100 hall which was V19 (CNA). V11 stated she has never worked on 100 hall so she didn't know any of the residents. V19 stated I did what I could to help but it was bad, weekend staffing is bad.
On 8/14/2024 at 1:25 PM, V19 (Certified Nurse Aid/CNA Supervisor) stated she worked on 8/11/2024. V19 stated the weekends are always bad due to younger staff and they call in all the time or don't show up. V19 stated it is a real struggle but this past Sunday, 8/11/2024, was the worst she has ever seen it. V19 stated it has been bad for last 6 months on the the weekends. V19 stated when she got to work on 8/11/2024 and noted the number of staff that were present, she then tried to call V1 and V2, but they were still sleeping so she was able to reach another manager. V19 stated she received a return call about 7:00AM from V1 and said V2 would be calling someone in to help. V19 stated she received a text later from V2 informing her the on-call nurse, V11, would be coming in to help. V19 stated V11 arrived around 10 :00 AM. V19 stated that breakfast was late getting served around 8:30 AM. V19 stated this is not acceptable care at all, the care was not good due to staffing. V19 stated I did the best I could but with only me it wasn't enough. Call lights were on too long.
On 8/14/2024 at 2:10 PM, spoke with V26 (R1's family member) via phone. V26 stated on Sunday 8/11/2024, R1 called her crying that morning and so V26 came out to the facility. V26 stated R1 was in a very depressed state. V26 stated she got there just as they were cleaning her up and staff had to change everything as she was soaked in urine. V26 stated weekends are low staff, the ones that show up are good but there are too many residents for just a few staff to care for.
On 8/14/2024 at 3:55 PM, V1 (Administrator) was asked if she was aware of only having 4 CNA's in the facility on 8/11/2024. V1 stated I received a text at 6AM but I didn't see it until I woke up at 7:45 AM and at that time I started calling people. V1 was asked if 4 CNA's for the 4 halls is acceptable staffing, V1 stated, it is not preferred. V1 stated they should have used the emergency number in this case.
On 8/14/2024 at 8:45AM, V6 (LPN) stated Yes, I worked on 8/11/2024 and we were very short on CNA's. V6 said We did the best we could. It wasn't the ideal situation, but we tried our best to take care of the residents. V6 stated he worked on 200 hall on 8/11/2024 and was able to help change some residents and answer lights sometimes.
On 8/15/2024 at 8:38 AM, V12 (CNA) stated staffing is normally pretty good but weekends are hectic. We have young ones that don't know how to separate work from play. V12 stated on this past Sunday (8/11/2024) we only had 4 CNA's, but we worked together as best we could. V12 stated I was on 200 hall, which is my normal hall. There are many residents on that hall that are dependent and lifts. V12 stated the call lights were on too long.
On 8/15/2024 at 8:45 AM, V13 (CNA) stated on Sunday 8/11/2024 the staffing was very short. V13 stated the call lights were on longer than usual because normally we have 2-3 CNA's on 400 hall which is 200 hall but Sunday there was just 1, me. V12 stated I wish it could have been better, but I did the best I could do. V13 stated V15 (CNA) came in at around 11:30 AM and helped with lunch and left at 2:00 PM. The nurse on my hall could not help due to restrictions.
On 8/15/2024 at 7:40 PM, V17 (LPN) was asked if she worked on 8/11/2024 dayshift, V17 stated yes and we only had 4 CNA's and there was only 1 CNA on the hall I was working on 100 hall. V17 stated care was really delayed that day. Something has to be done because this is horrible for the residents and we try, the ones that are there but there is just no way to take care of them with such a small amount of staff. V17 also stated that call lights were going off for a long, long time and they just couldn't get to them like they should have been.
The Midnight Census Worksheet dated 8/13/2024 documents the total census of 102 residents residing at the facility.
A document titled Time Detail Report for 8/11/2024 documents the total number of CNA's clocked in for 6 AM were 6 CNA's (total includes 2 CNAs for 300 hall, 5 LPNs (Licensed Practical Nurse) at 6 AM, 1 came in at 10:00 AM, and 1 LPN came in at 1:00PM.)
Jun 2024
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · 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 follow therapeutic dietary recommendations for residen...
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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 follow therapeutic dietary recommendations for residents at risk for weight loss for 1 of 1 (R64) resident reviewed for nutrition in a sample of 38. This failure resulted in R64 having a significant weight loss of 16.8% over a period of 6 months.
The Findings Include:
R64's Resident Face Sheet documents an admission date of 8/7/21 and a date of birth of [DATE]. This same document includes the following diagnoses: unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit.
R64's 06/2024 Physician Order Sheet documents a diet order for mechanical soft, high calorie/high protein (HCHP) diet.
R64's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that she is cognitively intact. This same MDS Section K0300 documents 'No' under the weight loss category question regarding Loss of 5% or more in the last month or 10% or more in the last 6 months.
On 6/13/24 at 12:45 PM, R64's lunch tray was delivered to her room and had turkey, gravy, bread, mashed potatoes/gravy, vegetable medley, pineapple cake, and a red juice drink. R64's meal ticket included that R64 should receive a fortified whole milk-8 ounces, offer ice cream, offer egg salad, tuna salad and hard boiled eggs. R64 stated at this time she doesn't really like the food today and is not very hungry. R64 stated that sometimes she gets a pudding and/or milk but not every time and she is never offered the egg/tuna salad or hard boiled eggs. At this time, R64 had a pudding but not a fortified milk.
On 6/13/24 at 1:00 PM, V21 (Certified Nurse Assistant/CNA) stated that the CNA's pass out the supplements that are prepared prior to the meal service, like pudding, milk or ice cream.
Review of R64's Comprehensive Care Plan does not include a focus area for nutrition or weight loss.
A 'Vitals Report dated 9/1/23-6/14/24 documents the following weights: September 2023-125.8 pounds, October 2023-125 pounds, January 2024-106 pounds, February 2024-100 pounds, March 2024- 104 pounds, and June 2024-96 pounds.
R64's Resident Progress Note dated 3/27/24 by V10 (Registered Dietitian/RD) documents that RD wound/wt (weight) note. Weights (3/7) 104# (pounds), 2/27: 100#, 1/23 106#, 1/12 112, and 9/7 125.8#. Resident with 21% weight loss/6 months. Within normal limits of IBW (Ideal Body Weight) 108-138 pounds. Body Mass Index: 18 (underweight). Resident (underweight) with Stage 2 P.U. (pressure ulcer) Rt (right) upper buttock. On a mechanical soft diet (has signed a waiver for regular potato chips). High Calorie High Protein supplement. Intakes 25-27%. On Remeron which can increase appetite. Bilateral heels boggy. Plan: Continue Arginaid daily, MVI (Multivitamin), Vitamin C, and Zn (Zinc) for healing needs. To boost calories/protein. Re-Recommended. Add: Fortified Pudding at lunch and supper. Will monitor. Refer PRN (as needed).
R64's Resident Progress Note dated 4/23/24 by V10 documents: Resident with resolved Stage 3 P.U., still has a Stage II P.U. on Rt buttock and P.U. on Lt (Left) buttock. Hx (history) poor-fair meal intakes. Remeron use may stimulate appetite. March 7 Wt 104 #, weights fluctuating. Continue M/S (Mechanical Soft) HCHP supplements all meals. Recommend fortified pudding at lunch and supper for additional protein. Monitor weights, intakes, skin. Refer PRN.
On 6/12/24 at 2:00 PM, V2 (Dietary Supervisor) stated that for some reason the two dietary (computer) programs are not communicating. V2 determined that the orders are put in for the supplements, but the labels are not printing for the dietary staff to know to prepare these supplements. V2 further stated that the staff prepares the HCHP food items prior to each meal and delivers to the dining room the resident will be dining in. V2 stated that the staff are alerted to prepare these food supplements from labels generated (from the system).
On 6/12/24 at 2:30 PM, V10 (Registered Dietitian) stated that anyone with a HCHP supplement ordered, it is procedure that residents will receive these supplements at all meals. V10 further stated that the only time that it would be specific to a certain meal would be when the order has that specific meal written in. When asked how V10 knows what residents require her assessment, V10 stated that she reviews charts offsite prior to her onsite facility visits twice a month to determine who needs to be evaluated. In addition, while onsite the staff can always let her know of any issues that need to be addressed that she was unaware of.
On 6/12/24 at 3:00 PM, V9 (Physician) stated that when a resident has weight loss and/or is at risk and there are supplements ordered, he would then expect those supplements to be provided to prevent weight loss/increase the intake.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours for 1 of 20 (R78) residents reviewed for ...
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Based on interview and record review, the facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours for 1 of 20 (R78) residents reviewed for abuse in the sample of 38.
Findings include:
1. R78's Face Sheet documented an admission date of 8/21/23 with diagnoses including: unspecified dementia, insomnia, bipolar disorder, anxiety disorder, depression, and hypothyroidism.
R78's 5/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R78 was cognitively intact.
R78's last reviewed/revised care plan documented in part .(R78) has dementia with anxiety, bipolar disorder, anxiety disorder, and depression . (R78) displays physical and verbal behaviors during hallucinations and delusional episodes. (R78) often misinterprets staff's intentions.) .
R78's 5/21/24 Loss Control/ Damage Report documented in part . Description of missing/damaged item(s) $100 missing from resident . When was the item(s) last observed: Date 5/19/24 . When was the item(s) discovered to be missing/ damaged: . 5/21/24 . Investigation: Searched room (and) all belongings . Conclusion . Money never found. All staff interviewed. Staff states that they had never seen resident (with) money that (R78's) friend keeps it with her due to resident being confused .
On 6/13/24 at 11:04 AM, R78 said she thought she had told the nurse and thought the nurse had found her missing money. R78 was asked if R78 knew who the nurse was she told about her missing money and R78 pointed to V20 (Activities Director). R78 said she was not sure when her money had went missing because it had been a while back. R78 stated I'm feeling a little confused today.
On 6/13/24 at 11:07 AM, V20 (Activities Director) said she was not aware of R78 missing any money. V20 said R78 had told her R78's phone was missing the morning of 6/13/24 and V20 had assisted R78 in finding R78's phone. V20 said R78 did have a wallet but was not aware if R78 ever had money in R78's wallet. V20 said R78 would have delusions R78 had items missing.
On 6/13/24 at 12:11 PM, V1 (Director of Nursing/ DON) said no investigation was completed for R78's allegation of missing money and it was not reported to Illinois Department of Public Health (IDPH). V1 said V22 (Administrator) was responsible for completing investigations and reporting to IDPH and V1 was unsure why V22 had not. V1 said he was not able to produce any investigation documentation.
On 6/13/24 at 12:17 PM, V22 (Administrator) said via a phone interview, V22 was aware of R78's allegation of missing money. V22 said after reporting R78's allegation to local law enforcement there was not enough evidence to substantiate R78 had missing money. V22 said due to local law enforcement not being able to substantiate R78's allegation V22 had not reported the incident to IDPH and that was a failure on my part.
The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documented in part .B. Initial steps and reports of alleged abuse or neglect . 2. If the matter involves alleged abuse or results in serious bodily injury, the Administrator, or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more than 2 hours after the matter becomes known or no later that 24 hours if the allegation does not involve abuse and does not result in serious bodily injury .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for 1 (R78) of 20 residents in a sample of 38. ...
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Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for 1 (R78) of 20 residents in a sample of 38.
Findings include:
1. R78's Face Sheet documented an admission date of 8/21/23 with diagnoses including: unspecified dementia, insomnia, bipolar disorder, anxiety disorder, depression, hypothyroidism.
R78's 5/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R78 was cognitively intact.
R78's last reviewed/revised care plan documented in part .(R78) has dementia with anxiety, bipolar disorder, anxiety disorder, and depression . (R78) displays physical and verbal behaviors during hallucinations and delusional episodes. (R78) often misinterprets staff's intentions.) .
R78's 5/21/24 Loss Control/Damage Report documented in part . Description of missing/damaged item(s) $100 missing from resident . When was the item(s) last observed: Date 5/19/24 . When was the item(s) discovered to be missing/ damaged: . 5/21/24 . Investigation: Searched room (and) all belongings . Conclusion . Money never found. All staff interviewed. Staff states that they had never seen resident (with) money that (R78's) friend keeps it with her due to resident being confused .
On 6/13/24 at 11:04 AM, R78 said she thought she had told the nurse and thought the nurse had found her missing money. R78 was asked if R78 knew who the nurse was she told about her missing money R78 pointed to V20 (Activities Director). R78 said she was not sure when her money had went missing because it had been a while back. R78 stated I'm feeling a little confused today.
On 6/13/24 at 11:07 AM, V20 (Activities Director) said she was not aware of R78 missing any money. V20 said R78 had told her R78's phone was missing the morning of 6/13/24 and V20 had assisted R78 in finding R78's phone. V20 said R78 did have a wallet but was not aware if R78 ever had money in R78's wallet. V20 said R78 would have delusions R78 had items missing.
On 6/13/24 at 12:11 PM, V1 (Director of Nursing/DON) said no investigation was completed for R78's allegation of missing money and it was not reported to Illinois Department of Public Health (IDPH). V1 said V22 (Administrator) was responsible for completing investigations and reporting to IDPH and V1 was unsure why V22 had not. V1 said he was not able to produce any investigation documentation.
On 6/13/24 at 12:17 PM, V22 (Administrator) said via a phone interview, V22 was aware of R78's allegation of missing money. V22 said after reporting R78's allegation to local law enforcement there was not enough evidence to substantiate R78 had missing money.
On 6/13/24 at 12:42 PM, V4 (Social Services Director) said she had questioned staff that usually worked on R78's hall. V4 said no staff had ever seen R78 with money.
The facility's revised 11/28/19 Abuse Prohibition and Reporting policy documented in part C. Investigation . 1. Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes . 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident . 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewer in the course of the investigation . 4. The Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of the reason for transfer/dishcharge ...
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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 written notification of the reason for transfer/dishcharge to residents, resident representitives and the Long Term Care Ombudsman office for 2 (R39 and R93) of 2 cognitively impaired residents reviewed for notice requirements of transfer/discharge in a sample of 38.
Findings include:
1. R39's Face Sheet documents an admission date of 2/15/2022 and includes diagnoses of heart failure, cerebral infarction, chronic kidney disease stage 3, ischemic cardiomyopathy, rheumatoid arthritis, hypertension, chronic systolic heart failure, diarrhea, constipation, GERD (gastroesophageal refulx disease), fatigue, benign prostatic hyperplasia, weakness, paroxysmal atrial fibrillation, anemia, chronic pain, insomnia, vitamin deficiency, hyperlipidemia, gout, and unspecified dementia.
R39's Mimimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.
R39's Progress Notes dated 2/9/2024 at 8:06 PM document EMS (Emergency Medical Service) in facility to transfer resident at this time. CCD (Continuity of Care), POLST (Practitioner Orders for Life Sustaining Treatment), and bed hold policy sent with them. No documentation was found in R39's record of written notification for the reason for R39's transfer/discharge presented to R39 or V18 (R39's Power of Attorney/POA).
R39's Progress Notes dated 3/2/2024 at 5:44 PM document Resident was transported out by EMS, report given to EMS, CCS (Critical Care Split Billing), bed hold and POLST printed and given to EMS. On 3/3/2024 at 12:33 AM, progress note documents Resident out of facility at this time at (name of local hospital Emergency Room). No documentation was found in R39's medical record to indicate written notification for the reason for R39's transfer was provided to R39 or V18 (POA).
On 6/14/2024 at 9:40 AM, written documentation of notification of R39's transfers to the local hospital were requested from V1 (Director of Nursing/DON). V1 was unable to present the requested documentation.
On 6/14/2024 at 11:22 AM, V18 (POA) stated she is the POA for R39. V18 states she did not receive any type of notifications in writing for description of reason for transfer to the hospital or bed hold policy information.
On 6/14/2024 at 1:05 PM, V1 again verified that there was no documentation available to validate the Transfer/Discharge notifications were presented to R39 or R39's POA.
2. R93's Face Sheet documents an admission date of 3/8/2024. R93 is alert to person only. R93's responsible party is documented on this face sheet as V17 (Family Member/Responsible Party).
R93's Progress Notes document on 3/15/2024 that R93 was transferred to the hospital for shortness of breath and V17 was notified via phone.
On 6/12/24 at 2:00PM, V1 (DON) stated that they provide the bed hold policy to the resident with their paperwork that they send to the hospital upon transfer.
On 6/12/24 at 2:30 PM, V3 (Medical Records) stated that the form is filled out and mailed to the family but no records are available to show that occurred for this hospitalization.
On 6/14/24 at 10:00 AM, V4 (Admissions) stated that she does not send written notification to the Ombudsman of resident transfers to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notification of the bed hold policy to resident rep...
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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 written notification of the bed hold policy to resident representatives for 2 (R93 and R39) of 2 cognitively impaired residents reviewed for notice of bed hold policy upon transfer in a sample of 38.
The Findings Include:
1. R39's Face Sheet documents an admission date of 2/15/2022 and includes diagnoses of heart failure, cerebral infarction, chronic kidney disease stage 3, ischemic cardiomyopathy, rheumatoid arthritis, hypertension, chronic systolic heart failure, diarrhea, constipation, GERD (gastroesophageal refulx disease), fatigue, benign prostatic hyperplasia, weakness, paroxysmal atrial fibrillation, anemia, chronic pain, insomnia, vitamin deficiency, hyperlipidemia, gout, and unspecified dementia.
R39's Mimimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment.
R39's Progress Notes dated 2/9/2024 at 8:06 PM document EMS (Emergency Medical Service) in facility to transfer resident at this time. CCD (Continuity of Care), POLST (Practitioner Orders for Life Sustaining Treatment), and bed hold policy sent with them.
R39's Progress Notes dated 3/2/2024 at 5:44 PM document Resident was transported out by EMS, report given to EMS, CCS (Critical Care Split Billing), bed hold and POLST printed and given to EMS.
On 6/14/2024 at 11:22 AM, V18 (R39's POA) stated she is the POA for R39. V18 states she does not receive any type of notifications in writing for description of reason for transfers to the hospital or bed hold policy information.
On 6/14/2024 at 9:40 AM, this surveyor requested transfer notification/bed hold policy documents for R39's recent transfers to the local hospital from V1 (Director of Nursing/ DON). V1 was unable to present evidence of the requested documents.
On 6/12/24 at 2:00PM, V1 stated that they only provide the bed hold policy/transfer paperwork to the resident upon transfer to the hospital, regardless of their cognition and do not send written documentation to the family.
2. R93's Face Sheet documents an admission date of 3/8/2024. R93 is alert to person only. R93's responsible party is documented on this face sheet as V17 (Family Member/Responsible Party).
R93's Progress Notes document on 3/15/2024 that R93 was transferred to the hospital for shortness of breath and V17 was notified via phone.
On 6/12/24 at 2:00PM, V1 (Director of Nursing/DON) stated that they only provide the bed hold policy to the resident with their paperwork upon transfer to the hospital, regardless of their cognition and do not send written documentation to the family.
On 6/12/24 at 2:30 PM, V3 (Medical Records) stated that the form is filled out and mailed to the family but no records are available to show that occurred for this hospitalization.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate a PASRR (Preadmission Screening and Resident Review) Lev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R53) of 1 resident reviewed for PASRR Screening in the sample of 38.
Findings Include:
R53's Face Sheet documented an initial admission date to the facility as 7/31/2023. Diagnoses listed on this form included but were not limited to: major depressive disorder, recurrent, unspecified.
R53's current physician orders documents Aripirazole 5mg (milligram) tablet by mouth daily for Major depressive disorder, recurrent, unspecified with a start date of 9/01/2023.
R53's Notice of PASRR Level I Screen Outcome dated 4/12/2019 in section PART I states based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness) and is checked No.
R53's Minimum Data Set (MDS) admission assessment dated [DATE] in Section A1500 asks is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, and this is documented No. This same MDS in section I5800 documented R53 has Depression (other than bipolar disorder).
On 6/13/2024 at 9:57 AM, V4 (admission Coordinator) stated R53 does not have a PASRR Level II completed at this time. V4 stated she was not aware that R53 would need a Level II completed and when she entered R53 into the PASRR electronic system, it did not notify her that she would need the Level II completed. V4 stated, R53 has been at the facility for respite care that ended up being longer than a few days. V4 stated she should have initiated a PASRR screening when R53 did not return home. V4 stated the facility does not have a specific PASRR policy.
On 6/14/2024 at 11:40 AM, V2 (Director of Nursing/DON) stated the facility does not have a specific PASRR screening policy.
Review of (Corporation Name) Pre-Admission, admission and Orientation of Residents policy with revised date of 6/1/2022 documents on page 2 of 5, under admission Process that all residents admitted shall be pre-screened by the Department of Aging or other State Agency. Admissions Director will ensure that the screening form has been obtained and placed in the electronic medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a PASRR (Preadmission Screening and Resident Review) Level II...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R19) of 1 resident reviewed for PASRR Screening in the sample of 38.
Findings Included:
R19's Face Sheet documented an initial admission date to the facility of 4/16/24. Diagnoses listed on this form included but were not limited to: bipolar disorder, current episode hypomanic.
R19's Notice of PASRR Level I Screen Outcome dated 3/22/2023 documented No Level II Required-No SMI/ID/RC (Serious Mental Illness/Intellectual Disability/Related Condition)
R19's Minimum Data Set (MDS) admission assessment dated [DATE] Section A1500 Preadmission Screening and Resident Review (PASRR) asks - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, and R19's is documented No. This same MDS in Section I, Active Diagnoses documents I5900 Bipolar Disorder.
On 6/13/2024 at 9:57 AM, V4 (admission Coordinator) stated R19 does not have a PASRR Level II completed at this time. V4 stated she was not aware that R19 needed a PASRR Level II completed. V4 stated when she put R19 in the electronic PASRR system it did not notify her that she would need a Level II. V4 stated she is not aware of any resident in the facility who is a Level II. V4 stated the facility does not have a specific PASRR policy.
On 6/14/2024 at 11:40 AM, V2 (Director of Nursing/DON) stated the facility does not have a specific PASRR screening policy.
Review of (Corporation Name) Pre-Admission, admission and Orientation of Residents policy with revised date of 6/1/2022 documents on page 2 of 5, under admission Process .All residents admitted shall be pre-screened by the Department of Aging or other State Agency. Admissions Director will ensure that the screening form has been obtained and placed in the electronic medical record.
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 interview, observation and record review, the facility failed to implement new interventions to prevent falls for 1 (R5...
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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 implement new interventions to prevent falls for 1 (R56) of 2 residents reviewed for falls in the sample of 38 .
The findings include:
R56's admission Record documented R56 was [AGE] years old with an admission date to the facility of 4/17/2024. Diagnoses listed include, but not limited to traumatic subdural hemorrhage with loss of consciousness status unknown, subsequent encounter, type 2 diabetes mellitus without complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, weakness, cellulitis, unspecified.
R56's Minimum Data Set (MDS) section C, dated 4/30/2024, documents that R56 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R56 is cognitively intact. The same MDS section GG0170, Mobility documents that R56 needs partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or support trunks or limbs, but provides less than half the effort) for toilet transfer.
R56's Fall Risk Assessment dated 4/17/2024 documents a score of 20, which indicates that R56 was a high risk for falls.
R56's Investigation Report for Falls dated 4/22/2024 documents resident was found sitting on buttocks on the floor. Resident attempted to get out of bed to use the restroom without assist. New intervention of visual cues to bathroom in place.
R56's Progress Notes document on 4/22/2024 at 3:55 PM, R56 was sitting in the floor on her buttocks. When asked, R56 stated she was attempting to use the restroom when she fell.
R56's Care Plan dated 4/17/2024 documents a focus area of The resident is at risk for falls, related to recent illness/hospitalization and new environment with a documented goal of the resident will have decreased risk for injury related falls this quarter. Interventions included instruct resident to call for assist before getting out of bed or transferring, orientate resident to room, surrounding areas, and use of call light, encourage resident to use side rails/enablers as needed, therapy to evaluate and treat as ordered, provide resident with specialized equipment: wheelchair and walker, assist resident with activities with an implementation date of 4/17/2024. New interventions included visual cues to bathroom documented after 4/22/2024 fall incident.
On 6/12/2024 at 2:10 PM, R56 stated she did have a fall in April. R56 stated she was trying to go to the bathroom when she slipped and fell. R56 stated, she does have a call light that she uses but does not have any reminders in her room to use the call light.
On 6/12/2024 at 2:15 PM, R56's room was observed to have no visual cues present in the room, on the bathroom door or in R56's bathroom. V5 (Certified Nurse Assistant/CNA), V6 (Licensed Practical Nurse/LPN), and V7 (CNA) verified that no visual cues are present in R56's room, on the bathroom door or in R56's bathroom as per the care plan.
On 6/12/2024 at 2:29 PM, V5 (CNA) stated R56 does not have a visual cue on her bathroom door. V5 stated the visual cue cards are placed on the bathroom doors and say Stop. Press Call Button in red letters.
On 6/12/2024 at 2:32 PM, V6 (LPN) stated R56 does not have a visual cue on her bathroom door. V6 stated she is not aware R56 is supposed to have a visual cue for bathroom assistance.
