GOLDWATER CARE PEORIA HEIGHTS
For profit - Corporation
94 Beds
GOLDWATER CARE
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#532 of 665 in IL
Photo by Goldwater Care Peoria Heights
Photo by Goldwater Care Peoria Heights
Photo by Goldwater Care Peoria Heights
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Goldwater Care Peoria Heights has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #532 out of 665 facilities in Illinois, placing them in the bottom half, and #7 out of 10 in Peoria County, meaning there are only a few local options that are better. Although the facility's trend is improving, with a reduction in reported issues from 24 in 2024 to just 2 in 2025, the overall situation remains concerning. Staffing is a significant weakness, with a rating of 1 out of 5 stars and a high turnover rate of 71%, which is well above the state average. Additionally, the facility has been fined $181,422, higher than 85% of Illinois facilities, suggesting repeated compliance problems. Specific incidents of concern include a failure to monitor critical laboratory results for a resident on anticoagulants, resulting in hospitalization, and another incident where a resident experienced ongoing pain due to medication mismanagement. Furthermore, there was a serious fall risk when staff left a resident unattended on the edge of the bed, leading to a fall. Overall, while there are some improvements, the facility has serious strengths and weaknesses that families should carefully consider.
- Trust Score
- F
- In Illinois
- #532/665
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 71% turnover. Very high, 23 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- $181,422 in fines. Lower than most Illinois facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Illinois. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 84 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 20%
Review needed
24 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 24 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Illinois average (2.5)
Significant quality concerns identified by CMS
Staff Turnover: 71%
25pts above Illinois avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $181,422
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: GOLDWATER CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (71%)
23 points above Illinois average of 48%
The Ugly 84 deficiencies on record
3 life-threatening 2 actual harm
Aug 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to investigate an allegation of abuse for 2 residents (R10 and R11) of five residents reviewed for abuse in a sample of ten. The Facility's Abu...
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Based on interview and record review the facility failed to investigate an allegation of abuse for 2 residents (R10 and R11) of five residents reviewed for abuse in a sample of ten. The Facility's Abuse Prevention and Reporting policy dated 10/24/22 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and service by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. The Facility's Abuse Prevention and Reporting policy dated 10/24/22 documents the definition of abuse as: any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This also includes the deprivation by an individual, mental, and psychosocial well-being. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. The policy also documents the definition of mental abuse as: the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. The policy documents the definition of verbal abuse as: the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidate, threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends and isolating a resident from social interaction or activities.The Facility's Abuse and Prevention and Reporting policy dated 10/24/22 documents Employees are required to report any incident, action or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In the absence of the administrator, reporting can be made to an individual who has been designated to act as administrator in the administrator's absence.The Facility's Resident Council dated 5/25/25 documents Dietary: resident asked for a snack from Dietary and was told no you are too fat. The Facility's Resident Council dated 5/25/25 documents Social Service: resident was asked by (V12/Social Services Director) if he would like to be homeless and was told (V12) would put him in a shelter. On 8/1/25 V1 (Administrator) stated that she had not seen or been told about what was stated in Resident Council meetings. On 8/5/25 at 1:35 PM V13 (Activity Director) confirmed that she was the staff member responsible for Resident Council. V13 stated that she did the meetings, typed up the minutes and put it in the book. V13 stated she had never been educated on what to do with any concerns/complaints that arise during the resident council meetings. On 8/5/25 at 9:30 AM both V1 (Administrator) and V3 (Regional Director) confirmed that there were no abuse investigations for either verbal abuse allegations that were documented on the Resident Council meeting minutes in May 2025.
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 F0565
(Tag F0565)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to address concerns voiced by residents during their resident council meetings. This failure has the potential to affect all forty-six resident...
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Based on interview and record review the facility failed to address concerns voiced by residents during their resident council meetings. This failure has the potential to affect all forty-six residents who reside in the facility. The facility's Grievances policy dated 9/25/2017 documents the policy's purpose as to ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. All alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, will be immediately reported to the administrator and as required by state law. The facility's Grievances policy also documents All written grievances shall include: The date the grievance was received; a summary statement of the grievance; department assigned to investigate; steps taken to investigate the grievance; summary of the pertinent findings or conclusions regarding the concern(s).statement as to whether the grievance was confirmed or not confirmed; corrective action taken or to be taken by the facility as the result of the grievance, including measures taken to prevent further potential violations of any resident right while the alleged violation is being investigated; the date the written decision was issued to the resident or the complainant. The facility's Grievances policy also documents Every effort shall be made to resolve grievances in a timely manner, usually within 5 business days (excludes weekends and holidays). Under certain circumstances, additional time may be needed to complete an investigation and implement measures to resolve grievances. In such cases, the resident or complainant should be notified of the extension. An appointed Grievance Official (usually the Social Services Director) is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations and maintaining the confidentiality of all information associated with grievances. The Facility's Resident Council dated February 2025 documents Nursing: (Medications) not getting passed some days on the east