On 6/12/2024 at 2:35 PM, V7 (CNA) stated R56 does not have a visual cue on her bathroom door. V7 stated the visual cue cards are placed on the bathroom doors that say Stop. Press Call Button in red letters.
The Accident/Incident Prevention with no date documents when a resident has been identified as a high risk for accidents/incidents, interventions will be put into place per the individual resident assessment and care plan
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 high calorie high protein supplements as order...
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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 high calorie high protein supplements as ordered for 4 (R14, R23, R26, and R246) of 4 residents reviewed for therapeutic diets in the sample of 38.
Findings Include:
1. R246's Face Sheet documents an admission date of 1/9/24 with a diagnosis of End Stage Renal Disease. R246's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R246 is cognitively intact.
R246's current Physician Orders documents Regular solids and High Calorie Supplement (HCS).
R246's Progress Notes dated 6/7/24 at 11:29 AM by V10 (Registered Dietitian/RD) documents Dietary to emphasize K+ (potassium) in diet: NO high K+ foods. Continue SF HCS (Sugar Free High Calorie Supplement) for additional protein/cals. Include HS (evening) snack (High) protein per MD .
On 6/11/24 at 12:32 PM, R246 was served a regular diet of polish sausage, potatoes, sauerkraut, biscuit and a regular size piece of cake. R246's meal card documented R246 should be offered reduced sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas.
On 6/12/2024 at 12:26 PM, R246 was served a regular diet of pork tenderloin with gravy, sweet potatoes and cabbage bake, and 2 salted caramel chocolate chip cookies. R246's meal card documented R246 should be offered reduce sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas.
On 6/13/2024 at 12:33 PM, R246 was served a regular diet of turkey with gravy, mash potatoes, bread and regular size of cherry cheesecake. R246's meal card documented R246 should be offered reduce sugar condiments, beverages, and half portion of desserts: Limit dairy to one serving daily, double egg at breakfast, avoid citrus fruits and bananas.
On 6/12/2024 at 1:02 PM, V14 (Dietary Assistant) stated dietary staff are responsible for high calorie supplements and high protein snacks. V14 stated, if a resident is to have high calorie supplements and/or high protein snacks a label would be printed for that resident from the dietary staff, placed on the supplement or snack and noted on the dietary card. V12 stated, R246 does not have a high calorie supplement note on the dietary card.
On 6/13/2024 at 9:29 AM, R246 stated he has not received a high protein snack in the evening since he has been admitted to the facility. R246 stated, he is not aware that he is getting a high calorie supplement at meals. R246 stated, he did get 2 salted caramel chocolate chip cookies for lunch on 6/12/2024. R246 stated he ate oatmeal, bacon, eggs and toast for breakfast this morning. R246 stated, he did get double portion of eggs during breakfast.
On 6/13/2024 at 12:45 PM, V11 (Certified Nurse Assistant/CNA) stated, R246 does not get a high calorie supplement. V11 stated R246 would have a printed label from dietary if he was to get a high calorie supplement.
On 6/13/2024 at 12:49 PM, V12 (CNA) stated he works 10:00 AM to 10:00 PM shift. V12 stated R246 does not get a high calorie supplement. V12 stated R246 should have a label printed from dietary if he was to get a high calorie supplement and a peanut butter sandwich in the cooler for his nighttime snack if he were to get a high protein snack. V12 stated he does not remember R246 having a peanut butter sandwich in the cooler when he works. V12 stated if residents are ordered a half size of desert, the kitchen would make smaller portion sizes to serve to those residents. V12 stated R246 is supposed to get half portion dessert. V12 stated, R246 did received regular size dessert today because dietary did not send out smaller portions of dessert.
On 6/13/2024 at 12:53 PM, V13 (CNA) stated, dietary prints out labels for residents who are to get a high calorie supplement and/or high protein snacks. V13 stated, R246 does not have a label for high calorie supplement or high protein snack that she knows of. V13 stated dietary will send out half portions of desserts for residents that will be a smaller portion than the regular. V13 stated R246 did get regular size dessert of 2 cookies the day before and regular piece of cherry cheesecake because dietary did not send out half portions. V13 stated she does not ask residents if they want half the portion.
On 6/13/2024 at 1:10 PM, V2 (Dietary Supervisor) stated, if residents have an order for high calorie supplement and/or high protein snack, they have a label that will be printed out from the dietary staff with the resident's name that is placed on items for the certified nurse assistances to serve at mealtimes. V2 stated examples of high calorie supplement would include fortified milk and fortified pudding. V2 stated examples of high protein would be a peanut butter sandwich. V2 stated high calorie supplements are scheduled for once daily and served in the morning with breakfast. V2 stated, R246 was ordered to have high calorie supplement and high protein snack, however, it was not put in the correct area for labels to be printed so R246 was not receiving his supplement or snack. V2 stated he does not have a waiver on file for R246 that documents R246 is not in agreement with his diet.
On 6/13/2024 at 1:26 PM, V10 (Registered Dietician/RD) stated she assesses residents twice a month. V10 stated when she assesses residents, she will document her evaluation and dietary recommendations on in the resident in the electronic health record and send to V2 (Dietary Manager) to review. V10 stated, she does not have residents sign a waiver if they do not agree with her dietary recommendations. V10 stated she does communicate with (Company Name) Dialysis Center on R246's dietary recommendations. V10 stated, R246 is ordered to have a high calorie supplement with every meal unless she specified only with breakfast and a high protein snack every evening.
2. R26's Face Sheet documents an admission date of 1/31/24 and includes diagnoses of unspecified protein-calorie malnutrition, traumatic subdural hemorrhage without loss of consciousness, cognitive communication deficit, other generalized epilepsy.
R26's MDS dated [DATE] documents a BIMS score of 03, indicating severe cognitive impairment.
R26's current Physician Orders document a Mechanical Soft with extra gravy/sauce HCHP (High Calorie High Protein) dated 5/16/2024.
R26's Progress Notes dated 5/16/24 by V10 (RD) documented No significant WT (weight) changes. However, WT trend -shows slowly declining WT. Est. (estimated) nutritional needs at 1820kcals (kilocalories) (28kcal/kg ABW) (calories/kilogram Adjusted Body Weight), 65g (gram) pro (protein) (1g pro/kg ABW), and 1820cc (cubic centimeter) fluid daily (1cc/kcal). Continue M/S (mechanical soft), extra sauces/gravies, HCHP all meals for additional cals/protein. Monitor WTs closely RT (related to) WT trend.
On 5/30/2024, V10's Progress Note documents . Res (resident) with 7.1% WT loss/3mos (months). May 8 WT: 143# (pounds) [DATE] WT: 154# BS (blood sugar):152-tday (today). Dx (diagnosis): DM (diabetes mellitus)-II. Continue M/S, extra gravies/sauces, HCHP. Recommend include SF (sugar free) health shake daily for additional cals. Monitor WTs and refer prn (as needed).
On 6/12/2024 at 12:30 PM, R26 was served a regular mechanical soft diet of pork tenderloin with gravy, soft chopped roasted sweet potatoes and chopped cabbage bake, and 2 soft baked chocolate chip cookies. No extra gravy was observed. V15 (Family) was feeding R26 at the dining table. R26's meal card documented Regular Mechanical Soft, extra Gravy to mechanical meat/extra gravy, high calorie/high protein supplement.
On 6/12/2024 at 1:02 PM, V14 (Dietary Assistant) stated dietary staff are responsible for high calorie supplements and high protein snacks. V14 stated if a resident is to have high calorie supplements and/or high protein snacks, a label would be printed from the dietary staff with that resident's name to be placed on the supplement or snack and noted on the dietary card.
On 6/12/2024 at 1:05 PM, V15 (Family) stated she comes every other day to the facility during lunch to feed and spend time with R26. V15 stated she has not seen a high calorie/high protein supplement or extra gravy being served to R26 any time that she has been here during lunch.
On 6/13/2024 at 12:44 PM, R26 was served a regular mechanical soft diet of ground hot turkey sandwich with gravy, mashed potatoes and gravy, vegetable medley (mechanical soft), pineapple cake. No extra gravy was observed. V11 (CNA) was assisting R26 at the dining table. R26's meal card documented Regular Mechanical Soft, extra Gravy to mechanical meat/extra gravy, high calorie/high protein supplement.
On 6/13/2024 at 12:47 PM, V11 (CNA) stated R26 did not receive a high calorie/protein supplement or extra gravy with his lunch today.
On 6/13/2024 at 12:50 PM, V12 (CNA) stated, R26 did not receive a high calorie/protein supplement or extra gravy with his lunch today.
On 6/13/2024 at 1:10 PM, V2 (Dietary Supervisor) stated if residents have an order for high calorie high protein supplement, a label will be printed out from the dietary staff with the resident's name and placed on items for the certified nurse assistants to serve at mealtimes. V2 stated, R26 is ordered to have a high calorie/high protein supplement that would be served at breakfast. V2 stated, R26 was ordered to have a high calorie/high protein supplement, however, it was not put in the correct area for labels to be printed so R26 was not receiving his supplement. V2 stated, he does not have a waiver on file for R26 that documents R26 is not in agreement with his diet.
On 6/13/2024 at 1:26 PM, V10 (RD) stated she assesses residents twice a month. V10 stated when she assesses residents, she documents her evaluation and dietary recommendations on the resident in the electronic health record and sends to V2 to review. V10 stated she does not have residents sign a waiver if they do not agree with her dietary recommendations. V10 stated R26 is ordered to have a high calorie/high protein supplement with every meal unless she specified it to only be with breakfast, lunch or dinner.
3. R14's Face Sheet documents an admission date of 8/30/22. This same document includes the following diagnoses: anxiety, urinary tract Infection, diaphragmatic hernia, and chronic kidney disease. R14's 5/1/24 Quarterly MDS documents a BIMS score of 15, indicating R14 is cognitively intact.
R14's Physician Order Sheet for June 2024 documents a regular diet with HPHC (High Calorie High Protein) supplement.
On 6/13/24 at 12:45 PM, R14 received the following items on her lunch tray: hot turkey with gravy, vegetable medley, pineapple cherry cheesecake and red juice.
R14's meal ticket that accompanied her tray delivery for this lunch meal on 6/13/24 lists in the notes section that R14 should be offered something on the always available menu; Serve 1 ounce extra protein at meals (1 ounce meat or cheese, 1 egg, 1/4 cup cottage cheese or 2 tablespoons of peanut butter); HCHP
On 6/13/24 at 12:45 PM, R14 stated that she occasionally gets a glass of milk with meals, but not every time. R14 further stated that she does not like eggs and can't say for sure whether she gets extra amounts of protein servings at her meals. R14 stated that she chooses to eat in her room.
On 6/13/24 at 1:00 PM, V19 (Dietary Assistant) stated that R14 did not get an extra portion of meat today because she probably would not eat it, due to not being a big eater.
On 6/13/24 at 2:30 PM, V2 (Dietary Supervisor) stated that R14 should receive the supplements and the extra protein at her meals as her tray card or diet order state.
4. R23's Face Sheet documents an admission date to the facility of 9/18/18. This same document lists the following diagnoses: Alzheimer's Disease, heart failure, dysphagia and chronic kidney disease.
R23's current Physician Orders for June 2024 document a diet order for pureed, HCHP supplement.
R23's 5/1/24 Quarterly MDS Section C documents a BIMS score of 8, indicating moderate cognitive impairment.
R23's lunch tray was delivered on 6/13/24 at 12:55 PM. R23 received a pureed hot turkey sandwich, mashed potatoes, gravy, pureed pineapple/cherry cake and a red juice drink. No fortified whole milk or fortified pudding was served to R23.
On 6/13/24 at 12:55 PM, V21 (Certified Nurse Assistant/CNA) verified that R23 did not receive a fortified whole milk or fortified pudding. V21 stated that she feeds R23 often and she does not typically receive those supplements with her meals.
R23's meal ticket that accompanied her lunch tray on 6/13/24 documents that R23 should receive fortified whole milk 8 ounces, fortified pudding 4 ounces and to offer her tomato juice.
On 6/13/24 at 2:30 PM, V2 stated that R23 should be receiving those supplements with her meals, but is unsure why the system is not printing off the label to direct the kitchen staff to make those supplements up.
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 label and store foods. This has the potential to affect all 100 residents residing in the facility.
The Findings Inc...
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Based on observation, interview and record review, the facility failed to properly label and store foods. This has the potential to affect all 100 residents residing in the facility.
The Findings Include:
On 6/11/24 at 9:30 AM during the initial tour of the kitchen, the following items were observed:
1. A case of bananas in the dry storeroom were on a stainless cart with multiple gnats swarming around over the ripe fruit.
2. The bulk powdered milk bin was found with a scoop in it and the handle touching the food source.
3. A bag of cookies were found opened, unsealed, and not dated in the dry store room.
4. A loaf of bread was found opened, unsealed, and not dated in the dry store room.
5. Hamburgers were opened, unsealed, and not dated in the freezer.
The facility's Food Storage and Labeling procedure with a revision date of 9/22 documents Food Storage: keep all food covered in a a re-sealable bag or container or the original container, if applicable. Keep open bags of food such as pasta, cake mix, gelatin mix closed with tape or rubber band or in a larger re-sealable bag .Labeling of refrigerated foods. The label should include: 1. product name, 2. date, 3. discard date .
On 6/11/24 at 10:00 AM, V2 (Dietary Supervisor) stated that he will discard the items that were not sealed and labeled properly and discard the bananas.
The Long Term Care Facility Application For Medicare and Medicaid, signed on 6/11/24, documents 100 residents reside in the facility.
Feb 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 F0558
(Tag F0558)
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 residents with an effective means to request a...
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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 residents with an effective means to request assistance in the absence of a functioning call light system for 2 of 17 residents (R1 and R2) reviewed for accommodation of needs in a sample of 17.
The Findings include:
1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Other pulmonary embolism, Sepsis, unspecified organism, Anxiety disorder, Weakness, Difficulty in walking, not elsewhere classified, Alzheimer's disease, Hyperlipidemia, Pain, Unspecified atrial fibrillation, Unspecified kidney failure, Essential (primary) hypertension.
R1's Care Plan, dated 01/05/24, documents R1's Care Information Interventions: Bowel and Bladder: Incontinent, Incontinent Toileting, and incontinent products: medium briefs, Dressing Assist of 1, Grooming assist of 1, Safe resident handling procedure-Transfer Method: Mechanical Lift with level of assist 2 sling size medium. R1 is at increased risk for skin impairment/pressure ulcers r/t (related to) decreased mobility, generalized muscle weakness following recent illness/hospitalization for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, hypertension, and hypothyroidism. R1 currently has excoriation to rectal area, and Pressure ulcer to mid spine and Moisture associated skin damage: R1 will have decreased risk of skin breakdown during this quarter. Interventions: Provide incontinent care after each incontinent episode. R1 is at risk for constipation due to Chronic Obstructive Pulmonary Disease, Hypothyroidism, history of constipation, diuretic medication use, and Narcotic medication use. Goal: R1 will have a bowel movement at least every 3 days during this quarter. Interventions include Assist R1 to the (toilet, bed pan, commode) to promote bowel movement as tolerated.
R1's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 10 which indicates that R1 has moderate cognitive impairment. Section GG documents R1 is dependent on staff for toileting, showers, repositioning and dressing. Section H documents that R1 has an indwelling catheter and is frequently incontinent of bowel.
On 01/29/24 at 11:10AM, R1 who was alert and oriented to person, place and time during interview stated there was a day or two last week when the call light system wasn't working correctly. R1 said they gave her some kind of bell thing to ring, but it was kind of useless cause she had to turn it to make noise with it. R1 said that she was unable to turn it to make noise so she could alert staff. R1 said it was so hard to turn because you had to hold the top and then use the other hand to turn the bottom, and you had to keep doing it to make some kind of noise.
On 01/29/24 11:25AM, V4 (Family Member) said that she knows they did have problems with the call lights system about a week ago or so. V4 said they did give R1 an alternative bell to ring for help. V4 said that R1 couldn't really ring the bell they gave her cause you had to turn the bottom to make noise and R1 couldn't really turn the bottom. V4 said that she even has a hard time turning the bottom of it to make a sound. V4 did demonstrate how hard it was turning the bottom of the noise maker to make a sound, which wasn't very loud when turned.
2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction.
R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system.
R2's MDS dated [DATE], Documents in Section C a BIMS score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel.
On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place, and time stated that call lights were not working one day last week and she was given a cowbell to ring in case she needed staff. R2 states that she had a hard time keeping track of the cowbell. R2 said that the cowbell wasn't attached to anything and most of the time it was on her table tray. R2 said she would bump the table tray with her wheelchair and the cowbell would fall under her bed. V2 said she was unable to reach it under her bed. R2 also stated that they keep her door closed because she had COVID and that no one could hear her ringing the cowbell when she did have it in hand. R2 said it took a long time before anyone came into help her.
On 01/25/24 at 10:28AM, a cowbell was observed under R2's bed.
On 1/25/24 at 3:30PM, V2 (Director of Nursing/DON) said he was aware that the call light system went down over the weekend. V2 said that he knows that maintenance contacted the call light system company. V2 said that he thought that the call lights system didn't work from Sunday into Monday. V2 said it wasn't just the call light system that wasn't working properly. V2 said that it started out that the lights outside the door wouldn't light up. V2 said then it was the call lights at the nurses station wasn't working then it moved to not working in the rooms or on the hall either. V2 said that he thinks they didn't have enough noise makers for all the residents. V2 stated that residents who didn't get the noise maker was turned into alternative call which is frequent checks every time you walk pass the room you are to look in on that resident. V2 said that he thinks the new call light system had gone down twice in a year. V2 said that they have had multiple times where one call light wouldn't work here and there. V2 stated that they will call the call light company to come and fix the call lights when they aren't working. V2 said if it's in a resident room they may move the resident out to a different room where the call light is working or give the resident an alternative call bell like a noise maker or put them on alternative call and check on them frequently. He said that everyone was alternative call last week when the call lights weren't working until they got noise makers.
On 01/29/24 at 2:15PM, V7 (Certified Nursing Assistant/CNA) stated that she was there one of the days that the call lights weren't working. V7 said the light was on in the residents' room, and alarming at the computer at first, but not on the hall. V7 said eventually the computer stopped working also, they had families calling them. V7 stated that every resident was provided with alternative bells that were loud.
On 01/29/24 at 2:30PM V9 (Certified Nursing Assistant/CNA) stated she was working when the call lights were malfunctioning at the facility. V9 said the call light system was messed up for 2 or 3 days.
Review of the facility policy titled Call Light with a revised date 01/04 documents an Objective To respond to resident's request and needs Equipment Functioning call light.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a resident's right to receive timely care and be treated w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a resident's right to receive timely care and be treated with dignity for 6 of 17 residents (R1, R2, R7, R8, R9, R10) reviewed for resident rights in a sample of 17.
The findings include:
1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Other pulmonary embolism, Sepsis, unspecified organism, Anxiety disorder, Weakness, Difficulty in walking, not elsewhere classified, Alzheimer's disease, Hyperlipidemia, Pain, Unspecified atrial fibrillation, Unspecified kidney failure, Essential (primary) hypertension.
R1's Care Plan, dated 01/05/24, documents R1's Care Information Interventions: Bowel and Bladder: Incontinent, Incontinent Toileting, and incontinent products: medium briefs, Dressing Assist of 1, Grooming assist of 1, Safe resident handling procedure-Transfer Method: Mechanical Lift with level of assist 2 sling size medium. R1 is at increased risk for skin impairment/pressure ulcers r/t (related to) decreased mobility, generalized muscle weakness following recent illness/hospitalization for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, hypertension, and hypothyroidism. R1 currently has excoriation to rectal area, and Pressure ulcer to mid spine and Moisture associated skin damage: R1 will have decreased risk of skin breakdown during this quarter. Interventions: Provide incontinent care after each incontinent episode. R1 is at risk for constipation due to Chronic Obstructive Pulmonary Disease, Hypothyroidism, history of constipation, diuretic medication use, and Narcotic medication use. Goal: R1 will have a bowel movement at least every 3 days during this quarter. Interventions include Assist R1 to the (toilet, bed pan, commode) to promote bowel movement as tolerated.
R1's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief Interview for Mental Status (BIMS) score of 10 which indicates that R1 has moderate cognitive impairment. Section GG documents R1 is dependent on staff for toileting, showers, repositioning and dressing. Section H documents that R1 has an indwelling catheter and is frequently incontinent of bowel.
On 01/29/24 at 11:10AM, R1 who is alert and oriented to person, place, and time stated that when she was admitted to the facility on [DATE] that she had hit her call light for assistance to go to the bathroom. R1 said that staff told her to just go in her disposable undergarment and they would change her when she is done. R1 said she now just uses the incontinent brief to have a bowel movement and has staff come in and clean her up after she has gone.
On 01/29/24 at 11:20 AM, V4 (Family Member) said that R1 hit her call light to ask for assistance with going to the toilet and that one of the staff told R1 to just go to the bathroom in her incontinence brief and that she would clean it up later after R1 was done. V4 (Family Member) stated that this occurred around 01/04/24 when R1 was admitted .
On 01/30/24 at 1:40PM, V2 (Director of Nursing/DON) said he was told that staff has told residents to go bathroom in their incontinence brief instead of using the toilet. V2 said he dealt with the incident right away. V2 said that the staff were educated right away. V2 said that this happened about a month ago.
2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction.
R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system.
R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a BIMS score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel.
On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place, and time, stated that there have been problems with her call light not being answered in a timely manner. R2 stated that she has had incontinent episodes while waiting for staff to answer her call light.
A facility document titled Grievance Report with R2's name and dated 11/17/23, states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes a long time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for a while and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistants do that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents.
3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing.
R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one.
R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a BIMS score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance with standing and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel.
On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview, stated that sometime staff will answer her light and other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long is it on her watch. R7 said when she hits her call light and has to wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions.
4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease.
R8's Care Plan, dated 12/30/23 documents Resident Care Information with interventions of: transfer method: dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs.
R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a BIMS score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and with standing and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel.
On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he has to go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff are not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he must wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff.
5. R9's face sheet, undated, documents R9 was admitted on [DATE] with diagnoses of cellulitis of right lower limb, Chronic lymphocytic leukemia of B cell type not having achieved remission, difficulty in walking, weakness, other abnormality of gait and mobility, cognitive communication deficit, unsteadiness on feet, obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, venous insufficiency, obstructive sleep apnea, hypertension, atherosclerotic heart disease, cerebral infraction history of, peripheral vascular disease, and chronic obstructive pulmonary disease.
R9's Care Plan, dated 12/14/23 documents Resident Care Information with interventions of: bowel incontinent, bladder foley catheter, bed pan for incontinent toileting, mobility of mechanical lift with 2 assist, Safe resident handling procedure- transfer mechanical lift with 2 staff assistance. And turn and reposition every two hours as tolerated. R9 is at risk for falls related to recent illness/hospitalization, new environment, Chronic obstructive pulmonary disease, chronic peripheral venous insufficiency, history of cerebral vascular accident, hypertension, peripheral vascular disease, and anemia with interventions of: orientate resident to room, surrounding areas, and use of call light system.
R9's Minimum Data Set (MDS), dated [DATE], Documents in Section C a BIMS score of 15 which indicates that R7 is cognitively intact. Section GG documents that R9 requires substantial/maximal assistance with toileting, showers, and lower body dressing.
On 01/25/24 at 1:17PM, R9 stated he has times where staff don't answer the call light in a timely manner, he said I guess it just depends on what is going on. R9 states he requires total assistance with transferring, and often gets stuck in his chair for a long time. R9 said he frequently asks to be put into bed after evening meal which is usually about 06:00PM. He said on one occasion it was after 08:00PM before staff even came back to assist him into bed. R9 said he waited for over two hours and had already been up in his chair for quite some time.
6. R10's Face sheet, undated, documents R10 was admitted [DATE] with diagnoses in part of Type 2 diabetes mellitus with diabetic neuropathy, blindness both eyes-affecting all levels of care, Chronic kidney disease, hypertension, hyperlipidemia, primary insomnia, anemia, recurrent depressive disorder and pain.
R10's Care Plan, dated 01/23/24 documents R10 is at risk for falls related to limited mobility, added risk factor of blindness. R10 had a fall prior to placement and experienced fractures to her right humerus, radius, and pelvis. Difficulty with walking, hypertension, muscle weakness. Interventions include: Re-educate on asking for assistance when needed, offer toileting before bedtime as tolerated, alternative call light, educate R10 on risk associated with not using call light to assist with transfers. Resident Care Information- alternative call light, bowel incontinent and bladder incontinent toileting of bedpan and toilet, mobility 1 assist, safe resident handling procedures stand pivot with assist of 1.
R10's Minimum Data Set (MDS), dated [DATE], documents in Section C a BIMS score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R9 requires substantial/maximal assistance with toileting, showers, and lower body dressing. Section H documents R10 is always incontinent of bladder and frequently incontinent of bowel.
On 01/29/24 at 9:26AM R10 who was alert and oriented to person, place, and time and stated that staff does not answer her call light when she pushes it. R10 says she pushes it 3 to 4 times at least, but sometimes it feels like over 100. R10 stated that she hoped none of this would go against her, but sometimes they shut her call light off and say they will be back, but never come back.
A review of facility policy titled Personal Care of Resident (revised 12/02) documents under Purpose To Provide that residents of the facility receive adequate care Procedure: document in part Each resident shall have proper daily personal attention and/or care, including skin, nails, hair and oral hygiene, in addition to treatment ordered by the physician.
A review of facility reports titled Grievance Reports documents on 01/11/24 summary of grievance: Power of Attorney calls with concerns regarding nursing care, 01/11/24 summary of grievance: wife and resident voices concerns about nursing care and dietary, 01/11/24 summary of grievance: Husband and resident voices concerns with nursing care, 12/29/23 summary of grievance: resident voices concerns with certified nurse assistant and care received, 12/29/23 summary of grievance: Resident voices concerns with certified nurse assistant and care received, and 12/27/23 summary of grievance: resident voicing concerns with call light and care.
On 01/25/24 at 3:30PM, V2 (Director of Nursing/DON) said he was aware of resident complaining about call lights not being answered in a timely manner. V2 said that he had problems with that in November. V2 said that he believes it was a CNA (Certified Nurse's Assistant) problem and that he educated the CNA's on answering the call lights in a timely manner. V2 said he did have a complaint about staff turning off call lights and saying that they would come back, but they wouldn't come back for a long time. V2 said he was working on a correction plan for this around 12/06/23 and this was the first week of the correction plan. V2 said that some of the complaints about them turning off the lights and not coming back was around the end of November when we had a complaint about it.
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 assistance with activities of daily living (ADL) for reside...
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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 assistance with activities of daily living (ADL) for residents requiring assistance with toileting hygiene for 4 of 17 residents (R1, R2, R7, and R8) reviewed for ADL care in a sample of 17.
The findings include:
1. R1's Face Sheet, undated, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Other pulmonary embolism, Sepsis, unspecified organism, Anxiety disorder, Weakness, Difficulty in walking, not elsewhere classified, Alzheimer's disease, Hyperlipidemia, Pain, Unspecified atrial fibrillation, Unspecified kidney failure, Essential (primary) hypertension.
R1's Care Plan, dated 01/05/24, documents R1's Care Information Interventions: Bowel and Bladder: Incontinent, Incontinent Toileting, and incontinent products: medium briefs, Dressing Assist of 1, Grooming assist of 1, Safe resident handling procedure-Transfer Method: Mechanical Lift with level of assist 2 sling size medium. R1 is at increased risk for skin impairment/pressure ulcers r/t (related to) decreased mobility, generalized muscle weakness following recent illness/hospitalization for Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, hypertension, and hypothyroidism. R1 currently has excoriation to rectal area, and Pressure ulcer to mid spine and Moisture associated skin damage: R1 will have decreased risk of skin breakdown during this quarter. Interventions: Provide incontinent care after each incontinent episode. R1 is at risk for constipation due to Chronic Obstructive Pulmonary Disease, Hypothyroidism, history of constipation, diuretic medication use, and Narcotic medication use. Goal: R1 will have a bowel movement at least every 3 days during this quarter. Interventions include Assist R1 to the (toilet, bed pan, commode) to promote bowel movement as tolerated.
R1's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 10 which indicates that R1 has moderate cognitive impairment. Section GG documents R1 is dependent on staff for toileting, showers, repositioning and dressing. Section H documents that R1 has an indwelling catheter and is frequently incontinent of bowel.
On 01/29/24 at 11:10AM, R1 who is alert and oriented to person, place and time stated that when she was admitted to the facility on [DATE] that she had hit her call light for assistance to go to the bathroom. R1 said that staff told her to just go in her disposable undergarment and they would change her when she is done. R1 said she now just uses the incontinent brief to have a bowel movement and has staff come in and clean her up after she has gone.
On 01/29/24 at 11:20 AM, V4 (Family Member) said that R1 hit her call light to ask for assistance with going to the toilet and that one of the staff told R1 to just go to the bathroom in her incontinence brief and that she would clean it up later after R1 was done. V4 (Family Member) stated that this occurred around 01/04/24 when R1 was admitted .
On 01/30/24 at 1:40PM, V2 (Director of Nursing/DON) said he was told that staff has told residents to go bathroom in their incontinence brief instead of using the toilet. V2 said he dealt with the incident right away. V2 said that the staff were educated right away. V2 said that this happened about a month ago.
2. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction.
R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system.
R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel.
On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place and time stated that there have been problems with her call light not being answered in a timely manner. R2 stated that call lights were not working one day last week, and she was given a cowbell to ring in case she needed staff assistance. R2 stated that she has a hard time keeping track of the bell because it wasn't attached to anything, and the cowbell would often fall on the floor under the bed. R2 said she was unable to reach the cowbell when it fell under the bed. R2 said they kept her door closed recently because she had COVID and no one could hear her ring the cowbell or when she would yell because the cowbell was on the floor. R2 stated that she has had an incontinent episode of bladder while waiting on staff to respond to her call light.
A facility document titled Grievance Report with R2's name and dated 11/17/23 states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes along time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for awhile and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistance does that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents.
3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing.
R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one.
R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel.
On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview stated that sometime staff will answer her light other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long it is on her watch. R7 said when she hits her call light and has to wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions. R7 said when staff finally gets to her, they tell her that they don't have enough staff.
4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease.
R8's Care Plan, dated 12/30/23 Resident Care Information with interventions of: transfer method: dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs.
R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status(BIMS) score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel.
On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he has to go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff is not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said she is always told there ae two staff on the hall and that R8 is a mechanical lift that takes 2 staff to assist. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he has to wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff.
On 01/29/2024 at 02:30PM, V9 (Certified Nurse Assistant/CNA) stated that she doesn't think people are getting proper incontinent care at night. V9 said in the mornings when she comes to work some of the residents tell her that they have not been changed since the evening shift the day before and you can just tell it's been a while since they have been changed.
The Facility's Personal Care of Residents dated 12/02 documents It is a policy of the facility to provide a plan of personal care for resident Purpose: To provide that resident of the facility receive adequate care.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a t...
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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 sufficient staff were available to provide needed care in a timely manner. This failure affected (R2, R3, R7, and R8 ) and has the potential to affect all 104 residents residing in the facility.
Findings Include:
1. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction.
R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: Bathroom Continent/Incontinent Toileting, Incontinence Products- wears underwear, Safe resident handling procedure-Transfer method stand pivot transfers with one assist. Orientate resident to room, surrounding area, and use of call light system.
R2's Minimum Data Set (MDS) dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 13 which indicates R2 is cognitively intact. Section GG documents that R2 requires partial/moderate assistance with toileting hygiene and requires supervision or touch assist with toilet transfers. Section H documents that R2 is occasionally incontinent of bladder and always continent of bowel.
On 01/25/24 at 10:25AM, R2 who was alert and oriented to person, place and time stated that there have been problems with her call light not being answered in a timely manner. R2 stated that she has had an incontinent episode of bladder while waiting on staff to respond to her call light.
A facility document titled Grievance Report with R2's name and dated 11/17/23 states under summary of the grievance that R2's son states that R2 is not getting taken to the bathroom when needed. R2's son states that the light is turned on and it takes a long time for anyone to answer which causes R2 to sit in a soiled incontinence brief. R2's son states that on Tuesday he was at the facility and the call light was going off for a while and nobody came. R2's son states that he went to the nurse's station and there were 3 to 4 nurses just sitting in the little station in the middle. R2's son stated that he told them that R2 needed to use the bathroom, and one stated that the certified nurse assistance does that, but one nurse did get up and take her. R2's son said that R2 feels embarrassed when she has accidents.
2. R3's Face Sheet, undated, documents R3 was admitted to the facility on [DATE] with diagnoses that include dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Difficulty in walking, not elsewhere classified, Parkinson's disease, Type 2 diabetes mellitus without complications, Other abnormalities of gait and mobility, Aphasia following unspecified cerebrovascular disease, Heart failure, unspecified, Chronic Obstructive Pulmonary Disease.
R3's MDS (Minimum Data Set) dated 11/13/23 documents R3 has a BIMS score of 6, which indicates R3 has severe cognitive impairment. Section GG documents partial/moderate assistance with toileting, substantial/maximum assistance with showering, dressing and personal hygiene. Section H documents R3 is occasionally incontinent of bladder and bowel.
R3's Care Plan dated 12/27/23 documents in part R3 is at risk for falls. Interventions include: encourage/assist resident not to reach past base of support, assist resident with activities of interest, and instruct resident to call for assist before getting out of bed or transferring, Resident care information documents in part safe resident handling procedure-transfer with supervision/touch assist.
On 01/29/2024 at 12:44pm R3 who was alert and oriented at time of interview, stated that she usually has problems with them answering her call light because they don't have enough staff. R2 stated most of the time they have enough staff to meet my needs, but then there are other times they don't.
3. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non dominant side, unspecified abnormalities of gait and mobility, constipation, obstructive and reflux uropathy, encounter for orthopedic aftercare, need for assistance with personal care, glaucomatous flecks right eye, pain, essential hypertension, hypothyroidism, hyperlipidemia, depression, anxiety disorder, personal history of transient ischemia attack and cerebral infraction without residual deficit, fractures of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing.
R7's Care Plan, dated 12/27/23, documents Resident Care Information with interventions of: bowel incontinent blader incontinent/catheter, continent/incontinent toileting: Toileting, with pull up incontinence products. Transfer method- stand pivot transfer to right side level assist of one.
R7's Minimum Data Set (MDS), dated [DATE], Documents in Section C a Brief interview for mental status (BIMS) score of 9 which indicates that R7 has moderate cognitive impairment. Section GG documents that R7 requires substantial/maximal assistance with toileting hygiene, dependent with dressing, R7 requires substantial/maximal assistance withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and frequently incontinent of bowel.
On 01/25/2024 at 10:58am, R7 who was alert and oriented to person, place, and time during interview stated that sometime staff will answer her light and other times they don't. R7 said that staff will answer the call light and say they will be back and then don't come back. R7 said that she has had to wait for an hour to an hour and a half on more than one occasion. R7 said that she has timed how long is it on her watch. R7 said when she hits her call light and must wait for a long period of time, she will start yelling for staff. R7 said that this has happened on several occasions. R7 said when staff finally gets to her, they tell her that they don't have enough staff. R7 stated that she has no problems with staff, but there are not enough staff to get to the bathroom on time.
4. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with diagnoses of acute respiratory disease, neurocognitive disorder with Lewy bodies, dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, stiffness right knee, pain, diarrhea, cellulitis of right toe, depression, osteoarthritis, obstructive sleep apnea, normal pressure hydrocephalus, hyperlipidemia and Parkinson's disease.
R8's Care Plan, dated 12/30/23 Resident Care Information with interventions of: transfer method: dependent, alternative call light, instruct R8 to call for assistance before getting out of bed or transferring. Turning and repositioning dependent. Bowel and bladder incontinent with incontinence products of medium incontinence briefs.
R8's Minimum Date Set (MDS), dated [DATE], Documents in Section C a BIMS score of 4 which indicates that R8 has severe cognitive impairment. Section GG documents that R8 needs substantial/maximal assistance with toileting hygiene and withstanding and transfers. Section H documents that R7 is occasionally incontinent of bladder and bowel.
On 01/25/2024 at 11:24am, V3 (Family Member) stated that she knows R8 is incontinent at times, but that other times he knows when he must go to the bathroom. V3 said that if R8 gets dirty or wet he becomes very agitated. V3 said that she knows that staff is not checking R8 every two hours. V3 said that R8 does not really push the call light button on his own. V3 said that the facility was supposed to be working on getting him a call light that will go off when R8 is moving around. V3 stated she has pushed the call light to ask for assistance for R8 many times. V3 stated that staff will come answer the call light and say they will be back and don't come back. V3 said she is always told there ae two staff on the hall and that R8 is a mechanical lift that takes 2 staff to assist. V3 said that if it is mealtime and R8 wants to lay down or is incontinent that he must wait until the meals are passed and every resident is fed. V3 stated she was told by day shift staff that R8 does not get changed on the midnight shift because they do not have enough staff. V3 stated she feels that lack of staff is what she believes is a major contributing factor in R8's lack of care.
On 01/29/24 at 2:05PM, V8 (Certified Nurse Assistant/CNA) stated that she believes call lights are answered in a timely manner when they have enough staff. V8 states at times there are only 4 CNA's to cover the four halls outside of the memory care unit.
On 01/29/2024 at 02:15PM, V7,(Certified Nurse Assistant/CNA) stated that she felt there is not enough staff, but that it does depend who is working if the work load is manageable.
On 01/29/2024 at 02:30PM, V9 (Certified Nurse Assistant/CNA) was asked if she knew of anyone turning call lights off and saying they will be back and then don't return. V9 stated no, but said she knows sometimes it happens unintentionally when we are short staffed. V9 stated they are short staffed all the time. V9 stated sometimes there will be only two people assigned to two different halls.
On 01/29/2024 at 03:15PM, V12 (Licensed Practical Nurse/LPN) admits that in her opinion staffing is unsafe. V12 stated that managers (nursing) refuse to cover the floor on off hours because they state that they are salary and will be written up. V12 stated that she has been assigned to multiple halls and expected to cover as both the nurse and CNA. V12 stated that management always says that they have nothing to complain about because they are fully staffed per state guidelines. V12 admits she has refused extra assignments before, she was told to work as the nurse and CNA at the same time on more than one hall. V12 said she was written up for refusing.
A review of facility reports titled Grievance Reports documents in part on 01/11/24 summary of grievance: Power of Attorney calls with concerns regarding nursing care, 01/11/24 summary of grievance: wife and resident voices concerns about nursing care and dietary, 01/11/24 summary of grievance: Husband and resident voices concerns with nursing care, 12/29/23 summary of grievance: resident voices concerns with certified nurse assistant and care received, 12/29/23 summary of grievance: Resident voices concerns with certified nurse assistant and care received, and 12/27/23 summary of grievance: resident voicing concerns with call light and care, and 11/27/23 summary of grievance: wife having concerns with resident not getting changed when needed and also with staff being short.
The Resident Matrix (undated) provided by the facility on 01/25/24, documents 104 residents reside in the facility.
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 F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call syst...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to affect all 104 residents residing in the facility.
Findings include:
On 01/25/24 at 10:25am, R2 states that there have been issues with call lights being answered in a timely manner. R2 said she was just moved to this hallway because of having COVID . R2 said that call lights were not working one day last week, and she was given a cowbell to ring in case she needed staff. R2 states that she has a hard time keeping track of it and it often falls under her bed, and she is unable to reach it. R2 also states that they keep her door closed because she has COVID and that no one could hear her ringing the bell and it was a long time before anyone came into help her. During the interview, the cowbell was observed under the bed.
On 01/25/24 at 11:24am, V3 (R8's Spouse) states that the power had gone out a few times, that the call light won't work right for a while, and they were not given an alternative call light.
On 01/25/24 at 03:15pm, V5 (Maintenance) said that on 01/17/24 that staff told him that the call lights weren't working right. V5 said that they checked them out and that they were working fine. V5 said that they told him it was 100 hall, but when they checked them out everything was working fine. V5 said the room light came on, the light outside the door worked and it worked up at the computer. V5 said that on Sunday 01/21/24 they had some trouble with the grid. V5 said the electric company did come out and they said it was a level 1 grid problem. V5 said that it effected the lights and various things. V5 said that they had flickering lights in the rooms and dining room. V5 said that some of the call lights weren't working either. V5 said that they were able to call the call light company and they fixed it after the power company fixed the grid. V5 said they did go out again on Monday 01/22/24, V5 said that they weren't able to fix it then, that they had to call the call light company and they had to come out and fix it. V5 said that it took the call light company a little bit to get to the facility because of the ice. V5 said that they were able to fix it when they got there on 01/22/24.
On 01/25/24 at 3:00PM, V6 (Maintenance) said that on 01/17/24 that some of the nursing staff said that the call light system wasn't working right, but when they went to check the call lights and they were working. V6 said that they told them that it was the 100 hall that wasn't working right. V6 said when they checked the call lights, all the call lights were working just fine. V6 said they worked in the rooms, hall lights and on the computer. V6 said that he did work on Sunday 01/21/24 and when he came in at 7am, the lights in the dining room weren't working and some of the resident bathrooms didn't have lights. V6 said other lights were flickering on and off. V6 said some of the other equipment, like the beds and stuff, weren't working correctly too. V6 said that staff had told him that the power had been out when he asked them about it. V6 also stated that no one had called and told him anything about the power going out, which is what is normally expected. V6 said he went to check the breakers to see if some of the breakers tripped and they were all fine. V6 said that he noticed the power company pulling up to a transformer outside of the building. V6 said that he went outside and talked to the power company. V6 asked if the power outage was on the facility end or if it was something to do with the power company. V6 said the power company told him that it was a level 1 grid outage and that they were there to work on it. V6 said that some of the call lights were not working properly. V6 said once the power company got everything working, he called the call light company, and they were able to fix everything over the phone. V6 said then on Monday, 01/22/24, all the call lights stopped working and that they had to call the call light system company to come and fix it. V6 said it was taking them a little longer to get to the facility because of the weather. V6 said that it took them several hours to get to the facility, but that they were able to fix it on Monday 1/22/24.
On 01/25/24 at 3:30PM, V2 (Registered Nurse/ Director of Nursing) said he was aware that the call light system went down over the weekend 01/21/24. V2 said that I know that Maintenance contacted the call light system company and I think the call lights didn't work from Sunday 01/21/24 into Monday 01/22/24. V2 said it wasn't just the call light system. V2 said that it started out that the lights outside the door wouldn't light up, then it was the call lights at the nurse's station wasn't working then it moved to not working in the rooms or hallway either. V2 said they did pass out some kind of noise maker to most residents. V2 said that he thinks they didn't have enough noise makers for all the residents. V2 said that the residents who didn't get the noise maker were placed on alternative call which is frequent checks every time you walk past the room you are to look in on that resident. V2 said that he thinks the new call light system had gone down twice in a year. V2 said that they have had multiple times where one call light wouldn't work here and there. V2 said that they will call the company to fix the call light. V2 said if it's in a resident room they may move the resident out to a different room where the call light is working, give the resident an alternative call bell like a noise maker, or put them on alternative call and check on them frequently. V2 said that everyone was placed on alternative call last week when the call lights weren't working until they got noise makers.
On 01/29/24 at 9:37 AM, the call light in room [ROOM NUMBER] was checked for proper functioning and it did not work at all.
On 1/29/24 at 10:20 AM, room [ROOM NUMBER] was checked and found not to be working at all. There were no residents residing in the room at this time.
On 01/29/24 at 10:20am, this surveyor notified V2 of the call lights not functioning in rooms [ROOM NUMBERS]. V2 was not aware that they were not functioning.
On 01/29/24 at 10:29AM, 302 and 102 were observed functioning at the light at the door and at the nurse's station.
On 01/29/24 at 10:30AM the call light system monitor at the nurse's station was observed, the call light system does have warnings on screen that read:
Warning 01/25/24 1:17PM a problem has been detected in the wireless device system. The system may be partially functional.
Warning 01/29/24 9:37AM A problem has been detected in the dome light system. The system may be partially functional.
On 01/29/2024 at 11:20 AM, V2 said that he spoke to V1 (Administrator) and V1 said that all other call lights are working, and that maintenance fixed the ones that weren't working.
On 01/29/24 at 3:00PM, V1 (Administrator) said that she was aware of a problem with the call lights where the light would come on, but the call light didn't have a dinging sound. V1 said that she has a call out right now for the call light system company to come look at the call lights starting at a negative number when it starts to count down. V1 said that they did call the call light company. V1 said that she was aware they had problems with the call lights over the weekend of 01/21/24, but that to her knowledge, the light was working on the computer. V1 said that they did contact the call light system company and that they were able to come in Monday 01/22/24 to fix it. V1 said that they did offer the residents alternative call lights. V1 said that Maintenance did go today and check all call lights to make sure all of them are working properly due to 102 and 302 not working properly earlier. V1 said that all call lights are working including 102 and 302. V1 said the V5 said he changed the cords earlier on 102 and 302 and mixed them up with the bad cords and that is why they weren't working.
On 01/29/24 at 02:15PM, V7(CNA) stated that she was there one of the days that the call lights weren't working. V7 said the light was on in the residents' rooms, and alarming at the computer at first, but not on the hall. V7 said that eventually the computer stopped working also, they had families calling them. V7 said everyone was provided with alternative bells that were loud.
On 01/29/24 at 02:30PM, V9 (CNA) said she was working when the call lights were malfunctioning, and it was a mess for 2 or 3 days.
A review of the facility policy titled Call Lights with a revision date of January 2004 documents an objective of, Respond to resident's requests and needs. The policy procedure states to Answer the call light promptly. The same policy goes on to state . If the call light is defective, report immediately to maintenance. In the same policy, in the key points it states . Check room frequently until call light is repaired. Fill out a maintenance work request form stating room number and take it to maintenance immediately .
The Resident Matrix (undated) provided by the facility on 01/25/24, documents 104 residents reside in the facility.
Nov 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
Resident Rights
(Tag F0550)
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 treat residents with respect and dignity by ensuring timely respons...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat residents with respect and dignity by ensuring timely responses to requests for assistance for 3 (R1, R7 and R8) of 8 residents reviewed for Resident Rights in the sample of 8.
R1's Resident Face Sheet documents an admission date of 10/22/23 and includes diagnoses of Cognitive Communication deficit, Difficulty in walking, not elsewhere specified; Weakness; Unsteadiness on feet.
R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires substantial/maximal assist for toilet transfers. This same MDS documents R1 is always incontinent of bowel and bladder.
R1's Care Plan lists a problem start date of 10/22/23 documenting that R1 requires dependent assistance of x(times)2 staff with stand-aid for transfers.
On 11/21/23 at 10:00 AM, R1, who was alert and oriented at the time of interview said that two staff help her up to her wheelchair. When asked if she has ever had to wait for assistance to the bathroom since admission, R1 was unsure of the date, but said that it did take a long time one day recently for staff to come when she pressed her light and she did wet herself a little while waiting.
A facility Grievance report dated 11/01/23 documents the following: R7 states that last night 2 CNAs (Certified Nurse Assistants) were very rude. Resident stated that it took them 1 ½ hours to take her to the bathroom. States they would come in but would not help her .
A facility Grievance report dated 11/10/23 documents the following: R8's husband came into writers office and stated that resident never received her lunch. Husband stated that they didn't bring her plate so they asked for a grilled cheese and soup and still had not received which was over 30 mins ago. Time is now 1:50pm. Husband also stated that when the call light is pushed it is never answered. He states he approached the nurse and felt like he was blown off. States there was 4 or 5 of them sitting in the middle yappin and not worried about taking care of patients.
Apr 2023
4 deficiencies
CONCERN
(D)
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 ensure residents received assistance with meals for 1 ...
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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 received assistance with meals for 1 of 2 (R134) residents reviewed for activities of daily living in the sample of 44.
Findings Include:
R134's facility Face Sheet with a print date of 4/13/23 documents R134 was admitted to the facility on [DATE] with diagnoses that include diabetes, need for assistance with personal care, glaucomatous flecks left eye, hypertension, and heart disease.
R134's MDS (Minimum Data Set) dated 3/27/23 documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R134 is cognitively intact.
R134's current Care plan documents an intervention under Resident Care Information of, Approach Start Date: 3/23/23 Eye Sight Device: Partially Blind. This same care plan documents, Problem Start Date: 4/5/23, (R134) requires minimal set-up assistance 0-1x with divided plate for eating/meals. This problem area includes the intervention of Eating Program: 1. Instruct/Encourage (R134) to pick up food with silverware. 2. Encourage (R134) on use of divided plate.
On 4/10/23 at 9:14 AM, R134 stated she has macular degeneration and doesn't see well. R134 stated she needs help with her meals, and she doesn't always get it.
On 4/10/23 at 12:50 PM, R134 was observed in her room sitting in her bed when her noon meal of chicken salad, fruit cup, bread, carrots, lemonade, and chocolate cake was served, by V15 (Certified Nursing Assistant/CNA). V15 set R134's plate on the bedside table and left the room. V15 returned with another (unknown) staff member and adjusted R134 in the bed and moved the bedside table to the other side of R134's bed and again left the room. R134 asked this surveyor what her food was and where it was at on the plate. R134 stated they were supposed to get her a plate with sides on it, but they hadn't yet. R134 then stated I guess they forgot to bring utensils for me while searching on her bedside table for utensils that were laying beside her plate. While doing this R134 was using her fingers to taste the food that was on her plate. R134 located the utensils by feel and began to eat. There was no assistance or guidance offered to R134 during this meal. R134's meal card located next to her plate did not document the level of assistance or adaptive equipment R134 was supposed to receive.
On 4/12/23 at 12:12 PM, R134 was served the noon meal of fish, baked potato, carrots, cake, and lemonade on a regular plate. R134 was sitting in the dining room with peers during the meal. R134 used her fork to pick her piece of bread up and tasted it. R134 then took the bread off the fork and attempted to spread butter on the bread. The butter was all located on a small section of the bread. R134 then attempted to cut her baked potato up like it was a piece of meat. No staff assistance was observed being provided by V5, V10, or V11 (CNA's) who were in the dining room assisting with the meal. At 12:27 PM, R134 asked V11 where her meat was on her plate and if she could cut it up for her. V11 cut R134's meat and guided R134's hand to show her where her meat was located on her plate. V11 did not tell R134 where the other food was located and at no time did any staff tell R134 what she had been served.
On 4/12/23 at 12:47 PM, V11 (CNA) stated R134 will usually ask where her food is located on her plate and they watch her and assist her with eating if she needs it.
On 4/12/23 at 2:04 PM, V5 (CNA) stated R134 gets set up and feeding assistance. V5 stated R134 is becoming shakier and has blurred vision and does require her food to be cut up and for someone to feed her. V5 stated she didn't know why R134 wasn't provided assistance with her meal on 4/12/23. V5 stated R134 should have received assistance.
On 4/12/23 2:14 PM, V10 (CNA) stated R134 gets assistance with her meals. When asked what type of assistance V10 stated, they help her eat. V10 stated staff sit with R134 at the table and help her eat. V10 stated R134 does try to feed herself though. When asked why R134 didn't receive assistance on 4/12/23 at the noon meal, V10 stated they usually wait until all of the plates are passed before they assist R134. V10 stated they will also cut up R134's food.
On 4/12/23 at 3:32 PM, this surveyor reviewed with V2 (Director of Nurses) the observations on 4/10/23 and 4/12/23 when R134 did not receive assistance with her meal and/or have her meal served on a divided plate. V2 stated he would expect staff to provide assistance and for the appropriate adaptive devices to be used.
The facility Personal Care of Residents policy dated 12/02 documents, It is a policy of the facility to provide a plan of personal care for residents. Under Procedure this policy documents, 1. Each resident shall have proper daily personal attention and/or care including skin, nails, hair, oral hygiene, in addition to treatment ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R53's medical record Face Sheet documents admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease with lat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R53's medical record Face Sheet documents admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease with late onset. R53's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 1, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R53's medical record Dietary Assessment dated 03/04/2023, documents: On a Mechanical Soft diet (Missing teeth). High Protein Supplement. Comfort foods. Fortified Pudding at lunch and supper. R53's Physician order sheet with a start date of 04/01/23 documents a mechanical soft diet with a start date of 12/09/22 and an end date of open ended.
3. R17's medical record Face Sheet documents admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R17's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 4, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R17's medical record Dietary Assessment dated 03/20/2023, documents: On a Mechanical Soft diet with Nectar thick liquids. Large portions at breakfast. High Calorie High Protein Supplement. Fortified Pudding at lunch and supper. R17's Physician order sheet dated 04/01/23 documents a mechanical soft diet with a start date of 04/22/22 and an end date of open ended.
4. R67's medical record Face Sheet documents admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R67's Minimum Data Set (MDS) dated , 3/08/2023, Section C, documents Brief Interview for Mental Status (BIMS) score is 0, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R67's medical record Dietary Assessment dated 03/10/2023, documents: On a Mechanical Soft diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper. R67's Physician Order Sheet dated 04/01/22 documents a mechanical soft diet with a start date of 03/03/22 and an end date of open ended.
5. R15's Dietitian assessment dated [DATE] at 4:11 PM documents: On a mechanical soft diet, with a high protein supplement. R15's intakes are 50 - 75% and weights are: 03/03/23 - 114, 02/03/23 - 115, 12/16/22 - 113.8, and 11/04/22 - 112.8. R15's Physician Order Sheet dated 04/01/23 documents a mechanical soft diet with a start date of 12/09/22 and an end date of open ended.
The Diet Recipe Card titled, Baked whitefish with gravy, that was substituted for the BBQ rib meal on Wednesday documents a portion size to be served for the mechanical soft diet as a #8 dipper (3.75 ounces, 0.5 cup).
The diet spreadsheet dated week 2, Day 9, Monday, documents: ground honey mustard chicken (#6 dip/1 cup) on finely soft, caramelized Naan bread (1 round/ 2 halves), pickled beets (4 ounce spoodle), soft canned chilled fruit (4 ounce spoodle).
On 04/10/23 at 11:40 AM V13 (Dietary Assistant) served the #12 scoop (2.875 ounces, 0.33 cup) of the mechanical ground honey mustard chicken to R53, R17, R67, and R15.
On 04/12/23 at 12:30 PM V13 (Dietary Assistant) served the #16 scoop (2.0 ounces, 0.25 cup) of the ground whitefish to R53, R17, R67, and R15.
On 04/12/23 at 12:45 PM V13 (Dietary Assistant) stated, they do not always have enough scoops of the appropriate sizes for all the dining rooms and she is one of the last serving dining rooms so she does not always get the appropriate scoops but she always tries to get one that is bigger than what she needs.
On 04/12/23 at 12:00 PM V14 (Dietary Assistant) served the #14 scoop (2.375 ounces, 0.33 cup) of the ground whitefish.
On 04/12/23 at 3:50 PM V8 (Registered Dietician) stated, the appropriate portion size for the #8 dipper which is a 0.5 cup of ground fish and the appropriate portion size for the chicken salad from Monday would be listed on the spreadsheet, that is how they should know what to serve.
On 04/12/23 at 3:00 PM V6 (Dietary Manager) stated, he does not know why they did not serve the appropriate portion sizes for the mechanical soft meals. V6 (Dietary Manager) stated he will have to do some training.
The facility policy number 12.08 dated 06/2010 with the subject of Liberalized Diets documents: Purpose: Increase ability to maintain acceptable weight and nutritional status, and improve, and improve quality of life for residents, improve residents nutritional status, improve dietary compliance, enhance caloric and nutrient intake and ultimately increase resident satisfaction.
Based on observation, interview, and record review the facility failed to ensure diets met the nutritional needs for 5 of 9 (R15, R17, R53, R62, R67) residents reviewed for nutrition in the sample of 44.
Findings Include:
1. R62's facility Face Sheet with a print date of 4/13/23 documents R62 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, anorexia, anemia, nausea, edema, and morbid obesity.
R62's MDS (Minimum Data Set) dated 2/8/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R62 is cognitively intact.
R62's current Care Plan documents a Problem Area with a start date of 6/8/22, (R62) is a vegetarian. Interventions are documented as Serve diet and supplements as MD (physician) order.
R62's Progress Notes dated 3/5/23 documents, DIETITIAN ASSESSMENT: On a Regular diet. High Calorie High Protein Supplement. Vegetarian preferences (Dislikes meat). Intakes 50-75%. Weights: (3/2): 193.2, (2/10): 194.7, (2/9): 198.2, (12/2): 213.8, and (9/3): 246.5. Current weight is down 20# (pounds)(9.6%) x (times)/3 months and down 53#(21.6%) x/6 months. Above IBW (ideal body weight) Range 122-154. Body Mass Index: 29.37 (Overweight-However with edema not a true indicator of risk). Has 1+ Right LE (lower extremity) edema and Non Pitting Left LE edema. Potential risk for weight changes. Has boggy left heel and skin tear right forearm. Labs: (2/14/23): Glucose 62(L/liters), Sodium 141, Potassium 4.2, Blood Urea Nitrogen 15, Creatinine 0.7, Hemoglobin 10.9(L), and Hematocrit 35.3(L). Estimated Needs: 1890 calories (30 kilo-calories per kg (kilogram) of IBW Range), 1890 cc (cubic centimeters) fluids(1 cc per kilo-calories), and 63-76 gram protein (1.0-1.2 injury factor). Expect weight changes as edema changes. Continue with diet Rx (prescription) and monitor.
On 04/11/23 at 12:40 PM, R62 was observed in her room and was served the noon meal. R62 was served pasta salad with a scant amount of what appeared to be shredded cheese, mashed potatoes with brown gravy, corn, and tea. R62's meal card documents R62 is on a regular diet, High Calorie, High Protein, with vegetarian menu preferences. On this same date at this same time, R62 stated she is very suspicious of brown gravy so she won't eat the potatoes. When asked about protein alternatives, R62 stated they serve eggs every morning but she doesn't eat them because the facility doesn't know how to cook them. R62 stated they don't serve much cheese which surprises her.
On 04/12/23 at 12:44 PM, R62 was served egg salad, cake, bread, baked potato, and carrots. R62's meal card located on her bedside table documented R62 was to receive a regular, high calorie, high protein diet with vegetarian menu preference. The meal card documents R62 is to receive 4 ounces of cottage cheese and documents dislikes as beef, chicken, fish, meat, pork, turkey. Under Notes this meal card documents, Vegetarian Menu Preference: Ok for cheese, yogurt, cottage cheese, eggs, beans, potatoes, rice, vegetables, and fruit.
On 4/12/23 at 2:24 PM V9 (Cook) stated R62 was supposed to be served egg salad with her noon meal on 4/11/23. V9 stated they do not have a vegetarian menu. V9 stated they try to experiment with different menu items so R62 gets a variety. V9 stated they made black bean meat loaf and they also serve R62 veggie burgers and cheese quesadillas. V9 stated R62 also got beans with her meal on 4/12/23. This surveyor reviewed the noon meal observation with V9 and she stated she made the baked beans for R62 and is not sure why they didn't go out with her meal. When asked how dietary aids know what to serve R62, V9 stated the cook tells them.
On 04/12/23 at 2:50 PM V6 (Dietary Manager) stated they do chef choice for R62 so she gets a variety of options. V6 stated it includes black bean burgers, rice, pasta, tomato soup, and egg salad. V6 stated they do not have a vegetarian menu and he has been trying to get one. This surveyor reviewed the 4/11/23 and 4/12/23 noon meal observations with V6. V6 stated there was no protein served in the 4/11/23 noon meal. V6 stated there should be protein served with each meal. When asked how the facility ensured R62 received the recommended amount of protein each day, V6 stated they just make sure R62 gets a protein substitute. When asked if R62 had been receiving the recommended amount of protein each day, V6 stated, No.
On 04/12/23 at 3:32 PM V2 (Director of Nurses) stated R62 should be getting protein with each meal.
On 04/12/23 at 3:59 PM V8 (Dietitian) stated the facility did not have a vegetarian menu to follow. V8 stated the facility gives R62 her preferences. This surveyor reviewed the observations of noon meal on 4/11/23 and 4/12/23 with V8. V8 stated R62 should have had a protein served with each meal. V8 stated it should be an equivalent of what a serving would be for three ounces of meat. V8 stated the fortified milk would make up for some of the protein and the cottage cheese would also. Reviewed the observations with no cottage cheese observed. V8 stated R62 should get a protein equivalent at each meal. V8 stated not getting the recommended protein could have an impact on R62's weight however she attributed R62's weight loss to her edema.
The facility Food Service policy dated 09/10 documents It is the policy of this facility to provide our residents with the option of resident choice dining, a Regular Diet is offered. Special conditions will be addressed on an individual basis.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
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 nutritional supplements as ordered for 15 of ...
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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 nutritional supplements as ordered for 15 of 20 (R10, R44, R8, R28, R36, R66, R53, R17, R4, R4, R38, R27, R56, R67, and R1) residents reviewed for nutritional supplements in a sample of 44.
Findings include:
On 04/10/2023 & 4/11/2023, at 12:00 p.m., the following residents were observed not receiving fortified pudding with their lunch meal as ordered: R10, R44, R8, R28, R36, R66, R53, R17, R64, R4, R38, R27, and R67. R56 & R8 did not receive fortified mashed potatoes on 4/10/2023, 4/11/2023, & 4/12/2023.
On 4/12/2023, at 2:00 p.m., V8 (Licensed Dietician Nutritionist), stated the residents had supplements recommended and was ordered by the primary physician and should have received their supplements as ordered on 4/10, 4/11, & 4/12/2023.
On 4/12/2023, at 2:30 p.m., V6 (Dietary Manager) stated that the residents should have gotten their supplements as ordered by their primary physician on 4/10, 4/11, & 4/12/2023 at lunch.
1. R10's medical record Face Sheet documents that R10 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, unspecified. R10's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 2, severe impairment, Section G, Functional Status documents Supervision with setup with eating. R10's medical record Dietary Assessment dated 1/27/2023, documents: On a Regular diet. Fortified Pudding at lunch and supper.
2. R44's medical record Face Sheet documents that R44 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, unspecified. R44's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 00, severe impairment, Section G, Functional Status documents Supervision with setup with eating. R44's medical record Dietary Assessment dated 01/20/2023, documents: On a Regular diet with High Calorie High Protein Supplement, Fortified Pudding at lunch and supper.
3. R8's medical record Face Sheet documents that R8 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. R8's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 2, severe impairment, Section G, Functional Status documents Extensive assistance with one-person physical assist with eating. R8's medical record Dietary Assessment dated 04/08/2023, documents: On a Regular diet with High Calorie High Protein Supplement, Fortified Mashed Potatoes and Pudding at lunch and supper, super cereal every a.m.
4. R28's medical record Face Sheet documents that R28 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R28's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 10, moderately impaired, Section G, Functional Status documents, Supervision with setup with eating. R28's medical record Dietary Assessment dated 03/20/2023, documents: On a Regular diet with High Calorie High Protein Supplement, Fortified Pudding three times a day.
5. R56's medical record Face Sheet documents that R56 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia with behavioral disturbance. R56's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 6, moderately impaired, Section G, Functional Status documents, Supervision with setup with eating. R56's medical record Dietary Assessment dated 03/31/2023, documents: On a Regular diet with High Calorie High Protein Supplement, Fortified mashed potatoes at lunch and supper.
6. R36's medical record Face Sheet documents that R36 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R36's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 8, moderately impaired, Section G, Functional Status documents, Supervision with setup with eating. R36's medical record Dietary Assessment dated 02/10/2023, documents: On a Regular diet and on 1/7/23, add fortified pudding at lunch and supper.
7. R66's medical record Face Sheet documents that R66 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R66's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 99, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R66's medical record Dietary Assessment dated 03/30/2023, documents: On a Regular diet with fortified pudding at lunch and supper.
8. R53's medical record Face Sheet documents that R53 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease with late onset. R53's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 1, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R53's medical record Dietary Assessment dated 03/04/2023, documents: On a Mechanical Soft diet (Missing teeth). High Protein Supplement. Comfort foods. Fortified Pudding at lunch and supper.
9. R17's medical record Face Sheet documents that R17 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R17's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 4, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R17's medical record Dietary Assessment dated 03/20/2023, documents: On a Mechanical Soft diet with Nectar thick liquids. Large portions at breakfast. High Calorie High Protein Supplement. Fortified Pudding at lunch and supper.
10. R64's medical record Face Sheet documents that R64 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, unspecified. R64's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 5, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R64's medical record Dietary Assessment dated 02/03/2023, documents: On a Regular diet with High Calorie High Protein Supplement. Dislikes the milk so fortified pudding served to replace milk.
11. R4's medical record Face Sheet documents that R4 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 6, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R4's medical record Dietary Assessment dated 02/24/2023, documents: On a Regular diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper.
12. R38's medical record Face Sheet documents that R38 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease with late onset. R38's Minimum Data Set (MDS) dated [DATE], Section C, documents Brief Interview for Mental Status (BIMS) score is 6, severely impaired, Section G, Functional Status documents, Supervision with one-person physical assist with eating. R38's medical record Dietary Assessment dated 03/05/2023, documents: On a Regular diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper.
13. R27's medical record Face Sheet documents that R27 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease, unspecified. R27's Minimum Data Set (MDS) dated , 2/15/2023, Section C, documents Brief Interview for Mental Status (BIMS) score is 0, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R27's medical record Dietary Assessment dated 02/10/2023, documents: On a Pureed diet with Mechanical Soft Desserts with High Calorie High Protein Supplements. Fortified Pudding to lunch and supper.
14. R67's medical record Face Sheet documents that R67 was admitted to the facility on [DATE] with a diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R67's Minimum Data Set (MDS) dated , 3/08/2023, Section C, documents Brief Interview for Mental Status (BIMS) score is 0, severely impaired, Section G, Functional Status documents, Supervision with setup with eating. R67's medical record Dietary Assessment dated 03/10/2023, documents: On a Mechanical Soft diet with High Calorie High Protein Supplement. Fortified Pudding at lunch and supper.
The facility's policy Supplementation with a revised date of 04/2022, documents under Purpose: To provide residents additional calories and/or protein to the Regular Diet in the form of supplements in order to improve caloric intake, promote weight gain or weight maintenance or improve wound healing.
15. R1's facility Face Sheet with a print date of 4/13/23 documents R1 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, dysphagia, protein-calorie malnutrition, and gastroesophageal reflux disease.
R1's MDS (Minimum Data Set) dated 3/8/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R1 is cognitively intact.
R1's current Care Plan documents an intervention under Resident Care Information with an approach date of 6/21/22 of, Mechanical soft. Thin Liquids. High Calorie High Protein Supplement.
R1's Progress Notes dated 3/10/23 documents, Dietitian/Quarterly Assessment: On a mechanical diet with high calorie high protein supplement. Fortified pudding at lunch and supper. Intakes 50-75%. Weights: (3/2): 104.8, (2/28): 104.8, (2/9) 105.2, recheck weight, (2/1): 101, (12/2): 104, and (9/3): 110.6. Below IBW (ideal body weight) Range 118-150 .
R1's Progress Notes dated 12/02/22 documents, Dietitian/Quarterly Assessment: .Plan: To stabilize weights. 1) Add: Fortified Pudding at lunch and supper. 2. Recheck weight.
On 04/12/23 at 12:45 PM R1 was served her noon meal in her room. The meal consisted of fish, carrots, baked potatoes, and cake. There was no pudding observed. R1's meal card located on her bedside table and dated 4/12/23 documented R1 was to received 4 ounces of fortified pudding. When asked if she received pudding R1 stated she did not but she does get it sometimes.
On 4/12/23 at 12:47 PM, when asked about R1's pudding, V11 (CNA/Certified Nursing Assistant) stated, We deliver what we are given.
On 04/12/23 12:52 PM, V13 (Dietary Aid) stated the prep cooks make the fortified puddings. V13 looked in the refrigerator located on the unit and was unable to locate fortified pudding for R1.
On 04/12/23 at 2:04 PM, V5 (CNA) stated the kitchen sends the supplements such as fortified pudding to the individual units. V5 stated sometimes they don't get them the way they are supposed to from the kitchen and if they realize they are missing they go to the kitchen and get it.
On 4/12/23 at 2:14 PM V10 (CNA) dietary staff deliver fortified pudding to the units and if they don't bring something the CNA's call the kitchen or go to the kitchen and get it. When asked if there was a reason R1 wasn't served fortified pudding, V10 stated that would be a question for dietary.
On 4/12/23 at 2:24 PM, V9 (Cook) stated dietary aids are supposed to ensure supplements are sent out with the resident meals. V9 stated she wouldn't know why R1 didn't receive fortified pudding since she doesn't work on that side while she is cooking. V9 stated they have new staff and she thinks things have gotten lost in the transition.
04/12/23 at 2:50 PM, V6 (Dietary Manager) stated the fortified puddings are made up by the night dietary aids for morning shift and morning shift makes it for the noon meal. V6 stated he doesn't know why R1 wasn't served fortified pudding and would expect dietary recommendations to be followed.
On 04/12/23 at 3:32 PM, V2 (Director of Nurses) stated he would expect dietary supplements to be served as ordered/recommended by the dietitian.
On 04/12/23 at 3:59 PM, V3 (Dietitian) stated R1 should have received the fortified pudding as recommended. V3 stated R1's weights have stabilized and she doesn't believe not getting the pudding at times would have a negative impact on R1's weights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
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 adaptive equipment was provided for 1 of 22 (R1...
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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 adaptive equipment was provided for 1 of 22 (R134) residents reviewed for nutrition in the sample of 44.
Findings Include:
R134's facility Face Sheet with a print date of 4/13/23 documents R134 was admitted to the facility on [DATE] with diagnoses that include diabetes, need for assistance with personal care, glaucomatous flecks left eye, hypertension, and heart disease.
R134's MDS (Minimum Data Set) dated 3/27/23 documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R134 is cognitively intact.
R134's current Care Plan documents an intervention under Resident Care Information of, Approach Start Date: 3/23/23 Eye Sight Device: Partially Blind. This same care plan documents, Problem Start Date: 4/5/23, (R134) requires minimal set-up assistance 0-1x with divided plate for eating/meals. This problem area includes the intervention of Eating Program: 1. Instruct/Encourage (R134) to pick up food with silverware. 2. Encourage (R134) on use of divided plate.
On 4/10/23 at 9:14 AM, R134 stated she has macular degeneration and doesn't see well. R134 stated she needs help with her meals, and she doesn't always get it.
On 4/10/23 at 12:50 PM, R134 was observed in her room sitting in her bed when her noon meal of chicken salad, fruit cup, bread, carrots, lemonade, and chocolate cake was served, by V15 (Certified Nursing Assistant/CNA). V15 set R134's plate on the bedside table and left the room. V15 returned with another (unknown) staff member and adjusted R134 in the bed and moved the bedside table to the other side of R134's bed and again left the room. R134 asked this surveyor what her food was and where it was at on the plate. R134 stated they were supposed to get her a plate with sides on it, but they hadn't yet. R134's meal card located next to her plate did not document the level of assistance or adaptive equipment R134 was supposed to receive.
On 4/12/23 at 12:12 PM, R134 was served the noon meal of fish, baked potato, carrots, cake, and lemonade on a regular plate.
On 4/12/23 at 12:47 PM, V11 (CNA) stated R134 was always served her meal on a regular plate.
On 4/12/23 at 2:04 PM, when asked if R134 ever had her meal served on adaptive equipment such as a divided plate, V5 (CNA) stated, No.
On 4/12/23 at 2:24 PM, V9 (Cook) stated she wasn't sure why R134 didn't have her meals served on a divided plate. V9 stated it may have just been new dietary staff not knowing R134 was supposed to be served on a divided plate.
On 4/12/23 at 2:50 PM, V6 (Dietary Manager) stated the dietary aids are responsible for ensuring residents receive adaptive equipment. V6 reviewed R134's meal card and noted there was no adaptive equipment listed on it. V6 stated if it isn't documented on the meal card then the dietary aids would not know she was supposed to get it.
On 4/12/23 at 3:32 PM, this surveyor reviewed with V2 (Director of Nurses) the observations on 4/10/23 and 4/12/23 when R134 did not have her meal served on a divided plate. V2 stated he would expect staff to provide the appropriate adaptive devices to be used.
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
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, interview and record review, the facility failed to identify, document, and treat a pressure injury for 1 ...
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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 identify, document, and treat a pressure injury for 1 of 3 residents (R3) reviewed for pressure ulcers in a sample of 4. This failure resulted in R3 sustaining a worsening Deep Tissue Injury/Pressure Wound to the right and left upper buttocks.
Findings include:
R3's face sheet documented an admission date of 8/30/22 and diagnoses including: chronic kidney disease stage three, weakness, difficulty in walking, atrial fibrillation, fracture of unspecified carpal bone right wrist, and traumatic subdural hematoma without loss of consciousness. R3's 11/30/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact and interviewable. R3's 8/31/22 care plan documented R3 was at increased risk for pressure ulcers, with interventions of pressure reducing device in wheelchair and bed, and assist with turning and repositioning. R3's 12/5/22 Braden assessment showed a score of 16, indicating R3 is a high risk for developing pressure ulcers/ injury. R3's 12/14/22 weekly skin check progress noted documented in part .No new areas of concerns as of this shift .coccyx skin integrity WNL (Within Normal Limits) . R3's 12/20/22 progress notes documented R3 was transferred to the hospital. R3's hospital medical record documented a 12/21/22 at 4:38 AM photograph of R3's buttocks and coccyx with dark purplish discoloration. R3's 12/21/22 hospital record History of Present Illness documented in part . [R3] is mostly bed bound. [R3] has a pressure wound to [R3's] buttocks region . R3's 12/25/22 facility readmission skin assessment progress note documented in part .resident has a 3 cm (centimeter) diameter of discoloration to both buttocks . R3's Physician Order Sheet (POS) as of 12/28/22 did not document any treatment ordered for R3's buttocks.
On 12/28/22 at 1:27 PM, a skin check was performed on R3 by V6 (Licensed Practical Nurse/LPN/ Wound Nurse) and V3 (LPN) and observed by this surveyor. R3 had purplish discoloration to the medial aspect of the right and left upper buttock measuring approximately 5.5 cm x 6 cm to the right buttock and 5.5 cm x 5.5 cm to the left buttock with a small 0.1 cm x 0.1 cm open area to the left buttock. V6 said she was not aware R3 had any wounds and stated R3 did not have any treatments in place.
On 12/29/22 at 12:00 PM, V10 (Wound Physician) said dark or purplish discoloration is likely a Deep Tissue Injury (DTI) from pressure. V10 said the appropriate treatment for DTI would be off loading pressure from the area and skin prep or opti-foam. V10 said if a DTI is not treated it can become an open pressure ulcer quickly. V10 said he was unable to say if a DTI/ pressure injury was avoidable or unavoidable for R3. V10 said a DTI was unstageable.
On 12/29/22 at 12:12 PM, R3 was lying in bed with a pillow under her left arm lying flat on the bed with a pressure reducing mattress. R3's wheelchair had a pressure reducing pad present. R3 said she did need assistance with turning and repositioning in bed. R3 said staff did not assist her with repositioning every two hours. R3 said she was not aware of any injury to her buttocks. R3 said the facility was not treating her buttocks prior to the 12/20/22 discharge to the hospital or after her 12/25/22 return to the facility. R3 said she had a foley catheter for a long time and was continent of bowel.
On 12/30/22 at 12:00 PM, V12 (Registered Nurse/RN) said he was the admitting nurse when R3 returned to the facility from the hospital on [DATE]. V12 said he did perform a skin assessment for R3 and did notice some discoloration on R3's buttocks but said he could not clearly remember. V12 said if a resident has any change in skin condition, V6 (LPN/ Wound Nurse) should be notified for further assessment of any skin changes. V12 said the facility had standing orders for new skin concerns. V12 said he did not notify R3's medical provider or use a standing order for any new treatment. V12 said he did not notify V6 (LPN/ Wound Nurse) of any new skin concerns with R3's 12/25/22 readmission skin assessment.
On 12/29/22 at 12:25 PM, V2 (Assistant Director of Nursing/ADON) said V6 (LPN/ Wound Nurse) should be aware of all resident skin changes. V2 said V6 was alerted to skin concerns via word of mouth by facility staff during report or would be notified due to a new treatment being ordered or by facility staff opening an event in the resident's Electronic Medical Record (EMR). V2 said V6 completed all the treatments for residents and would evaluate wounds during their treatment.
The facility's 07/2016 Pressure Injury Prevention and Treatment Protocol policy documented in part .7. When a resident is admitted to the facility or develops a pressure injury . A. Assess the pressure injury for location, size . C. Notify physician of . assessment and obtain orders for treatment .J. For those residents that cannot reposition themselves, transfer self out of bed or cannot turn and position themselves in bed, staff will be responsible for .
Nov 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R3's Face Sheet documented admission date of 4/20/2022 with a diagnosis in part of Parkinson's disease, Dementia in other dis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R3's Face Sheet documented admission date of 4/20/2022 with a diagnosis in part of Parkinson's disease, Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
R3's Quarterly Minimum Data Set (MDS) dated on 7/27/2022 documented in part, a Brief Interview for Mental Status (BIMS) score of 6 which indicates his cognitive skills for decision making was severely impaired. R3's functional status requires extensive assistance of 2 staff members for bed mobility and transferring, and 1 staff assist for toileting and he is not steady without staff assistance.
R3's John Hopkins Fall Risk Assessment Tool dated 7/26/22 documents a score of 26, which indicates R3 is at high risk for falls.
R3's Care plan documented in part, Problem: (R3) is at high risk for falling related to weakness, Parkinson's Disease, Hypertension (HTN), neuropathy and spinal stenosis. He needs frequent reminders to complete tasks. Approach Start Date: 11/15/2022 Assess footwear. Approach Start Date: 09/29/2022 Assist resident to seating option of choice to watch television as tolerated. Approach Start Date: 07/26/2022 Scoop mattress. Approach Start Date: 06/09/2022 non-slip surface to wheelchair. Approach Start Date: 04/21/2022 Assist resident with activities of interest. Approach Start Date: 04/21/2022 Orientate resident to room, surrounding areas, and use of call light system. Also, R3's Care plan documented in part, Problem: Resident Care Information, Approach for Safe Resident Handling procedures, Transfer Method: Stand pivot transfer with gait belt and forward wheel walker level of assistance x2 (two staff).
R3's Fall Event report dated of 8/18/2022 at 7:40 PM documented in part, (R3) slid out of wheelchair, and that the care plan was not reviewed.
R3's Interdisciplinary Team (IDT) progress note dated on 8/19/2022 at 12:26 PM documented, Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 8/18/2022. Exchange wheelchair nonslip surface to pommel (wedge) cushion in place to prevent future occurrences.
R3's Care Plan did not have an intervention updated for the fall event on 8/18/2022 in which the IDT meeting on 8/19/2022 recommended a Pommel (wedge) cushion be put in place to prevent further fall occurrences.
On 11/22/2022 at 9:40 AM, V17 Certified Nursing Assistant (CNA) and V18 CNA's assisted R3 from his bed to his wheelchair without use of a gait belt. V17 and V18 were on each side of R3 assisting him under his arms and holding the back of his incontinent brief to steady him while pivoting to sit down. V17 and V18 then transferred R3 on and off the toilet back to his wheelchair with no gait belt. R3's wheelchair had a green nonslip matt and no cushion in the chair.
On 11/22/2022 at 9:50 AM, V17 stated (R3) requires close supervision and is a high risk for falls. V17 stated, (R3) tries to get up on his own when he shouldn't. V17 stated, (R3) more unsteady today because he was tired from being up late, and most days he stands better. When surveyor asked V17 if (R3) should have been transferred with a gait belt V17 stated, no, he did not need a gait belt because he usually stands up well and can transfer easily.
On 11/22/2022 at 2:15 PM, V23 CNA stated she works on the memory care unit sometimes and was familiar with (R3). V23 stated, she uses a gait belt to transfer any resident at high risk for fall unless they are a mechanical lift.
On 11/22/2022 at 2:24 PM, V24 stated (R3) was at risk for falls and required extensive assist for 1 person to transfer him. V24 stated, she would use a gait belt if (R3) would allow her but sometimes he is resistive to the use of a gait belt, and she would not force it.
On 11/22/2022 at 2:30 PM, V15 CNA stated she works on the memory care unit and was familiar with (R3)'s plan of care. V15 stated, she helps (R3) transfer and uses a gait belt to transfer him.
On 11/22/2022 at 2:55 PM, V2 Director of Nursing (DON) stated he would have expected staff to use a gait belt for R3's transfer.
On 11/22/2022 at 3:30 PM both V1 Administrator and V29 Special Care Coordinator were asked why R3 did not have a pommel (wedge) cushion on his care plan as it was recommended by the IDT meeting notes on 8/19/2022. V1 and V29 both stated they did not know why the pommel cushion recommendation had not been put on R3's care plan. V29 stated, she would check and see. V29 proceeded with surveyor to check on R3's pommel (wedge) cushion and R3 was sitting up in his wheelchair with no cushion under him. V29 looked in R3's room for the cushion and did not find it. V29 asked V16 (Licensed Practical Nurse) where (R3)'s wheelchair cushion was, and V16 stated she did not know.
On 11/22/2022 at 3:50 PM, V29 (Special Care Coordinator) stated (R3) did previously have a pommel (wedge) cushion in place but it must have been taken to the laundry. V29 stated, she would have expected staff to have another cushion to replace the one that was sent to laundry so he would not be without it. V29 also stated, she would have expected the pommel (wedge) cushion to be put on his care plan for all staff to be aware of the intervention and did not know why it did not get carried over to the care plan.
On 11/22/2022 at 4:00 PM, V31 (Occupational Therapist) stated R3 was not currently on therapy but he recalls he brought a pommel (wedge) cushion to the unit recently requested by (V1) because (R3) did not have one in place. V31 also stated, he would recommend staff use a gait belt when they transfer R3.
The facility Emergency Care Procedure policy dated 4/03/18 documents under A. Falls: 1. Check the resident immediately .2. Check resident's ability to explain what happened .3. Check if, or with anyone who witnessed the accident. Determine, if possible, where, how, and when the accident occurred. 4. Check for any possible dislocation or possible fracture .5. Exercise special care in transferring the resident, being careful not do more damage .6. Call the resident's physician. 7. If head injury has occurred with loss of consciousness, notify physician immediately for orders to transfer to emergency room. 8. If head injury has occurred, notify physician, and monitor vital signs and neuro checks at least every four (4) hours for 24 hours, or until stable .9. If a fall is unwitnessed, notify physician and initiate neuro checks at least every four (4) hours for twenty-four (24) hours, or until stable, or as otherwise ordered by physician.
Based on observation, interview, and record review the facility failed to implement new interventions for falls and failed to make sure previous interventions were in place to prevent falls for 2 of 3 residents (R1 and R3) reviewed for falls in the sample of 8.
Findings Include:
1.R1's Resident Face Sheet with a print date of 11/22/22 documents R1 was admitted to the facility on [DATE] with diagnoses that include dementia, anxiety, unsteadiness, unspecified protein-calorie malnutrition, dysphagia, repeated falls, abnormal posture, cognitive communication deficit, Parkinson's disease, heart disease, and obstructive and reflux uropathy.
R1's MDS (Minimum Data Set) dated 09/19/22 documents R1 has modified independence in cognitive skills for daily decision making.
R1's John Hopkins Fall Risk Assessment Tool dated 11/21/22 documents a score of 23, which indicates R1 is at high risk for falls.
R1's care plan documents a problem area of R1 is at risk for falling related to new environment, generalized weakness, Parkinson's Disease and HTN (hypertension). This problem area includes the following interventions, Encourage R1 to wear proper footwear as tolerated (11/08/22), Visual Cues in bedroom (10/18/22), non-slip surface to wheelchair (10/14/22), Assist resident to bathroom before bed as tolerated (9/21/22), When observed awake, assist out of bed as tolerated (9/13/22), scoop mattress (9/6/22), floor mats (9/2/22), Educate resident to ask for assistance with taking showers as tolerated (8/29/22), alternate call light (8/25/22), assist resident with activities of interest (8/16/22), Encourage resident to use side rails/enablers as needed (8/16/22), instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly. (8/16/22), Provide resident with specialized equipment walker/wheelchair. (8/16/22), Therapy to evaluate and treat as ordered. (8/16/22).
R1's Event Report dated 11/03/22 documents under description 2 scratches to back. Under progress notes it documents, 11/03/22 10:55 AM CNA (Certified Nursing Assistant) and another floor nurse informed this nurse that resident was observed to be sitting in the floor of his bathroom. Treatment nurse observed 2 new scratches to resident's back. No other injuries observed. Resident denied harm/pain at this time .
R2's progress notes and care plan do not document a new intervention was implemented after this fall.
On 11/22/22 at 4:19 PM, V2 (DON) stated, the fall on 11/03/22 was not entered into the Event Reports as a fall and that is what triggers them to follow up and put new interventions in place. V2 stated he would expect the staff to enter it as a fall so new interventions could be implemented.
On 11/22/22 at 5:40 AM, R1 was observed in his room sitting in his wheelchair. R1 stated he has fallen while at the facility. A scoop mattress was not observed, and no visual cues were observed.
On 11/22/22 at 7:46 AM observed R1's room with V2 (Director of Nurses/DON) present. V2 confirmed there were no visual cues and no scoop mattress in place.
On 11/22/22 at 4:19 PM, V2 (DON) stated, R1 was recently moved to his current room, and he is assuming the scoop mattress and visual cues did not get moved with R1. V2 stated he would expect the interventions to be in place.
May 2022
7 deficiencies
3 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 observation, interview, and record review the facility failed to ensure effective interventions were implemented to pre...
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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 effective interventions were implemented to prevent falls for residents with dementia were implemented for 4 of 7 (R9, R10, R69, R74) residents reviewed for falls in the sample of 47. This failure resulted in 1. R74 having a fall in the shower that resulted in a fracture of R74's tibia/fibula that required surgical repair, 2. R10 having a fall that resulted in a fractured clavicle and a right femoral neck fracture that required surgical repair, and 3. R69 having a fall that resulted in a fractured pubic ramus and a fractured humerus.
Findings Include:
1. R74's Resident Face Sheet dated 4/29/22 documents R74 was admitted to the facility on [DATE] with diagnoses to include pyogenic arthritis, weakness, nondisplaced oblique fracture of shaft of left fibula, restlessness and agitation, insomnia, depressive episodes, and cognitive communication deficit and spinal stenosis.
R74's MDS (Minimum Data Set) dated 3/14/22 documents R74 has a BIMS (Brief Interview for Mental Status) score of 02, which indicates R74 has severe cognitive impairment. The same MDS documents in Section G, R74 requires assist of one person for bed mobility, transfer, walking, dressing, toilet use, and personal hygeine and documents under Section J R74 has a history of falls.
R74's John Hopkins Fall Risk Assessment Tool dated 1/17/2022 documents a score of 28 which indicates R74 is at high risk for falls.
R74's Care plan dated 3/10/22 documents a problem area of R74 is at risk for falling R/T (related to) recent illness/hospitalization and new environment, HTN, (hypertension), cerebral infarction, AFIB, (Atrial Fibrillation), and incontinence. She has a low BIMS Score, sometimes a difficult time understanding/making others understand her. She has a history of crawling onto the floor at times. She does not comply with weight bearing recommendations d/t (due to) poor safety awareness and cognitive deficits. She (R74) is impulsive. The interventions for R74's fall problem area documented on 3/1/22 are as follows; redirect resident when observed in other resident room as tolerated, assist resident with activities of interest, encourage resident to use side rails/enablers as needed, instruct resident to call for assist before getting out of bed or transferring, encourage resident to stand slowly, orientate resident to room, surrounding areas, use of call light system, provide resident with specialized equipment: walker/wheelchair and therapy to evaluate and treat as ordered. Other interventions documented on R74's fall care plan are; 4/5/22-dump wheelchair, 3/21/22-encourage resident to sleep in her bed as tolerated, 3/14/22-assess footwear, 3/11/22-encourage resident to ask for assistance when carrying beverage as tolerated, 3/7/22-R74 loves pretty things. Offer pretty, sparkly bright, items throughout the day to sort through, and 3/7/22-encourage resident to lead order of tasks in shower as tolerated.
On 4/26/22 at 10:44 AM, R74 was observed self-propelling wheelchair about the facility with an orthopedic type boot on her left foot/leg.
R74's facility Event Report dated 3/2/22 documents under progress notes, 3/2/22 5:47 PM staff was attempting to assist resident with a shower resident became agitated and attempted to hit staff causing resident to fall to the floor resident did not hit her head. Resident complains of left ankle and left leg pain, bruising and swelling noted to areas, no other injuries noted. Resident refused pain med at this time, no other complaints of pain. V33 (Physician) informed, awaiting further orders .3/2/22 6:49 PM MD (physician) order xray of L (left) leg: (name of radiology company) contacted and will be out tonight. 3/2/22 8:02 PM .completed xray at this time. 3/2/22 9:46 PM Requested PRN (as needed) analgesic (pain medication) for c/o (complaints of) left ankle pain; only has routine Tylenol 650 mg TID (three times daily) and not due again until morning. V33 orders ibuprofen 400 mg TID PRN (as needed) x (times) 48 hours; notified of safety alerts. 3/2/22 10:16 PM Called to check on x-ray results . 3/2/22 10:52 PM Xray results received; Comminuted spiral fracture is seen of the distal tibia. Oblique nondisplaced proximal fibular fracture is seen. There does (sic) appear to be a subacute chronic transcervical right femoral neck fracture with a 8 mm (millimeter) displacement. V33 notified and orders to send to hospital 3/7/22 9:51 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/02. Intervention of encourage resident to lead order of tasks in shower as tolerated in place to prevent future occurrences.
R74's local hospital report with a service date of 3/8/22 documents .patient (R74) w/hx (with history) of dementia, from local nursing home, s/p GLF (status post ground level fall). Staff reported patient slipped and fell in the shower, injuring her left lower leg. Xrays were done at the nursing facility, showing left tib/fib (tibia/fibula) fracture. She was admitted for her injuries and evaluated by ortho (orthopedics) who took patient to OR (operating room) for fix on 3/5/22. She did not have any operative complications. She has worked with therapy and achieved pain control. She is tolerating her diet and voiding independently. She is stable for d/c (discharge) to facility . Under Operative Procedures Performed R74's hospital record documents an Open Reduction Internal Fixation of fracture of tibia and fibula.
On 05/03/22 at 3:18 PM, V32 (Certified Nursing Assistant/CNA) stated she was working the night R74 fell in the shower and fractured her leg. V32 stated R74 had an episode of incontinence so they were giving R74 a shower. V32 stated R74 had a behavior and swung out a bit and ended up falling. V32 stated they got the nurse, got R74 dressed and into bed, and she believes they either got x-rays at the facility or sent her out to the hospital. When asked about fall interventions for R74, V32 stated they have fun bags to keep her distracted. V32 stated distraction is key for R74.
On 5/3/2022 at 2:16 PM, V3 (Unit Coordinator) stated they were having a hard time getting R74 to a therapeutic dose of psychiatric medication. V3 stated R74 is very impulsive and independent. V3 stated R74 swung her body with her feet planted on the ground which resulted in the fracture of her leg and the fall to the ground.
R74's facility Event Reports documents the following falls;
2/28/22 5:58 PM, (R74) found in someone else's room at this time. No witnesses to fall. (R74) is free from skin abnormalities/redness at this time. (R74) does not complain of pain .Neurochecks q (every) 4 h (hours) for 24 h initiated. 3/1/22 8:50 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 02/28. Intervention of redirect (R74) when observed in other residents room as tolerated in place to prevent future occurrences.
3/9/22 4:20 PM (R74) was observed sitting on her bedroom floor (R74) was asked if she fell and (R74) stated 'I don't know what happened appeared that (R74) was attempting to put her glass of water on dresser and slid from chair, cup and water were on the floor resident was carrying cup of water previously no new injuries noted resident denies pain to any area neuro checks WNL (within normal limits) . 3/11/22 9:08 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 3/09. Intervention of encourage (R74) to ask for assistance when carrying beverage as tolerated in place to prevent future occurrences.
3/11/22 2:31 PM (R74) had unwitnessed fall in room at this time. (R74) was trying to transfer herself from wheelchair to her bed. (R74) slid onto floor and cannot stand. No rotation or shortening noted and (R74) does not complain of any new pain, just requesting to be picked up off the floor . 3/14/22 8:53 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/11. Intervention of assess footwear in place to prevent future occurrences.
3/20/22 3:52 PM (R74) was observed lying on her bedroom floor (R74) was curled up lying with hands under her head as if sleeping area clean dry free of clutter resident stated 'I was trying to sleep' no new injury noted no deformity rotation or shortening of extremities noted 3/21/22 09:08 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/20. Intervention of encourage (R74) to sleep in bed as tolerated in place to prevent future occurrences.
4/1/22 4:36 PM (R74) found on floor of room at this time. Resident screaming out for 'George.' (R74) on knees at this time and states that she fell. (R74) cannot articulate how or why she fell. (R74's) L (left) lower leg red and warm to touch. (R74) complains of moderate pain to L lower leg. Lower left leg external rotation could be due to boot 4/5/22 X-ray to check status of surgical site. Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/01. Intervention in place to dump wheelchair seat.
On 05/03/22 at 11:07 AM V16 (LPN/Licensed Practical Nurse) stated she wasn't sure what R74's fall interventions were off the top of her head. V16 stated she was sure it was increased toileting.
2. R10's Resident Face Sheet dated 4/29/22 documents R10 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, unsteadiness on feet, weakness, age-related osteoporosis, vitamin deficiency, cognitive communication deficit, and unspecified psychosis.
R10's MDS (Minimum Data Set) dated 4/7/22 documents R10 has a moderate cognitive impairment and requires extensive assistance with bed mobility, transfers, toilet use, and personal hygeine.
R10's Care Plan focus documents a problem area for falls with a start date of 04/10/19 as follows - R10 is at risk for falling r/t (related to): Alzheimer's disease, unspecified dementia, unsteadiness on feet, weakness, thyrotoxicosis, cognitive communication deficit, dizziness and giddiness, unspecified psychosis, emphysema. Psychotropic and narcotic medication use. Oxygen use prn. She has history of crawling out bed or wheelchair and sitting on the floor. Goal - Short-term goal target date: 10/08/21 - R10 will have minimal risk for injury related falls. Approach with start dates to include: 04/27/22 - Encourage resident to ask staff for assistance as tolerated; 04/22/22 - assess footwear; 04/08/22 - PT (physical therapy) eval and treat; 04/05/22 - evaluate resident for walking program; 03/30/22 - NP (Nurse Practitioner) to assess; 03/14/22 - anti-roll backs; 03/11/22 - encourage resident to sit on perimeter of dining area during mealtimes as tolerated; 03/07/22 - redirect to quiet area if overstimulated as tolerated; 02/09/22 - encourage R10 to ask for assistance when moving furniture as tolerated; 02/07/22 - offer chore activity near evening meal as tolerated; 01/27/22 - encourage resident to sleep in bed as tolerated; 01/03/22 - encourage resident to ask for assistance when looking for car keys; 12/20/21 - offer sensory activity as tolerated; 11/22/21 - non-slip surface to wheelchair; 11/16/21 - assess wheelchair; 11/10/21 - assess footwear; 11/04/21 - encourage resident to increase foot clearance as tolerated; 10/18/21 - sensory machine at bedtime; 10/12/21 - encourage frequent rest periods as tolerated; 10/05/21 - encourage resident to walk with staff assistance as tolerated; 09/29/21 - scoop mattress; 09/28/21 - non-skid socks; 02/28/21 - visual cues; 09/13/21 - encourage resident to change positions slowly as tolerated; 09/08/21 - reorient to new environment as tolerated; 06/15/20 - redirect if observed going into peers room; 04/10/19 - alternate call lights; 04/10/19; encourage R10 to use side rails and hand rails as needed; 04/10/19 - instruct R10 to call for assist before getting out of bed or transferring. Encourage resident to stand slowly; 04/10/19 - provide R10 with specialized equipment: walker, w/c (wheelchair) as needed.
R10's John Hopkins Fall Risk Assessment Tool documents a score of 30 on 12/30/21 and a score of 26 on 4/14/22 which indicates R10 is at high risk for falls.
R10's facility Event Report dated 4/7/22 documents under progress notes, 4/6/22 11:17 PM (R10) up and alert self -propelling via w/c (wheelchair) this evening. (R10) observed by staff trying to stand up out of w/c and walk. (R10) redirected. 4/7/22 03:00 PM (R10) had a witnessed fall by the nurses station. (R10) has been getting up and ambulating without her wheelchair most of the day and has to be continuously reminded to stay in wheelchair. Fall was witnessed by this nurse. (R10) fell on right hip/side and did not hit head. Immediately assessed and pain noted to right groin. Unable to complete ROM (range of motion) due to pain. 2 cm x 1 cm (centimeter) skin tear to right elbow. Steri strips in place V33 (physician) was contacted and notified of findings. Awaiting further orders 4/7/22 03:30 PM Per V33, order received to monitor. 4/7/22 05:09 PM (R10) still complaining of a lot of pain to right hip/groin. V33 notified and ordered x-ray. 4/7/22 06:55 PM Assessment performed on resident upon coming onto shift r/t (related to) fall. (R10) presenting with increase in respirations, guarding right leg; holding right hip/groin and moaning/groaning/whimpering. 'It hurts, it hurts,' with facial grimacing. Has right leg drawn close to body. (R10) unable to extend/move right leg, unable to console/distract/reassure. PAINAD scare score = 9/10 (severe). (Name of local radiology company) contacted for ETA (estimated time of arrival) for STAT (immediate) xray, and they said they did not receive electronic xray order and it'll be 4-6 hours before tech can come to perform xray. DON (Director of Nursing) and POA (power of attorney) notified and okay with transfer to hospital. 4/7/22 07:09 PM (R10) departed via ambulance . 4/8/22 12:00 AM Called (name of local hospital) to get update on resident. Confirmed (R10) fractured right hip; surgery tomorrow 4/8/22 08:58 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/07. Intervention of PT (physical therapy) eval (evaluate) and treat in place to prevent future occurrences.
R10's local hospital discharge information record documents a hospital stay beginning on 4/7/22 with a diagnosis of closed right hip fracture, closed fracture of first thoracic vertebra, unspecified fracture morphology, and closed displaced fracture of right femoral neck. R10's local hospital record includes a right hip x-ray on 4/7/22 that documents, History: Trauma. Findings: There is an acute displaced fracture of the right femoral neck . R10's local hospital record includes a cervical spine CT (computerized tomography) without contrast dated 4/7/22 that documents the following impression; Study is limited by motion artifact. No acute fracture allowing for limitation by motion artifact. Unchanged mild wedging of C6 vertebral body. Fracture of superior endplate of T1 vertebral body this is new when compared to the prior study similar to the prior study.
On 5/03/22 at 9:48 AM V24 (CNA) stated she was working the day R10 fell. V24 stated she was redirecting another resident when the nurse told her R10 had fallen and asked for help. V24 stated R10 was saying her hip hurt. V24 stated it was before dinner and there were three CNA's and a nurse working. When asked if that was enough staff to provide appropriate supervision for the residents V24 stated it was. V24 stated R10 was by the nurses station when she fell. V24 stated R10 forgets she can't walk and attempts to stand up out of her wheelchair and staff have to remind her to sit down. V24 stated she didn't have any concerns with the care that was provided to R10 after she fell. When asked what interventions were in place to prevent falls V24 stated they keep R10 by the nurse's station when they can and sit next to her at meals. V24 stated they provide 1:1 interaction after dinner when behaviors are more likely. V24 stated she wasn't aware of any specific fall interventions for R10. V24 stated all of the residents wear no slip socks and they are checked at least every two hours for toileting.
On 05/03/22 at 11:07 AM V16 (Licensed Practical Nurse/LPN) stated she was working the day R10 fell. V16 stated she was sitting inside the nurse's station and R10 was in her wheelchair sitting outside of the nurse's station. V16 stated R10 had been redirected to stay in her wheelchair and then R10 attempted to stand up and fell. V16 stated R10 was complaining of pain and was transferred to the local hospital for evaluation.
R10's facility Event Reports documents the following falls:
1/2/22 Staff found (R10) on dining room floor (R10) stated 'I was trying to walk to find my husband and my car keys.' Area clean dry and free of clutter, hematoma noted to left elbow/forearm no deformity rotation or shortening of extremities noted neuro checks WNL .encouraged to request assistance when needing or wanting to ambulate . 1/3/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 01/02/22. Intervention of encourage (R10) to ask for assistance when looking for car keys in place to prevent future occurrences.
1/31/22 05:07 AM-At approx 0445 (4:45 AM), noise heard from (R10's) bedroom. R10 found on the floor next to her bed. Bed was in lowest position with call light in reach. (R10) doesn't remember how she fell .Hematoma noted to R (right) side of head. 1 cm (centimeter) x 1 cm bruise R bridge of nose and small cut. 1 cm x 1 cm bruise R check. 2 cm x 1 cm ST (skin tear) right elbow . 2/1/22 01:24 AM x-ray obtained .resident compliant. 2/1/22 03:46 AM xray results received and subacute nondisplaced distal clavicle fracture' V33 informed awaiting further orders. 2/1/22 04:02 PM Order received for resident to wear a sling to right arm. 2/7/22 12:04 PM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 1/31/22. Intervention of body pillow in place to prevent future occurrences.
1/31/22 5:56 PM (R10) fell again this evening, same presentations as previous fall. Vitals WNL. 2/7/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 01/31/22. Intervention of offer chore activity near evening meal time as tolerated in place to prevent future occurrences.
2/8/22 (R10) was in dining room when she stood up from wheel chair and attempted to move furniture (R10) then fell backwards landing on her buttocks before this writer could react to her and prevent fall. Area clean, dry, and free of clutter, no rotation, deformity, shortening or lengthening of extremities noted. (R10) has an abrasion and 2 cm diameter hematoma to lateral left knee. (R10) did not hit her head. (R10) did bite her top lip- lip bifurcated approx 0.5 cm in length 2/9/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 2/8/22. Intervention of encourage (R10) to ask for assistance when moving furniture as tolerated in place to prevent future occurrences.
3/3/22 (R10) had unwitnessed fall at nurses station at this time. (R10) appears to have been ambulating without assistance. Wheelchair near by. (R10) is sitting on bottom with back to nurses station leaning against counter. Skin tear to left elbow measures 9 cm (centimeter). Skin flap able to be repositioned over wound. Cleansed, steri strip, and boarder gauze applied. (R10) able to move all extremities without difficulty. No other obvious signs of injury or deformity, able to move all extremities without difficulty . 3/7/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/03. Interventions of redirect to quiet area if overstimulated as tolerated in place to prevent future occurrences.
3/9/22 (R10) was at dining room table and attempted to stand (R10) tripped over her foot causing her to fall before staff was able to reach her. Area clean, dry, free of clutter, no deformity rotation or shortening of extremities. (R10) did hit the left side of her head resulting in a hematoma left mid scalp and also has redness to left forehead/temporal area .(R10) encouraged to request assistance when wanting to stand or transfer . 3/11/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/09. Intervention of encourage resident to sit on perimeter of dining area during mealtimes as tolerated in place to prevent future occurrences.
3/13/22 (R10) was observed lying on the floor at nurses station area clean dry free of clutter appeared (R10) was attempting to stand from WC (wheelchair) no injury noted no rotation deformity or shortening extremities noted 3/14/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/13. Interventions of anti roll backs in place to prevent future occurrences.
3/29/22 (R10) had witnessed fall at this time. (R10) did not hit her head. (R10's) ROM are within normal limits. ST (skin tear) to R elbow noted upon inspection 3/30/22, Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 03/29. Intervention of NP (Nurse Practitioner) to assess in place to prevent future occurrences.
4/3/22 (R10) was observed sitting on the floor in front of door of kitchenette. (R10) stated 'I was trying to walk over yonder', area clean dry and free of clutter. (R10) denied hitting her head however a 2 cm (centimeter) diameter hematoma was noted to left side back of head. No rotation deformity shortening of extremities noted. No other injury noted . (R10) laughing and smiling. (R10) denies pain. (R10) encouraged to request assistance when wanting to transfer or ambulate .4/15/22 Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/03. Intervention in place to evaluate (R10) for walking program.
4/21/22 (R10) had an unwitnessed fall in room. (R10) was found sitting on the floor by her bed. Bed in lowest position. (R10) immediately assessed and no injuries found. (R10) assisted back to bed and was educated on the importance of not getting up without help. (R10) showed understanding. ROM completed and WNL but limited to RLE (right lower extremity) due to recent fx (fracture)
4/26/22 (R10) was observed lying on floor in dining room, area clean dry free of clutter. No deformity rotation or shortening of extremities noted . (R10) has a 2.5 cm diameter hematoma to back of mid scalp neuro checks wnl for (R10). (R10) encouraged to use wc (wheelchair) or request for assistance for transferring 4/27/22 10:21 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 04/26. Intervention of encourage resident to ask staff for assistance as tolerated in place to prevent future occurrences
On 04/26/22 at 11:02 AM, this surveyor was in the dining room screening residents, when this surveyor turned around and saw R10 laying on the floor in the dining area in front of the resident rooms with a pillow under her head. V17 (LPN) was observed assessing R10. R10's wheelchair was sitting next to her. R10 was transferred to her wheelchair with three staff using a mechanical lift appropriately. There were no obvious signs of distress observed.
On 4/29/22 at 9:43 AM, V20 (CNA) stated the interventions staff implement for fall prevention for R10 are to keep her out of her room as much as possible and R10 prefers that. V20 stated they also check on R10 frequently.
On 05/03/22 at 8:45 AM when asked what interventions were in place to prevent falls, V22 (CNA) stated if residents are not in bed they take them to the nurse's station and do an activity with them. V22 stated they do bed checks every two hours and check on R10 more often than that. When asked how often they check on R10, V22 stated they try to check on R10 every 30 minutes.
On 05/03/22 at 2:16 PM, V3 (Unit Coordinator) reviewed R10's falls and interventions and stated R10 is very delusional. V3 stated one second R10 is checking on her grandma and the next second R10 is going to work. V3 stated this can change within a minute. When asked if encouraging R10 to ask for assistance was an appropriate intervention if R10 is delusional and has a diagnosis of dementia, V3 stated R10 is still rational. V3 stated R10 gets set on a task so you help her with the task she is on. V3 stated R10 will get your attention if needed.
3. R69's facility Resident Face Sheet dated 4/29/22 documents R69 was admitted to the facility on [DATE] with diagnoses that include unspecified fracture of right pubis, unspecified dementia, mild cognitive impairment, unspecified displaced fracture of surgical neck of left humerus, repeated falls, brief psychotic disorder, and dementia.
R69's MDS dated [DATE] documents R69 has a BIMS score of 03, which indicates R69 has a severe cognitive impairment. R69's MDS documents under Section G R69 requires assist of one staff for bed mobility, transfer, walking, locomotion, toileting, and personal hygeine. R69's MDS documents under Section J that R69 has had falls with major injury since admission to the facility.
R69's John Hopkins Fall Risk Assessment Tool dated 2/25/22 documents R69 has a fall risk score of 22 which indicates R69 is at high risk for falls.
R69's Care Plan focus documents a problem area for falls with a start date of 09/16/20 as follows - R69 is at risk for falling r/t recent illness/hospitalization and new environment. R69 sits on floor, hides under tables, furniture, attempts to sleep on the floor, runs, and prays while on her knees. Goal target date: 10/01/21 - R69 will have decreased risk for injury related to falls this quarter. Approach with start dates to include: 04/18/22 - visual cues in resident bathroom; 04/13/22 - encourage resident to use arms of chair to lower self into chair as tolerated; 03/28/22 - treat underlying condition; 03/07/22 - assess wheelchair; 02/28/22 - alternate call light; 02/25/22 - visual cues in resident room; 02/22/22 - assess resident for soft collar to improve posture to decrease loss of balance as tolerated; 02/07/22 - encourage resident to ask for assistance when changing clothes as tolerated; 02/07/22 - PT and treat; 01/27/22 - med review; 11/19/21 - encourage resident to not reach past base of support; 09/16/20 - assist resident with activities of interest; 09/16/20 - encourage resident to use side rails/enablers as needed; 09/16/20 - instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly.
R69's Event Report dated 2/27/22 documents under progress notes, 2/27/22 02:57 PM (R69) was found on her bedroom floor. (R69) stated she 'slipped' area clean dry free of clutter. 6.5 cm laceration to right side forehead with moderate amount of bleeding noted. Edges of laceration unable to be approximated due to missing skin flap no other injury noted. No deformity rotation or shortening of extremities noted . (R69) denies pain . Ambulance called for transport to (name of local hospital) for probable sutures. Direct pressure applied to wound and (R69) observed until EMT's (Emergency Medical Technicians) arrived 2/27/22 06:37 PM (R69) returned back to facility from hospital at approx (approximately) 5:55 pm; q4h (every four hours) neuro checks entered WNL, no s/s (signs or symptoms) or c/o (complaints of) pain at this time; sutures to right forehead with dry dressing in place. 2/27/2022 10:41 PM CT (computerized tomography) of head and spine were done at hospital. 2/28/2022 01:19 AM (R69) resting in bed with no s/s or c/o pain/distress . 02/28/2022 08:58 AM Root Cause Analysis: Interdisciplinary Team met to discuss fall that occurred on 02/27. Intervention of alternate call light in place to prevent future occurrences. 3/5/2022 02:30 PM (R69 has slept most of shift sutures to forehead intact no warmth drainage or swelling noted, scheduled Norco 5-325 has been effective for pain control no complaints of pain due to fractures of pelvic ramus.
R69's Event Report dated 4/17/22 documents under progress notes, 4/17/2022 12:38 AM CNA (Certified Nursing Assistant) on hall discovered (R69) on floor sitting on buttocks in bathroom. Prior to fall (R69) noted to be in bed with call light in reach. (R69) did not use the call light for assistance. (R69) continues to self transfer and self ambulate. Staff unaware (R69) up in bathroom (R69) voice c/o pain to left hip MD (physician) notified with request for an order to x-ray. Will continue to monitor. 4/17/2022 01:30 AM MD responded with okay to obtain x-ray. 04/17/22 04:32 AM x-rays completed at this time. 04/17/2022 10:00 PM (name of local radiology company) contacted for xray results. X-rays were performed to the left arm and left hip. #1 Left humerus- displaced left surgical neck humeral fracture. #2 Left hip-Chronic fracture of the ischium, displaced fracture of the inferior right pubic bone. Present on previous study but more displaced now. V33 (Physician) contacted and advised this nurse with the following- May ambulated as tolerated. Needs to see orthopedic, can wait until tomorrow. Sling needs to be worn
R69's facility x-ray reports document on 3/1/22 under impressions: 1. Acute mildly displace fracture of medial right superior pubic ramus and acute non-displaced impacted fracture of inferior right pubic ramus .
On 04/28/22 at 9:55 AM, an alternate call light was observed on R69's bed. R69 was observed wearing a sling on her left arm, sitting in a wheelchair next to her bed, brushing her hair. Visual cues were observed in the bathroom to use the call light when getting up.
On 04/29/22 at 1:34 PM, V17 (Licensed Practical Nurse/LPN) stated she remembered a CNA (unknown) telling her R69 was on the floor. V17 stated R69 said she had slipped and was always trying to go to the bathroom by herself. V17 stated they have two or three CNA's and one nurse working on night shift and that is enough staff to supervise the residents and prevent falls. V17 stated residents are all checked every two hours while in bed. When asked what fall preventions were in place for R69, V17 stated they do more frequent checks on her and have R69 sit where they can see her. When asked how often R69 is checked on, V17 stated she wasn't sure.
On 05/03/22 at 3:09 PM, V31 (LPN) stated she was working when R69 fell. V31 stated R69 was up walking around all night. V31 stated they kept redirecting R69 but they can't force them to stay still. V31 stated R69 was finally in bed and then was found in the bathroom by the CNA's. When asked how often staff check on R69 on midnight shift V31 stated she knew they did two rounds and she was typically checking on residents also. V31 stated there wasn't any certain protocol on how often R69 was checked. V31 stated R69 had been checked about 30 minutes prior to the fall when V31 helped R69 to the bathroom. When asked if she was familiar with R69's fall interventions V31 stated, Just visual cues. When asked what she meant by visual cues V31 stated that is what the chart says. V31 stated she was assuming it meant if you see R69 try to redirect her or assist her. V31 stated she always reminds her to use her call light and she (R69) will sometimes use it.
On 04/29/22 at 2:24 PM, V18 (Certified Nursing Assistant/CNA) stated he was working one time when R69 fell but was unable to remember when it was. V18 stated R69 usually falls on day shift or midnight shift. V18 stated he thinks R69 was by her bed and she probably fell trying to get in or out of the bed. V18 stated R69 always falls by her bed and that R69 never falls in her bathroom.
R69's facility Event Reports document the following falls:
1/24/22 At approx. (approximately) 0525 (5:25 AM) noise heard near nurses station, resident (R69) observed by CNA holding onto a kitchen cart with wheels and fell down onto floor, on right side, hitting head, l[TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R74's Resident Face Sheet dated 4/29/22 documents R74 was admitted to the facility on [DATE] with diagnoses that include unsp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R74's Resident Face Sheet dated 4/29/22 documents R74 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia with behavioral disturbance, cerebral infarction, generalized anxiety disorder, restlessness and agitation, insomnia, and other specified depressive episodes. R74's 3/14/22 Minimum Data Sheet (MDS) section C showed a Brief Interview for Mental Status (BIMS) score of 2, showing severe cognitive impairment and section G showing supervision and setup only with eating. R74's Electronic Medical Record (EMR) did not show any care plans for weight loss.
R74's EMR showed a 4/9/22 dietary progress note . On a Regular diet with High Calorie High Protein Supplement . Resides on . where additional snacks available between meals . Weights: (4/1): 95, (3/1): 106, (1/3): 103, and (10/4): 108. Current weight is down 11#(10.4%) x/1 month, down 8#(7.8%) x/3 months, and down 13#(12.0%) x/6 months. Below IBW Range 105-134. Body Mass Index: 16.83 (Normal/ Healthy Weight) .PLAN: To stabilize weights. 1). ADD: Fortified Pudding at lunch and supper.
On 05/03/22 at 11:41 AM, V14 (Licensed Practical Nurse/LPN/Care Plan Coordinator/CPC) said any resident with severe weight loss should have a care plan with interventions including monitoring monthly or more frequent weights, monitoring of food intake percentages, and monitoring dietary supplement intake. V14 said if a resident has significant weight loss and does not have a care plan for weight loss the likely outcome will be no correction of the problem and the resident will continue to lose weight.
3. R72's Face Sheet documents admission to this facility on 03/03/22 with diagnoses to include dementia without behavioral disturbance, abnormal weight loss, gastro-esophageal reflux disease without esophagitis, and urinary tract infection.
R72's admission weight dated 03/03/2022 is documented at 90.4lbs (pounds) with a BMI (body mass index) of 17.65.
A progress note dated 04/19/2022 at 4:45 PM documents V5 (Primary Care Physician - PCP) ordered dronabinol 2.5 mg (milligram); bid (twice daily) 1 hour before lunch and dinner.
R72's POS (Physicians Order Sheet) documents an order for dronabinol - Schedule III capsule; 2.5 mg amt (amount): 1 capsule; 2.5 mg; oral to be administered 1 hour before lunch and dinner for abnormal weight loss. Start date: 04/20/22.
A progress note dated 04/20/22 at 10:03 AM documents dronabinol rx (prescription) faxed to V5 at this time awaiting signature.
A progress note dated 04/27/22 at 12:02 PM documents the facility contacted V5's office regarding the Marinol (dronabinol) prescription - Office states they will be sending a signed script today.
R72's April 2022 MAR (Medication Administration Record) documents dronabinol 2.5 mg was not administered due to drug not being available from 04/20/22 to 04/28/22.
R72's May 2022 MAR documents dronabinol has not been administered for weight loss since the medication was ordered on 04/20/22.
R72's record dated 04/19/22 documents a weight of 82.8lbs with a BMI of 16.17. This shows an 8.41% weight loss in 6 weeks, indicating a severe weight loss.
On 04/29/22 at 11:54 AM, V2 (DON - Director of Nursing) stated when the MAR documents not administered: drug not available it means the facility is usually waiting for a signed prescription from the physician. V2 acknowledged a week passed before the facility contacted V5's office to follow-up on R72's prescription for Marinol. V2 confirmed R72's Marinol still had not been received and administered to R72 for weight loss. V2 stated he would expect the nurses to follow-up across shifts to verify resident medications are in place and being administered timely and as ordered.
Based on observation, interview, and record review the facility failed to follow therapeutic dietary recommendations for residents with significant weight loss; and failed to implement medication prescribed specifically for weight loss for 4 of 7 (R9, R69, R72, R74) residents reviewed for weight loss in a sample of 47. This failure resulted in R72 having an 8.41% (severe weight loss) in a period of just over 1 month, R9 having a 12.3% weight loss in six months, and R69 having a 5.4% weight loss in one month and a 17.8% weight loss in six months.
Findings Include:
1. R9's Resident Face Sheet dated 4/29/22 documents R9 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease, dementia, major depressive disorder, anxiety disorder, history of cerebral infarct (stroke), dysphagia, anorexia nervosa, and vitamin deficiency.
R9's MDS (Minimum Data Set) dated 4/5/22 documents R9 has severely impaired cognitive skills and requires one person physical assist to eat.
R9's Physician Order Report dated 3/28/22 to 4/28/22 documents a physician order for a regular diet with high calorie supplement.
R9's facility care plan dated 7/14/21 documents a problem area of Resident requires assistance with eating and putting on shirt related to diagnosis of dementia. Interventions include eating program Step 1. Set meal up completely, instruct resident to feed self, if he/she does so reward with praise. If not move to next step, Step 2. Place utensil in resident's hand, instruct to put food on utensil and place into mouth. If he/she does so reward with praise. If not, move to next step. Step 3. Place hand over resident's hand, filling utensil with food and guiding to resident's mouth. If he/she does so reward with praise. If not move to next step. Step 4. Place food on residents utensil and put food into resident's mouth, tell resident to chew then swallow after each bite. If he/she does so reward with praise. R9's care plan does not address weight loss and/or interventions to prevent weight loss.
R9's dietitian assessment dated [DATE] documents, On a regular diet with high calorie supplement. Fortified pudding at lunch and supper and fortified whole milk at meals. Intakes 25-50%. Refusing meals at times. On Remeron/Megace which can increase/stimulate appetite Weights: (4/1): 107, (3/1): 106, (1/3): 119, (12/31):119, and (10/4): 122. Current weight is down 12# (pounds) (10.1%) x 88 days, down 12# (10.1%) x/3 (times 3) months, and down 15# (12.3%) x/6 months. Below IBW (Ideal Body Weight) Range 132-166. Body Mass Index: 16.27 (Underweight- However with edema not a true indicator of risk). Has 2+(plus) Bilateral LE (lower extremity) edema, (Diagnosis CHF) (Congestive Heart Failure). Potential risk for weight changes. Skin free of open areas Continue with diet Rx (prescription) as weights up 1# x/1 month. Monitor.
R9's Vitals Report dated 11/01/21 to 4/29/22 documents the following weights; 11/03/21- 124 pounds, 12/01/21-109 pounds, 1/3/22- 119 pounds, 2/2/22-103 pounds, 4/1/22- 107 pounds, 4/29/22- 116 pounds.
On 4/28/22 beginning at 11:42 AM, R9 was served lemonade and fortified milk, chicken, roasted red potatoes, broccoli, and bread. R9's meal card observed lying on the table next to his tray documented R9 was to have gotten a regular diet with a high calorie supplement, and fortified mashed potatoes. R9 was not served mashed potatoes.
On 4/28/22 at 12:20 PM V27 (Dietary Assistant) stated R9 should have received fortified mashed potatoes with his noon meal on 4/28/22.
On 04/28/22 at 2:15 PM V4 (Dietary Manager) stated R9 should have been served fortified mashed potatoes.
2. R69's Resident Face Sheet dated 4/29/22 documents R69 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, cognitive communication deficit, anorexia nervosa, general anxiety disorder, nausea, heartburn, and irritable bowel syndrome.
R69's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 03, which indicates R69 has a severe cognitive impairment. R69's MDS documents under Section G that R69 requires physical assist of one person for eating.
R69's Physician Order Report dated 3/29/22 to 4/29/22 documents a physician order for ensure, one with meals with a start date of 3/21/22 and an end date of 4/29/22 and a physician order for ensure one four times a day as tolerated by resident and per request. R69's Physician Order Report documents a physician order for a regular diet.
R69's Dietitian assessment dated [DATE] documents, On a regular diet with Fortified Mashed Potatoes at Lunch/Supper. Ice Cream at lunch and supper. Ensure TID (three times daily) provided by family. Intakes 25-75%. On Remeron which can increase appetite .Weights (4/1): 88, (3/1): 93, (1/1): 98.2, and (10/4): 107. Current weight is down 5# (pounds) (5.4%) x/1 (times 1) month, down 10# (10.4%) x/3 months, and down 19# (17.8%) x/6 months. Below IBW (ideal body weight) Range 102-131. Body Mass Index 16.09 (Underweight) Continue with diet Rx. (prescription) Monitor.
R69's Vitals Report dated 11/01/21 to 4/29/22 documents the following weights; 11/03/21-100.1 pounds, 12/01/21- 97 pounds, 1/1/2022- 98.2 pounds, 2/2/22- 93 pounds, 3/1/22- 93 pounds, 4/1/22- 88 pounds, 4/28/22- 96 pounds.
R69's Care Plan dated 10/01/21 documents a problem area of Resident requires assistance with putting on shirt and eating related to diagnosis of dementia. She has a low BIMS (Brief Interview for Mental Status) Score, and usually understands but misses some content, finishing thoughts, etc. The interventions listed for this problem area are, Eating program: Step 1: Set meal up completely, instruct resident to feed self. If he/she does so, reward with praise. If not, move to the next step. Step 2: Place utensil in resident's hand, instruct to put food on utensil and place into mouth. If he/she does so, reward with praise. If not, move to next step. Step 3. Place hand over resident's hand, filling utensil with food and guiding to resident's mouth. If he/she does so, reward with praise. If not, move to next step. Step 4: Place food on resident's utensil and put food into resident's mouth, tell resident to chew then swallow after each bite. If he/she does so, reward with praise. R69's care plan does not document a problem area and/or interventions to prevent weight loss.
On 04/26/22 at 12:12 PM, R69 was served roast turkey and gravy, mashed potatoes, mixed vegetables, bread, butter, and an eclair. R69 was observed feeding herself and no supplements were observed served to R69.
On 4/28/22 beginning at 11:42 AM, R69 was served lemonade, broccoli with cheese on it, red roasted potatoes, meat (chicken), bread, and cream pie. R69 was not served an ensure, mashed potatoes, or ice cream with this meal. R69's meal card documented she should have been served fortified mashed potatoes.
On 04/28/22 at 9:05 AM V19 (Certified Nursing Assistant/CNA) stated R69 was given ensure when she asked for them which was usually after lunch. V19 stated the ensure was provided for R69 by her family.
On 4/28/22 at 2:21 PM V26 (Resident Assistant) stated R69 gets the ensure when she asks for them. When asked how often she gets ice cream, V26 stated they just give them to her when she asks for them. When asked if she gets the ice cream and ensure with each meal, V26 stated she usually asks for Coke. V26 stated it is not documented anywhere when they give her the ensure or the ice cream.
On 4/28/22 at 2:31 PM V24 (CNA) stated R69 gets ensure when she asks for them. When asked how often R69 asks for them V24 stated she asks for them with each meal. When this surveyor confirmed R69 asks for ensure and ice cream with each meal, V24 stated she was only with R69 during one meal a day (supper) and she (V24) tries to remember everyday but sometimes when it is chaotic it gets missed.
On 4/29/22 at 9:43 AM, V20 (CNA) stated they used to document giving the ensure and ice cream under the snack section but that got discontinued. V20 stated she usually gives R69 an ensure at breakfast and lunch but sometimes R69 won't drink it and she gives R69 the ice cream whenever she asks for it.
On 04/29/22 at 1:46 PM, V17 (LPN/Licensed Practical Nurse) stated R69 doesn't eat much so they started giving her ensure. V17 stated the order is for meal times but she usually asks for them in between meals. V17 stated they give them to her when she asks for them. When asked if there was a system in place to ensure R69 gets them when she didn't ask for them, V17 stated R69 has never had a problem asking for them. V17 stated she asks for them at least three times a day and sometimes more. When asked if it was documented anywhere, V17 stated she didn't think so.
On 4/28/22 at 2:48 PM, V3 (Dementia Unit Coordinator) stated R69 gets ensure for significant weight loss and R69's family supplies it. V3 stated R69 has had some mental health issues and she was sent out for a psychiatric evaluation and wasn't taking anything by mouth. When asked if there was anyway the facility was tracking to ensure R69 was offered and/or served ensure and ice cream as ordered/recommended, V3 stated she wasn't sure and she would have to check to see if there was anyway they were tracking it.
On 4/28/22 at 12:20 PM, V27 (Dietary Assistant) stated she served regular mashed potatoes today because they didn't have any fortified mashed potatoes brought to them by the kitchen. When asked if she let the kitchen know she didn't get fortified mashed potatoes to serve, she said she hadn't. V27 stated they didn't serve fortified mashed potatoes to anyone for the noon meal on 4/28/22. V27 stated R9 and R69 should have both received fortified mashed potatoes.
On 04/28/22 at 1:59 PM, V4 (Certified Dietary Manager) stated they did not have fortified mashed potatoes to serve R9 and R69. V4 stated they should have had them and they didn't. V4 stated she told V27 all she had to do was call the kitchen when that happened. When asked about R69's supplements, V4 stated they try to change it up and they usually keep ice cream in the freezer. When asked how she ensures R69 is getting the supplements every day V4 stated she should. V4 stated the CNA's (Certified Nursing Assistants) should offer it. V4 stated she did not have R69 on ensure. V4 stated dietary is not allowed to give ensure because it is a physician's order so the nurses administer it.
On 5/4/22 at 9:50 AM, V29 (Dietician) stated she is not sure if there is a system in place to ensure R69 gets the ensure and ice cream as ordered/recommended. V29 stated she doesn't have any concerns the residents have not been getting supplements routinely but they should have been served fortified mashed potatoes with the noon meal as recommended.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to ensure treatment for pain was effecively provided for 1 (R226) of 3 residents reviewed for pain management in the sample of 47. This failur...
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Based on interview and record review, the facility failed to ensure treatment for pain was effecively provided for 1 (R226) of 3 residents reviewed for pain management in the sample of 47. This failure resulted in R226 experiencing uncontrolled pain after admission and while participating in the therapy program, ultimately going 4 days without receiving a narcotic as ordered for pain control.
Findings Include:
R226's out of state hospital record documents a hospital admission date of 03/20/22 with the diagnosis of intractable pain/metastatic renal cell carcinoma. R226 was discharged from the hospital to this facility on 04/15/22 with discharge medication orders to include Fentanyl 100mcg/hr (microgram/hour), place 1 patch on the skin every third day for 6 days for severe chronic pain with opioid tolerance, start date 04/16/22.
R226's resident face sheet dated 4/29/22 documents admission to this facility on 04/15/22 with the following diagnoses in part - Orthopedic aftercare, acute embolism and thrombosis unspecified deep vein lower extremity, pain in leg, and weakness. R226's diagnosis of intractable pain/metastatic renal cell carcinoma was not included.
R226's facility POR (Physician's Order Report) dated 3/28/22 to 4/28/22 includes - Fentanyl patch 72 hour, 100mcg/hr, 1 patch transdermal, place 1 patch on the skin every third day for 6 days, start date 04/16/22, discontinue 04/19/22 for diagnosis of pain in leg.
R226's April 2022 MAR (Medication Administration Record) documents in part - Assess pain every shift using 0-10 scale or verbal descriptor scale to begin on 04/19/22. R226 was assessed to have experienced the following pain - 04/19/22 - generalized at a 6 on day shift and 7 on evening shift; 04/20/22 no pain on day shift and leg pain at a 7 on evening shift; 04/21/22 documents R226 is having no pain this day; 04/22/22 hip, back, and left leg pain at an 8 on day shift, and moderate generalized pain on evening shift; 04/23/22 generalized pain at a 7 with no pain on the evening shift; 04/24/22 no pain on day shift and leg pain at a 7 on the evening shift; 04/25/22 all over pain on day shift at an 8 with generalized pain at a 6 in the evening; 04/26/22 no pain on day shift with leg pain at a 5 on evenings; 4/27/22 documents no pain.
R226's Fentanyl 100mcg patch every 72 hour was documented as not administered from 04/16/22 to 04/19/22 due to not being available.
A progress note dated 04/18/22 at 4:42 PM documents - Signed Rx (prescription) for Fentanyl patches sent to CCP (critical care pharmacy) at this time. NP (Nurse Practitioner) gives one time order for 50mcg patch until 100mcg is delivered. 50mcg patch pulled from stat-safe .
A progress note dated 04/18/22 at 4:52 PM documents Fentanyl 50mcg was pulled from the stat safe and applied to R226's right shoulder, which is half the physician ordered dose.
A progress note dated 04/19/2022 at 03:24 PM documents a Fentanyl 100mcg patch was administered to R226. There is no documentation on the MAR to confirm this.
R226's POR dated 3/28/22 to 4/28/22 also documents - Fentanyl patch 72-hour 100mcg/hr 1 patch transdermal for leg pain every 3 days, start date 04/21/22.
R226's April 2022 MAR documents Fentanyl 100mcg patch was administered on 04/21/22, is blank on 04/24/22, with the next 100mcg patch applied on 04/27/22.
R226's progress note dated 04/24/2022 at 2:02 PM documents - Resident out of fentanyl 100mcg/hr patch. Pharmacy called for e-pull. Order faxed . Awaiting call back.
R226's progress note dated 04/24/2022 at 9:54 PM documents - Fentanyl 100mcg patch unavailable in stat safe. Only one 50mcg available and placed on residents right upper arm. This dose is not documented on R226's April MAR.
R226's progress note dated 04/26/22 documents the resident is out of Fentanyl 100mcg and unavailable in the facility stat safe. The facility documented Fentanyl 50mcg was available and was placed on R226's arm on 04/26/22, half the ordered dose. This dose is not documented on R226's April MAR.
R226's April 2022 MAR continues to document Fentanyl 100mcg patch was administered on 04/27/22 as prescribed.
On 04/27/22 at 9:30 AM, R226 stated he admitted to this facility from an out of state hospital after undergoing surgical repair of left hip. He stated it took several weeks for the hospital to get his pain under control and manageable. He stated he discharged to this facility for after care and therapy in hopes to go home when he gets stronger. R226 stated when he first got here on 04/15/22, his pain medications were messed up and he did not get his Fentanyl patch the first several days. He confirmed he did participate in therapy, but it was rough because he was in so much pain. He stated he didn't quit, though. R226 stated that he believes his Fentanyl got straightened out, but it took about another week to get his pain under control, and he began to feel better on 04/25/22.
On 04/29/22 at 2:30 PM, V2 (Director of Nursing - DON) stated R226's Fentanyl 100mcg prescription was originally sent to the wrong pharmacy by the out of state discharging hospital causing a delay in the administration of this pain patch to the resident.
On 05/03/22 at 3:10 PM, V28 (Physical Therapy Assistant - PTA) stated R226 told to him there was an issue with the facility getting his pain medication initially but thought this had been taken care of a few days after admission. V28 stated R226 was in a lot of pain when he began therapy and did report this to V28.
On 05/04/22 at 10:21 AM, V2 (DON) verified V25 (Family Member) brought in Fentanyl patches picked up at the local pharmacy on 04/18/22, but they were 75mcg only, so the facility continued to pull Fentanyl 50mcg from the stat safe. V2 stated he believed R226's pain was partially covered by giving the half dose of 50mcg available and thought the facility would have gotten approval from a nurse practitioner, physician, or on call clinician upon administration of Fentanyl 50mcg on 04/18, Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 since this was not administered as prescribed, but was not able to provide corroborating documentation of obtaining the approval.
On 05/04/22 at 1:00 PM, V30 (Nurse Practitioner) stated she spoke with the facility on 04/18/22 and gave verbal approval to administer a 50mcg Fentanyl patch to R226 since the 100mcg prescription was still not available. V30 stated she was not involved in giving approval for R226 to receive Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mcg on 04/27 and would have expected the facility to contact the physician to get approval to do so since this was not administered as prescribed.
The facility Pain Management Policy dated 09/10 documents, The Facility is dedicated to the philosophy that all residents should be as free of pain as possible, through a combination of medical intervention and functional therapy Procedure: 1. Residents will be assessed for pain using the Geriatric Pain Assessment upon admission, quarterly and with any significant change in resident condition. A standardized 0-10 scale of Verbal Descriptor Scale (VDS) will be utilized to determine pain intensity. 2. The physician will then be contacted, if needed, regarding the pain or pain indicators. Licensed staff will document any contact with the physician and the physician's response. 3. An individualized care plan will be developed and implemented. 4. If the resident's pain is not being controlled, a Pain Tracking Log may be implemented to track pain and response to medication and/or treatment. 5. Residents will be monitored until pain is resolved or is under control and periodically thereafter. 6. Licensed staff will document any complaints of pain and the resident's response to the medication/treatment in resident's record. 7. In the event that there are no new medication orders from the physician, licensed staff will continue to monitor the resident's condition, keeping the primary physician informed. 8. The Medical Director will be notified of resident's condition, physician notification and lack of response, should that occur. 9. Alternative methods of pain control will also be attempted .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure physician's orders were carried out and followed up on in a timely manner to promote residents' highest practicable level of functio...
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Based on interview and record review, the facility failed to ensure physician's orders were carried out and followed up on in a timely manner to promote residents' highest practicable level of functioning for 2 (R72 and R 226) of 3 residents reviewed for following physician's orders in the sample of 47.
1.a) R72's Face Sheet documents admission to this facility on 03/03/22 with diagnoses to include Unspecified dementia without behavioral disturbance, Urinary tract infection, Encounter for prophylactic measures, abnormal weight loss, and gastro-esophageal reflux disease without esophagitis.
R72's record contains a prescription dated 03/22/22 by V5 (Primary Care Physician - PCP) documents an order for urinalysis and culture if indicated due to UTI (urinary tract infection) symptoms and dysuria.
R72's progress note dated 03/23/2022 at 1:38 AM, documents - UA (urinalysis) specimen collected at this time, lab contacted for pickup.
R72's lab report dated 03/23/22 documents an abnormal urinalysis with subsequent culture ordered due to this abnormal finding .collected by clean catch dated 03/23/22 at 1:20 AM; received 03/23/22 at 4:02 AM; and verified on 03/23/22 at 4:46 AM.
R72's urine culture lab result dated 03/24/22 at 11:27 PM documents a positive result for Escherichia coli (e-coli) verified on 03/25/22 at 4:26 PM.
R72's record contains a scanned order from V5 for Ciprofloxacin 250 mg twice daily with a start date of 03/25/22, end date 03/30/22. A handwritten note on this order by V5 dated 04/01/22 documents the order was sent to the local pharmacy last week, but if it needed to be sent to another pharmacy, please do.
R72's record contains a scanned prescription to an out-of-town pharmacy dated 04/08/22 for Cipro 250mg (milligram) take 1 tablet by mouth twice a day for 5 days.
R72's progress note dated 04/09/2022 at 6:27 AM, documents - Received order per V5 (Primary Care Physician - PCP) to start cipro 250mg BID X (twice a day times) 5 days. Orders processed . There is no documentation in R72's record confirming this medication was started at this time.
R72's Physician Order Report dated 3/1/22 to 4/29/22 documents a prescription for Cipro 250mg (milligram) take 1 tablet by mouth twice a day, start date 04/13/22.
R72's April 2022 MAR (Medication Administration Record) documents administration of Cipro as prescribed dated 04/13/22 through 04/17/22.
R72's progress note dated 04/14/2022 at 10:39 AM, documents - Res (resident) started antibiotic 4/13/2022. Res continues to take ABX (antibiotic), no adverse side effects noted.
There is no documentation in R72's record to explain the 21-day delay between the urinalysis and culture on 03/23/22 to when Cipro was started on 04/13/22.
R72's progress note dated 04/18/2022 at 1:22 AM, documents - Resident finished ABX r/t UTI. No adverse effects noted. VS (vital signs) remain WNL (within normal limits).
There was a 19-day delay from the time R72's urinary culture results were received until R72 began her antibiotic treatment on 04/13/22.
On 04/29/22 at 8:30 AM, V2 (Director of Nursing - DON) stated he doesn't know why there was a delay in treatment for R72, but it looks like the order was missed on 03/25/22 and nursing did not follow-up on faxing the prescription to the correct pharmacy. V2 stated the facility followed up with V5's office on 04/08/22, obtaining a new order dated 04/09/22, but confirmed R72 still did not receive her first dose of antibiotic treatment until 04/13/22. V2 confirmed it took a total of 19 days for R72 to receive her antibiotic and he would have expected nursing to follow-up with the physician or pharmacy sooner so there would be no delay in treatment.
1. b) R72's admission weight dated 03/03/2022 is documented at 90.4lbs (pounds) with a BMI (body mass index) of 17.65.
A progress note dated 04/19/2022 at 4:45 PM documents V5 (Primary Care Physician - PCP) ordered dronabinol 2.5 mg (milligram); bid (twice daily) 1 hour before lunch and dinner.
R72's POS (Physicians Order Sheet) dated 3/1/22 to 4/29/22 documents an order for dronabinol - Schedule III capsule; 2.5 mg amt (amount): 1 capsule; 2.5 mg; oral to be administered 1 hour before lunch and dinner for abnormal weight loss. Start date: 04/20/22.
A progress note dated 04/20/22 at 10:03 AM documents dronabinol rx (prescription) faxed to V5 at this time awaiting signature.
A progress note dated 04/27/22 at 12:02 PM documents the facility contacted V5's office regarding the Marinol (dronabinol) prescription - Office states they will be sending a signed script today.
R72's April 2022 MAR (Medication Administration Record) documents dronabinol 2.5 mg was not administered due to drug not being available from 04/20/22 to 04/28/22.
R72's May 2022 MAR documents dronabinol has not been administered for weight loss since the medication was ordered on 04/20/22.
R72's record dated 04/19/22 documents a weight of 82.8lbs with a BMI of 16.17. This shows an 8.41% weight loss in 6 weeks, indicating a severe weight loss.
On 04/29/22 at 11:54 AM, V2 (DON - Director of Nursing) stated when the MAR documents not administered: drug not available it means the facility is usually waiting for a signed prescription from the physician. V2 acknowledged a week passed before the facility contacted V5's office to follow-up on R72's prescription for Marinol. V2 confirmed R72's Marinol still had not been received and administered to R72 for weight loss. V2 stated he would expect the nurses to follow-up across shifts to verify resident medications are in place and being administered timely and as ordered.
2. R226's out of state hospital record documents a hospital admission date of 03/20/22 with the diagnosis of intractable pain/metastatic renal cell carcinoma. R226 was discharged from the hospital to this facility on 04/15/22 with discharge medication orders to include Fentanyl 100mcg/hr (microgram/hour), place 1 patch on the skin every third day for 6 days for severe chronic pain with opioid tolerance, start date 04/16/22.
R226's resident face sheet documents admission to this facility on 04/15/22 with the following diagnoses in part - Orthopedic aftercare, acute embolism and thrombosis unspecified deep vein lower extremity, pain in leg, and weakness. R226's diagnosis of intractable pain/metastatic renal cell carcinoma was not included.
R226's facility POR (Physician's Order Report) dated 3/28/22 to 4/28/22 includes - Fentanyl patch 72 hour, 100mcg/hr, 1 patch transdermal, place 1 patch on the skin every third day for 6 days, start date 04/16/22, discontinue 04/19/22 for diagnosis of pain in leg.
R226's April 2022 MAR (Medication Administration Record) documents in part - Assess pain every shift using 0-10 scale or verbal descriptor scale to begin on 04/19/22. R226 was assessed to have experienced the following pain - 04/19/22 - generalized at a 6 on day shift and 7 on evening shift; 04/20/22 no pain on day shift and leg pain at a 7 on evening shift; 04/21/22 documents R226 is having no pain this day; 04/22/22 hip, back, and left leg pain at an 8 on day shift, and moderate generalized pain on evening shift; 04/23/22 generalized pain at a 7 with no pain on the evening shift; 04/24/22 no pain on day shift and leg pain at a 7 on the evening shift; 04/25/22 all over pain on day shift at an 8 with generalized pain at a 6 in the evening; 04/26/22 no pain on day shift with leg pain at a 5 on evenings; 4/27/22 documents no pain.
R226's Fentanyl 100mcg patch every 72 hour was documented as not administered from 04/16/22 to 04/19/22 due to not being available.
A progress note dated 04/18/22 at 4:42 PM documents - Signed Rx (prescription) for Fentanyl patches sent to CCP (critical care pharmacy) at this time. NP (Nurse Practitioner) gives one time order for 50mcg patch until 100mcg is delivered. 50mcg patch pulled from stat-safe.
A progress note dated 04/18/22 at 4:52 PM documents Fentanyl 50mcg was pulled from the stat safe and applied to R226's right shoulder, which is half the physician ordered dose.
A progress note dated 04/19/2022 at 03:24 PM documents a Fentanyl 100mcg patch was administered to R226. There is no documentation on the MAR to confirm this.
R226's POR dated 3/28/22 to 4/28/22 also documents - Fentanyl patch 72-hour 100mcg/hr 1 patch transdermal for leg pain every 3 days, start date 04/21/22.
R226's April 2022 MAR documents Fentanyl 100mcg patch was administered on 04/21/22, is blank on 04/24/22, with the next 100mcg patch applied on 04/27/22.
R226's progress note dated 04/24/2022 at 2:02 PM documents - Resident out of fentanyl 100mcg/hr patch. Pharmacy called for e-pull. Order faxed . Awaiting call back.
R226's progress note dated 04/24/2022 at 9:54 PM documents - Fentanyl 100mcg patch unavailable in stat safe. Only one 50mcg available and placed on residents right upper arm. This dose is not documented on R226's April MAR.
R226's progress note dated 04/26/22 documents the resident is out of Fentanyl 100mcg and unavailable in the facility stat safe. The facility documented Fentanyl 50mcg was available and was placed on R226's arm on 04/26/22, half the ordered dose. This dose is not documented on R226's April MAR.
R226's April 2022 MAR continues to document Fentanyl 100mcg patch was administered on 04/27/22 as prescribed.
On 04/27/22 at 9:30 AM, R226 stated he admitted to this facility from an out of state hospital after undergoing surgical repair of left hip. He stated it took several weeks for the hospital to get his pain under control and manageable. He stated he discharged to this facility for after care and therapy in hopes to go home when he gets stronger. R226 stated when he first got here on 04/15/22, his pain medications were messed up and he did not get his Fentanyl patch the first several days. He confirmed he did participate in therapy, but it was rough because he was in so much pain. He stated he didn't quit, though. R226 stated that he believes his Fentanyl got straightened out, but it took about another week to get his pain under control, and he began to feel better on 04/25/22.
On 04/29/22 at 2:30 PM, V2 (Director of Nursing - DON) stated R226's Fentanyl 100mcg prescription was originally sent to the wrong pharmacy by the out of state discharging hospital causing a delay in the administration of this pain patch to the resident.
On 05/03/22 at 3:10 PM, V28 (Physical Therapy Assistant - PTA) stated R226 told to him there was an issue with the facility getting his pain medication initially but thought this had been taken care of a few days after admission. V28 stated R226 was in a lot of pain when he began therapy and did report this to V28.
On 05/04/22 at 10:21 AM, V2 (DON) verified V25 (Family Member) brought in Fentanyl patches picked up at the local pharmacy on 04/18/22, but they were 75mcg only, so the facility continued to pull Fentanyl 50mcg from the stat safe. V2 stated he believed R226's pain was partially covered by giving the half dose of 50mcg available and thought the facility would have gotten approval from a nurse practitioner, physician, or on call clinician upon administration of Fentanyl 50mcg on 04/18, Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 since this was not administered as prescribed, but was not able to provide corroborating documentation of obtaining the approval.
On 05/04/22 at 1:00 PM, V30 (Nurse Practitioner) stated she spoke with the facility on 04/18/22 and gave verbal approval to administer a 50mcg Fentanyl patch to R226 since the 100mcg prescription was still not available. V30 stated she was not involved in giving approval for R226 to receive Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 and would have expected the facility to contact the physician to get approval to do so since this was not administered as prescribed.
The facility Pharmaceutical Procedures policy dated 10/18/19 documents the purpose of the policy is, 1. To provide the appropriate control of procurement, distribution, administration, and utilization of drugs to the facility. 2. To provide the facility residents with the safest, effective and most rational form of drug therapy at a reasonable cost. 3. To serve as the primary resource of drug information and education to professional personnel in providing quality pharmacotherapy to the facility. Under Emergency Medication Supply the policy documents, .A. Convenience drug boxes may be kept by the facility containing a reasonable number of medications normally used to treat immediate non-life-threatening conditions. Such medications may be oral, rectal or injectable G. The use of convenience boxes is to be for starter doses and normal ordering procedures should follow to ensure the resident receives a full supply of the ordered medication.
The facility Pharmacy Products and Service Agreement dated 11/01/2018 documents under Emergency Drug Services (a) If permitted by Applicable Law and requested by Facilities, Pharmacy shall provide, maintain, and replenish, in a prompt and timely manner, an emergency drug supply (E-kit) .(b) Pharmacy shall provide any Pharmacy Product needed on an emergency basis as promptly as is reasonably practicable. In the event Pharmacy cannot furnish a Pharmacy Product ordered on an emergency basis in a reasonably prompt manner, Pharmacy shall use its best efforts to determine whether another pharmacy provider is capable of providing such Pharmacy Product to Facilities more promptly than Pharmacy. If so, Pharmacy shall make arrangements with such other pharmacy provider to provide such Pharmacy Product to Facilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medications were delivered from the pharmacy and administered timely for 2 of (R72, R226) 2 residents reviewed for pharmacy services...
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Based on interview and record review, the facility failed to ensure medications were delivered from the pharmacy and administered timely for 2 of (R72, R226) 2 residents reviewed for pharmacy services in the sample of 47.
Findings Include:
1.a) R72's Face Sheet documents admission to this facility on 03/03/22 with diagnoses to include Unspecified dementia without behavioral disturbance, Urinary tract infection, Encounter for prophylactic measures, abnormal weight loss, and gastro-esophageal reflux disease without esophagitis.
R72's record contains a prescription dated 03/22/22 by V5 (Primary Care Physician - PCP) documents an order for urinalysis and culture if indicated due to UTI (urinary tract infection) symptoms and dysuria.
R72's progress note dated 03/23/2022 at 1:38 AM, documents - UA (urinalysis) specimen collected at this time, lab contacted for pickup.
R72's lab report dated 03/23/22 documents an abnormal urinalysis with subsequent culture ordered due to this abnormal finding .collected by clean catch dated 03/23/22 at 1:20 AM; received 03/23/22 at 4:02 AM; and verified on 03/23/22 at 4:46 AM.
R72's urine culture lab result dated 03/24/22 at 11:27 PM documents a positive result for Escherichia coli (e-coli) verified on 03/25/22 at 4:26 PM.
R72's record contains a scanned order from V5 for Ciprofloxacin 250 mg twice daily with a start date of 03/25/22, end date 03/30/22. A handwritten note on this order by V5 dated 04/01/22 documents the order was sent to the local pharmacy last week, but if it needed to be sent to another pharmacy, please do.
R72's record contains a scanned prescription to an out-of-town pharmacy dated 04/08/22 for Cipro 250mg (milligram) take 1 tablet by mouth twice a day for 5 days.
R72's progress note dated 04/09/2022 at 6:27 AM, documents - Received order per V5 (Primary Care Physician - PCP) to start cipro 250mg BID X (twice a day times) 5 days. Orders processed . There is no documentation in R72's record confirming this medication was started at this time.
R72's Physician Order Report dated 3/1/22 to 4/29/22 documents a prescription for Cipro 250mg (milligram) take 1 tablet by mouth twice a day, start date 04/13/22.
R72's April 2022 MAR (Medication Administration Record) documents administration of Cipro as prescribed dated 04/13/22 through 04/17/22.
R72's progress note dated 04/14/2022 at 10:39 AM, documents - Res (resident) started antibiotic 4/13/2022. Res continues to take ABX (antibiotic), no adverse side effects noted.
There is no documentation in R72's record to explain the 21-day delay between the urinalysis and culture on 03/23/22 to when Cipro was started on 04/13/22.
R72's progress note dated 04/18/2022 at 1:22 AM, documents - Resident finished ABX r/t UTI. No adverse effects noted. VS (vital signs) remain WNL (within normal limits).
There was a 19-day delay from the time R72's urinary culture results were received until R72 began her antibiotic treatment on 04/13/22.
On 04/29/22 at 8:30 AM, V2 (Director of Nursing - DON) stated he doesn't know why there was a delay in treatment for R72, but it looks like the order was missed on 03/25/22 and nursing did not follow-up on faxing the prescription to the correct pharmacy. V2 stated the facility followed up with V5's office on 04/08/22, obtaining a new order dated 04/09/22, but confirmed R72 still did not receive her first dose of antibiotic treatment until 04/13/22. V2 confirmed it took a total of 19 days for R72 to receive her antibiotic and he would have expected nursing to follow-up with the physician or pharmacy sooner so there would be no delay in treatment.
1. b) R72's admission weight dated 03/03/2022 is documented at 90.4lbs (pounds) with a BMI (body mass index) of 17.65.
A progress note dated 04/19/2022 at 4:45 PM documents V5 (Primary Care Physician - PCP) ordered dronabinol 2.5 mg (milligram); bid (twice daily) 1 hour before lunch and dinner.
R72's POS (Physicians Order Sheet) dated 3/1/22 to 4/29/22 documents an order for dronabinol - Schedule III capsule; 2.5 mg amt (amount): 1 capsule; 2.5 mg; oral to be administered 1 hour before lunch and dinner for abnormal weight loss. Start date: 04/20/22.
A progress note dated 04/20/22 at 10:03 AM documents dronabinol rx (prescription) faxed to V5 at this time awaiting signature.
A progress note dated 04/27/22 at 12:02 PM documents the facility contacted V5's office regarding the Marinol (dronabinol) prescription - Office states they will be sending a signed script today.
R72's April 2022 MAR (Medication Administration Record) documents dronabinol 2.5 mg was not administered due to drug not being available from 04/20/22 to 04/28/22.
R72's May 2022 MAR documents dronabinol has not been administered for weight loss since the medication was ordered on 04/20/22.
R72's record dated 04/19/22 documents a weight of 82.8lbs with a BMI of 16.17. This shows an 8.41% weight loss in 6 weeks, indicating a severe weight loss.
On 04/29/22 at 11:54 AM, V2 (DON - Director of Nursing) stated when the MAR documents not administered: drug not available it means the facility is usually waiting for a signed prescription from the physician. V2 acknowledged a week passed before the facility contacted V5's office to follow-up on R72's prescription for Marinol. V2 confirmed R72's Marinol still had not been received and administered to R72 for weight loss. V2 stated he would expect the nurses to follow-up across shifts to verify resident medications are in place and being administered timely and as ordered.
2. R226's out of state hospital record documents a hospital admission date of 03/20/22 with the diagnosis of intractable pain/metastatic renal cell carcinoma. R226 was discharged from the hospital to this facility on 04/15/22 with discharge medication orders to include Fentanyl 100mcg/hr (microgram/hour), place 1 patch on the skin every third day for 6 days for severe chronic pain with opioid tolerance, start date 04/16/22.
R226's resident face sheet documents admission to this facility on 04/15/22 with the following diagnoses in part - Orthopedic aftercare, acute embolism and thrombosis unspecified deep vein lower extremity, pain in leg, and weakness. R226's diagnosis of intractable pain/metastatic renal cell carcinoma was not included.
R226's facility POR (Physician's Order Report) dated 3/28/22 to 4/28/22 includes - Fentanyl patch 72 hour, 100mcg/hr, 1 patch transdermal, place 1 patch on the skin every third day for 6 days, start date 04/16/22, discontinue 04/19/22 for diagnosis of pain in leg.
R226's April 2022 MAR (Medication Administration Record) documents in part - Assess pain every shift using 0-10 scale or verbal descriptor scale to begin on 04/19/22. R226 was assessed to have experienced the following pain - 04/19/22 - generalized at a 6 on day shift and 7 on evening shift; 04/20/22 no pain on day shift and leg pain at a 7 on evening shift; 04/21/22 documents R226 is having no pain this day; 04/22/22 hip, back, and left leg pain at an 8 on day shift, and moderate generalized pain on evening shift; 04/23/22 generalized pain at a 7 with no pain on the evening shift; 04/24/22 no pain on day shift and leg pain at a 7 on the evening shift; 04/25/22 all over pain on day shift at an 8 with generalized pain at a 6 in the evening; 04/26/22 no pain on day shift with leg pain at a 5 on evenings; 4/27/22 documents no pain.
R226's Fentanyl 100mcg patch every 72 hour was documented as not administered from 04/16/22 to 04/19/22 due to not being available.
A progress note dated 04/18/22 at 4:42 PM documents - Signed Rx (prescription) for Fentanyl patches sent to CCP (critical care pharmacy) at this time. NP (Nurse Practitioner) gives one time order for 50mcg patch until 100mcg is delivered. 50mcg patch pulled from stat-safe.
A progress note dated 04/18/22 at 4:52 PM documents Fentanyl 50mcg was pulled from the stat safe and applied to R226's right shoulder, which is half the physician ordered dose.
A progress note dated 04/19/2022 at 03:24 PM documents a Fentanyl 100mcg patch was administered to R226. There is no documentation on the MAR to confirm this.
R226's POR dated 3/28/22 to 4/28/22 also documents - Fentanyl patch 72-hour 100mcg/hr 1 patch transdermal for leg pain every 3 days, start date 04/21/22.
R226's April 2022 MAR documents Fentanyl 100mcg patch was administered on 04/21/22, is blank on 04/24/22, with the next 100mcg patch applied on 04/27/22.
R226's progress note dated 04/24/2022 at 2:02 PM documents - Resident out of fentanyl 100mcg/hr patch. Pharmacy called for e-pull. Order faxed . Awaiting call back.
R226's progress note dated 04/24/2022 at 9:54 PM documents - Fentanyl 100mcg patch unavailable in stat safe. Only one 50mcg available and placed on residents right upper arm. This dose is not documented on R226's April MAR.
R226's progress note dated 04/26/22 documents the resident is out of Fentanyl 100mcg and unavailable in the facility stat safe. The facility documented Fentanyl 50mcg was available and was placed on R226's arm on 04/26/22, half the ordered dose. This dose is not documented on R226's April MAR.
R226's April 2022 MAR continues to document Fentanyl 100mcg patch was administered on 04/27/22 as prescribed.
On 04/27/22 at 9:30 AM, R226 stated he admitted to this facility from an out of state hospital after undergoing surgical repair of left hip. He stated it took several weeks for the hospital to get his pain under control and manageable. He stated he discharged to this facility for after care and therapy in hopes to go home when he gets stronger. R226 stated when he first got here on 04/15/22, his pain medications were messed up and he did not get his Fentanyl patch the first several days. He confirmed he did participate in therapy, but it was rough because he was in so much pain. He stated he didn't quit, though. R226 stated that he believes his Fentanyl got straightened out, but it took about another week to get his pain under control, and he began to feel better on 04/25/22.
On 04/29/22 at 2:30 PM, V2 (Director of Nursing - DON) stated R226's Fentanyl 100mcg prescription was originally sent to the wrong pharmacy by the out of state discharging hospital causing a delay in the administration of this pain patch to the resident.
On 05/03/22 at 3:10 PM, V28 (Physical Therapy Assistant - PTA) stated R226 told to him there was an issue with the facility getting his pain medication initially but thought this had been taken care of a few days after admission. V28 stated R226 was in a lot of pain when he began therapy and did report this to V28.
On 05/04/22 at 10:21 AM, V2 (DON) verified V25 (Family Member) brought in Fentanyl patches picked up at the local pharmacy on 04/18/22, but they were 75mcg only, so the facility continued to pull Fentanyl 50mcg from the stat safe. V2 stated he believed R226's pain was partially covered by giving the half dose of 50mcg available and thought the facility would have gotten approval from a nurse practitioner, physician, or on call clinician upon administration of Fentanyl 50mcg on 04/18, Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 since this was not administered as prescribed, but was not able to provide corroborating documentation of obtaining the approval.
On 05/04/22 at 1:00 PM, V30 (Nurse Practitioner) stated she spoke with the facility on 04/18/22 and gave verbal approval to administer a 50mcg Fentanyl patch to R226 since the 100mcg prescription was still not available. V30 stated she was not involved in giving approval for R226 to receive Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 and would have expected the facility to contact the physician to get approval to do so since this was not administered as prescribed.
The facility Pharmaceutical Procedures policy dated 10/18/19 documents the purpose of the policy is, 1. To provide the appropriate control of procurement, distribution, administration, and utilization of drugs to the facility. 2. To provide the facility residents with the safest, effective and most rational form of drug therapy at a reasonable cost. 3. To serve as the primary resource of drug information and education to professional personnel in providing quality pharmacotherapy to the facility. Under Emergency Medication Supply the policy documents, .A. Convenience drug boxes may be kept by the facility containing a reasonable number of medications normally used to treat immediate non-life-threatening conditions. Such medications may be oral, rectal or injectable G. The use of convenience boxes is to be for starter doses and normal ordering procedures should follow to ensure the resident receives a full supply of the ordered medication.
The facility Pharmacy Products and Service Agreement dated 11/01/2018 documents under Emergency Drug Services (a) If permitted by Applicable Law and requested by Facilities, Pharmacy shall provide, maintain, and replenish, in a prompt and timely manner, an emergency drug supply (E-kit) .(b) Pharmacy shall provide any Pharmacy Product needed on an emergency basis as promptly as is reasonably practicable. In the event Pharmacy cannot furnish a Pharmacy Product ordered on an emergency basis in a reasonably prompt manner, Pharmacy shall use its best efforts to determine whether another pharmacy provider is capable of providing such Pharmacy Product to Facilities more promptly than Pharmacy. If so, Pharmacy shall make arrangements with such other pharmacy provider to provide such Pharmacy Product to Facilities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure medications were administered per physician orders for 2 (R72, R226) of 4 residents reviewed for significant medication errors in the...
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Based on interview and record review the facility failed to ensure medications were administered per physician orders for 2 (R72, R226) of 4 residents reviewed for significant medication errors in the sample of 47.
1.a) R72's Face Sheet documents admission to this facility on 03/03/22 with diagnoses to include Unspecified dementia without behavioral disturbance, Urinary tract infection, Encounter for prophylactic measures, abnormal weight loss, and gastro-esophageal reflux disease without esophagitis.
R72's record contains a prescription dated 03/22/22 by V5 (Primary Care Physician - PCP) documents an order for urinalysis and culture if indicated due to UTI (urinary tract infection) symptoms and dysuria.
R72's progress note dated 03/23/2022 at 1:38 AM, documents - UA (urinalysis) specimen collected at this time, lab contacted for pickup.
R72's lab report dated 03/23/22 documents an abnormal urinalysis with subsequent culture ordered due to this abnormal finding .collected by clean catch dated 03/23/22 at 1:20 AM; received 03/23/22 at 4:02 AM; and verified on 03/23/22 at 4:46 AM.
R72's urine culture lab result dated 03/24/22 at 11:27 PM documents a positive result for Escherichia coli (e-coli) verified on 03/25/22 at 4:26 PM.
R72's record contains a scanned order from V5 for Ciprofloxacin 250 mg twice daily with a start date of 03/25/22, end date 03/30/22. A handwritten note on this order by V5 dated 04/01/22 documents the order was sent to the local pharmacy last week, but if it needed to be sent to another pharmacy, please do.
R72's record contains a scanned prescription to an out-of-town pharmacy dated 04/08/22 for Cipro 250mg (milligram) take 1 tablet by mouth twice a day for 5 days.
R72's progress note dated 04/09/2022 at 6:27 AM, documents - Received order per V5 (Primary Care Physician - PCP) to start cipro 250mg BID X (twice a day times) 5 days. Orders processed . There is no documentation in R72's record confirming this medication was started at this time.
R72's Physician Order Report dated 3/1/22 to 4/29/22 documents a prescription for Cipro 250mg (milligram) take 1 tablet by mouth twice a day, start date 04/13/22.
R72's April 2022 MAR (Medication Administration Record) documents administration of Cipro as prescribed dated 04/13/22 through 04/17/22.
R72's progress note dated 04/14/2022 at 10:39 AM, documents - Res (resident) started antibiotic 4/13/2022. Res continues to take ABX (antibiotic), no adverse side effects noted.
There is no documentation in R72's record to explain the 21-day delay between the urinalysis and culture on 03/23/22 to when Cipro was started on 04/13/22.
R72's progress note dated 04/18/2022 at 1:22 AM, documents - Resident finished ABX r/t UTI. No adverse effects noted. VS (vital signs) remain WNL (within normal limits).
There was a 19-day delay from the time R72's urinary culture results were received until R72 began her antibiotic treatment on 04/13/22.
On 04/29/22 at 8:30 AM, V2 (Director of Nursing - DON) stated he doesn't know why there was a delay in treatment for R72, but it looks like the order was missed on 03/25/22 and nursing did not follow-up on faxing the prescription to the correct pharmacy. V2 stated the facility followed up with V5's office on 04/08/22, obtaining a new order dated 04/09/22, but confirmed R72 still did not receive her first dose of antibiotic treatment until 04/13/22. V2 confirmed it took a total of 19 days for R72 to receive her antibiotic and he would have expected nursing to follow-up with the physician or pharmacy sooner so there would be no delay in treatment.
1. b) R72's admission weight dated 03/03/2022 is documented at 90.4lbs (pounds) with a BMI (body mass index) of 17.65.
A progress note dated 04/19/2022 at 4:45 PM documents V5 (Primary Care Physician - PCP) ordered dronabinol 2.5 mg (milligram); bid (twice daily) 1 hour before lunch and dinner.
R72's POS (Physicians Order Sheet) dated 3/1/22 to 4/29/22 documents an order for dronabinol - Schedule III capsule; 2.5 mg amt (amount): 1 capsule; 2.5 mg; oral to be administered 1 hour before lunch and dinner for abnormal weight loss. Start date: 04/20/22.
A progress note dated 04/20/22 at 10:03 AM documents dronabinol rx (prescription) faxed to V5 at this time awaiting signature.
A progress note dated 04/27/22 at 12:02 PM documents the facility contacted V5's office regarding the Marinol (dronabinol) prescription - Office states they will be sending a signed script today.
R72's April 2022 MAR (Medication Administration Record) documents dronabinol 2.5 mg was not administered due to drug not being available from 04/20/22 to 04/28/22.
R72's May 2022 MAR documents dronabinol has not been administered for weight loss since the medication was ordered on 04/20/22.
R72's record dated 04/19/22 documents a weight of 82.8lbs with a BMI of 16.17. This shows an 8.41% weight loss in 6 weeks, indicating a severe weight loss.
On 04/29/22 at 11:54 AM, V2 (DON - Director of Nursing) stated when the MAR documents not administered: drug not available it means the facility is usually waiting for a signed prescription from the physician. V2 acknowledged a week passed before the facility contacted V5's office to follow-up on R72's prescription for Marinol. V2 confirmed R72's Marinol still had not been received and administered to R72 for weight loss. V2 stated he would expect the nurses to follow-up across shifts to verify resident medications are in place and being administered timely and as ordered.
2. R226's out of state hospital record documents a hospital admission date of 03/20/22 with the diagnosis of intractable pain/metastatic renal cell carcinoma. R226 was discharged from the hospital to this facility on 04/15/22 with discharge medication orders to include Fentanyl 100mcg/hr (microgram/hour), place 1 patch on the skin every third day for 6 days for severe chronic pain with opioid tolerance, start date 04/16/22.
R226's resident face sheet documents admission to this facility on 04/15/22 with the following diagnoses in part - Orthopedic aftercare, acute embolism and thrombosis unspecified deep vein lower extremity, pain in leg, and weakness. R226's diagnosis of intractable pain/metastatic renal cell carcinoma was not included.
R226's facility POR (Physician's Order Report) dated 3/28/22 to 4/28/22 includes - Fentanyl patch 72 hour, 100mcg/hr, 1 patch transdermal, place 1 patch on the skin every third day for 6 days, start date 04/16/22, discontinue 04/19/22 for diagnosis of pain in leg.
R226's April 2022 MAR (Medication Administration Record) documents in part - Assess pain every shift using 0-10 scale or verbal descriptor scale to begin on 04/19/22. R226 was assessed to have experienced the following pain - 04/19/22 - generalized at a 6 on day shift and 7 on evening shift; 04/20/22 no pain on day shift and leg pain at a 7 on evening shift; 04/21/22 documents R226 is having no pain this day; 04/22/22 hip, back, and left leg pain at an 8 on day shift, and moderate generalized pain on evening shift; 04/23/22 generalized pain at a 7 with no pain on the evening shift; 04/24/22 no pain on day shift and leg pain at a 7 on the evening shift; 04/25/22 all over pain on day shift at an 8 with generalized pain at a 6 in the evening; 04/26/22 no pain on day shift with leg pain at a 5 on evenings; 4/27/22 documents no pain.
R226's Fentanyl 100mcg patch every 72 hour was documented as not administered from 04/16/22 to 04/19/22 due to not being available.
A progress note dated 04/18/22 at 4:42 PM documents - Signed Rx (prescription) for Fentanyl patches sent to CCP (critical care pharmacy) at this time. NP (Nurse Practitioner) gives one time order for 50mcg patch until 100mcg is delivered. 50mcg patch pulled from stat-safe.
A progress note dated 04/18/22 at 4:52 PM documents Fentanyl 50mcg was pulled from the stat safe and applied to R226's right shoulder, which is half the physician ordered dose.
A progress note dated 04/19/2022 at 03:24 PM documents a Fentanyl 100mcg patch was administered to R226. There is no documentation on the MAR to confirm this.
R226's POR dated 3/28/22 to 4/28/22 also documents - Fentanyl patch 72-hour 100mcg/hr 1 patch transdermal for leg pain every 3 days, start date 04/21/22.
R226's April 2022 MAR documents Fentanyl 100mcg patch was administered on 04/21/22, is blank on 04/24/22, with the next 100mcg patch applied on 04/27/22.
R226's progress note dated 04/24/2022 at 2:02 PM documents - Resident out of fentanyl 100mcg/hr patch. Pharmacy called for e-pull. Order faxed . Awaiting call back.
R226's progress note dated 04/24/2022 at 9:54 PM documents - Fentanyl 100mcg patch unavailable in stat safe. Only one 50mcg available and placed on residents right upper arm. This dose is not documented on R226's April MAR.
R226's progress note dated 04/26/22 documents the resident is out of Fentanyl 100mcg and unavailable in the facility stat safe. The facility documented Fentanyl 50mcg was available and was placed on R226's arm on 04/26/22, half the ordered dose. This dose is not documented on R226's April MAR.
R226's April 2022 MAR continues to document Fentanyl 100mcg patch was administered on 04/27/22 as prescribed.
On 04/27/22 at 9:30 AM, R226 stated he admitted to this facility from an out of state hospital after undergoing surgical repair of left hip. He stated it took several weeks for the hospital to get his pain under control and manageable. He stated he discharged to this facility for after care and therapy in hopes to go home when he gets stronger. R226 stated when he first got here on 04/15/22, his pain medications were messed up and he did not get his Fentanyl patch the first several days. He confirmed he did participate in therapy, but it was rough because he was in so much pain. He stated he didn't quit, though. R226 stated that he believes his Fentanyl got straightened out, but it took about another week to get his pain under control, and he began to feel better on 04/25/22.
On 04/29/22 at 2:30 PM, V2 (Director of Nursing - DON) stated R226's Fentanyl 100mcg prescription was originally sent to the wrong pharmacy by the out of state discharging hospital causing a delay in the administration of this pain patch to the resident.
On 05/03/22 at 3:10 PM, V28 (Physical Therapy Assistant - PTA) stated R226 told to him there was an issue with the facility getting his pain medication initially but thought this had been taken care of a few days after admission. V28 stated R226 was in a lot of pain when he began therapy and did report this to V28.
On 05/04/22 at 10:21 AM, V2 (DON) verified V25 (Family Member) brought in Fentanyl patches picked up at the local pharmacy on 04/18/22, but they were 75mcg only, so the facility continued to pull Fentanyl 50mcg from the stat safe. V2 stated he believed R226's pain was partially covered by giving the half dose of 50mcg available and thought the facility would have gotten approval from a nurse practitioner, physician, or on call clinician upon administration of Fentanyl 50mcg on 04/18, Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 since this was not administered as prescribed, but was not able to provide corroborating documentation of obtaining the approval.
On 05/04/22 at 1:00 PM, V30 (Nurse Practitioner) stated she spoke with the facility on 04/18/22 and gave verbal approval to administer a 50mcg Fentanyl patch to R226 since the 100mcg prescription was still not available. V30 stated she was not involved in giving approval for R226 to receive Fentanyl 100mcg on 04/19, Fentanyl 100mcg on 04/21, Fentanyl 50 mcg on 04/24, Fentanyl 50mcg on 04/26, and Fentanyl 100mc on 04/27 and would have expected the facility to contact the physician to get approval to do so since this was not administered as prescribed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain aseptic technique during incontinence care and catheter care for two residents (R71 and R14) of twelve residents rev...
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Based on observation, interview, and record review, the facility failed to maintain aseptic technique during incontinence care and catheter care for two residents (R71 and R14) of twelve residents reviewed for infection control in the sample of 47.
Findings include:
1. R71's Resident Face Sheet documented an admission date of 12/30/2021 and diagnoses in part, of personal history of urinary tract infections.
R71's Minimum Data Set (MDS) dated on 4/6/2022 documented a Brief Interview for Mental Status (BIMS) summary score of 7 which indicates severe cognitive impairment. This same MDS documented R71 requires limited assistance of one person for bed mobility, transfer, and toileting, and documented R71 is always incontinent of urinary and bowel.
R71's care plan dated 12/31/2021 documented in part, provide incontinent care after each incontinent episode.
On 04/26/22 at 10:54 AM, V11 (family member) stated, (R71) was having some increased confusion and agitation and the nurses were obtaining a urinalysis.
On 04/28/22 at 10:30 AM, V6 (Certified Nursing Assistant/CNA) provided incontinence care to R71. V6 set up on a clean surface with a water basin, washcloths, and a no rinse peri-wash. There was no hand sanitizer set up. V6 (CNA) washed her hands prior to the procedure, donned gloves, and proceeded to cleanse the perineal area. V6 (CNA) doffed contaminated gloves and donned new gloves throughout the procedure without use of hand hygiene between her glove changes. After the procedure was completed, V6 (CNA) stated she would have normally used hand sanitizer between the glove changes, but she was nervous and forgot.
2. R14's Resident Face Sheet documented an admission date of 3/14/2022 with diagnoses in part, of Infection and inflammatory reaction due to indwelling urethral catheter.
R14's MDS dated on 3/21/2022 documented a BIMS summary score of 14 which indicates R14 is cognitively intact. This same MDS documented R14 requires extensive assistance of 2 persons for bed mobility, transfer, and is dependent for toileting, and documented R14 has an indwelling catheter and is frequently incontinent of bowel.
R14's care plan documented in part, (R14) has an indwelling catheter related to urethral stent. Provide catheter care as needed.
On 04/28/22 at 10:45 AM, R14's catheter care was provided by V8 (CNA). V8 set up a water basin, washcloths, dry cloths, no rinse peri-wash, and hand sanitizer. V8 washed her hands prior to the procedure and donned gloves appropriately. V8 proceeded to cleanse the urethra and catheter tubing appropriately with a wet washcloth and no-rinse peri wash. V8 then doffed and donned new gloves throughout the procedure without using hand sanitizer between her glove changes.
On 04/28/22 at 11:30 AM V8 stated she would normally have used hand sanitizer between glove changes, but she forgot because she was nervous during the observation.
On 04/29/22 at 1:46 PM, V2 (Director of Nursing/DON) stated he would expect staff to use hand hygiene between glove changes during incontinent care and catheter care per their policy and planned to review this with all staff in an in-service.
Facility Policy entitled; Standard Precautions date revised on 8/2009 documented in part, Procedure: 1. Hand Hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR). c. Hand Hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedures on the same resident to prevent cross contamination to different body sites. 2. Gloves. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments.
Facility Policy entitled, Catheter Care, dated on 6/2005 documented in part, Procedure: 3. Wash hands and put on disposable gloves. 6. Remove gloves and wash your hands.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 6 harm violation(s), $80,971 in fines, Payment denial on record. Review inspection reports carefully.
- • 40 deficiencies on record, including 6 serious (caused harm) violations. Ask about corrective actions taken.
- • $80,971 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (20/100). Below average facility with significant concerns.
Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Manor Court Of Carbondale's CMS Rating?
CMS assigns MANOR COURT OF CARBONDALE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Illinois, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Manor Court Of Carbondale Staffed?
CMS rates MANOR COURT OF CARBONDALE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 54%, compared to the Illinois average of 46%.
What Have Inspectors Found at Manor Court Of Carbondale?
State health inspectors documented 40 deficiencies at MANOR COURT OF CARBONDALE during 2022 to 2024. These included: 6 that caused actual resident harm and 34 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Manor Court Of Carbondale?
MANOR COURT OF CARBONDALE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by UNLIMITED DEVELOPMENT, INC., a chain that manages multiple nursing homes. With 120 certified beds and approximately 98 residents (about 82% occupancy), it is a mid-sized facility located in CARBONDALE, Illinois.
How Does Manor Court Of Carbondale Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, MANOR COURT OF CARBONDALE's overall rating (3 stars) is above the state average of 2.5, staff turnover (54%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Manor Court Of Carbondale?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Manor Court Of Carbondale Safe?
Based on CMS inspection data, MANOR COURT OF CARBONDALE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Illinois. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Manor Court Of Carbondale Stick Around?
MANOR COURT OF CARBONDALE 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 Manor Court Of Carbondale Ever Fined?
MANOR COURT OF CARBONDALE has been fined $80,971 across 2 penalty actions. This is above the Illinois average of $33,889. 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 Manor Court Of Carbondale on Any Federal Watch List?
MANOR COURT OF CARBONDALE 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.