side. CNA (Certified Nursing Aide) not checking residents, talking on their phones in the rooms, not passing ice and drinks, not answering call lights, talking about outside stuff in front of residents, not feeding the feeders. The Facility's Resident Council dated March 2025 documents CNA: not answering call lights, turning call lights off without getting help, being told you are not mine today, feeders not being fed. The Facility's Resident Council dated April 2025 documents Nursing: (Medications) not being passed at right time CNA: some people being told to do their own (cares). The Facility's Resident Council dated May 2025 documents Housekeeping: Housekeepers telling residents they have a job, can't help them. Nursing: (Medications) not passed in the (morning) Friday and Saturday of last week.The Facility's Resident Council dated June 2025 documents CNA: (first) shift not doing as they should, not getting walked when needed. The Facility's Resident Council dated July 2025 documents CNA: being told not my resident. The Facility's Concern/Compliment Form dated 6/27/25 documents that R7 reported that he did not remember getting his medications for the last two nights on second shift (6/25/25 and 6/26/25). The form documents that V2 (Director of Nursing) documented in the Summary of pertinent findings: MAR (Medication Administration) indicated (medications) received, discussed with nurses to make sure resident is awake/alert to know/remember he received (medications).On 8/1/25 at 2:30 PM V2 (Director of Nursing) confirmed that she was aware of R7's concern and that she checked the resident's MAR to confirm that R7 did receive his medications. V2 confirmed that she did not ask any other residents if they receive their medications in a timely manner. V2 confirmed that this investigation was considered complete and that she was not aware of the repeated concerns regarding residents not receiving their medications.On 8/5/25 at 8:15 AM R7 confirmed that he had voiced a complaint regarding not receiving his medications as scheduled. R7 stated he had not been asked about his concern, and he was not informed of any resolution to said complaint. On 8/5/25 at 9:30 AM R8 (Resident Council President) stated that she was aware of other residents complaining about not receiving medications. R8 stated that she thought the problem was nurse specific. R8 would not elaborate. R8 stated that she has not been asked about any concerns voiced in resident council meetings. We do them (meetings) every month, but we don't ever get a response on stuff. On 8/5/25 at 1:35 PM V13 (Activity Director) confirmed that she was the staff member responsible for Resident Council. V13 stated that she did the meetings, typed up the minutes and put it in the book. V13 stated she had never been educated on what to do with any concerns/complaints that arise during the resident council meetings. On 8/5/25 at 10:30 AM V1 (Administrator) stated that all complaints and concerns voiced in Resident Council should be treated like a grievance. V1 confirmed that the concerns/complaints voiced during Resident Council meetings for February through present (July 2025) did not have any follow up and/or documentation of resolution of resident concerns. The Facility's Census provided on 8/1/25 documents 46 residents currently reside in the facility.
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure resident room temperatures were maintained at a safe and comfortable temperature of 71 degrees Fahrenheit or higher for...
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Based on observation, interview, and record review the facility failed to ensure resident room temperatures were maintained at a safe and comfortable temperature of 71 degrees Fahrenheit or higher for 14 of 15 residents (R2-R15) reviewed for safe and comfortable environment in the sample of 17.
Findings include:
The facility's Maintenance Policy (undated) documents, Purpose: To ensure the building (interior and exterior), grounds, and equipment are maintained in a safe and operatable manner. Policy: It is the policy of the facility to provide a safe, accessible, effective environment of care that is consistent with its mission, services, and laws and regulations.
The facility's Code White-Extreme Weather dated 9-22-22 documents, Purpose: To provide staff specific guidance and instruction on how to initiate an emergency code and steps to be taken to ensure the safety of residents and staff in the event of extreme weather/temperature related conditions. The facility will follow federal requirement to maintain facility temperatures between 71-80 degrees Fahrenheit.
The Local AccuWeather website documents the weather for Peoria Heights Illinois was a high of 30 degrees F (Fahrenheit) and a low of 16 degrees F on Sunday 12-1-24, a high of 25 degrees F and a low of 14 degrees F on Monday 12-2-24, and a high of 27 degrees F and a low of 24 degrees on Tuesday 12-3-24.
On 12-3-24 from 9:45 AM through 10:15 AM a tour of the facility was conducted with V2 (Director of Nursing). During this timeframe V2 obtained resident room temperatures by using an infrared temperature gun that was pointed at the highest point of the residents' walls. R2's room was 67 degrees F, R3 and R4's room was 63 degrees F, R5's room was 60 degrees F, R6's room was 63.3 degrees F, R7's room was 64.2 degrees F, R8's room was 55.8 degrees F, R9's room was 55 degrees F, R10 and R11's room was 59 degrees F, R14's room was 64 degrees F, R13's room was 66 degrees F, and R14 and R15's room was 60 degrees F. All heaters in R2-R15's rooms were not working during this timeframe.
On 12-3-24 at 9:45 AM R2 stated, It's cold in here.
On 12-3-24 at 9:55 AM both R3 and R4 were sitting in bed in their rooms with two top covers on. R3 stated, It has been cold all day.
On 12-3-24 at 10:00 AM R5 was lying in bed in her room with a stocking cap on. R5 stated, It feels like it is 40 degrees in here. It has been really cold in here for the last couple days. My heat has not been working.
On 12-3-24 at 10:05 AM R6 stated, I am cold.
On 12-3-24 at 10:07 AM R7 was lying in bed with two blankets. R7 stated, I have not had heat in my room for two days. It has been really cold.
On 12-3-24 at 10:09 AM R8 stated, It is cold. I feel like there is a windmill blowing on me.
On 12-3-24 at 10:12 AM R9 stated, The heat has been off for a couple days. The staff are saying the heat is not working. It has been cold.
On 12-3-24 at 10:15 AM R11 stated, I have been cold for a few days.
On 12-3-24 at 10:17 AM R12 was sitting in her bed with a stocking cap, gloves, and a coat on. R12 stated, I wish they would get some heat on and working around here. I am cold.
On 12-3-24 at 10:20 AM both R14 and R15 both confirmed their heater has not worked for at least a day and their room has been cold.
On 12-3-24 at 10:30 AM V2 confirmed that R2-R15's room heaters were run from a boiler and their heaters had not been working since sometime the day before (12-2-24).
Oct 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one (R30) of two residents reviewed for PASARR scre...
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Based on interview and record review, the facility failed to complete a new/updated PASARR (Preadmission Screening and Resident Review) Level II for one (R30) of two residents reviewed for PASARR screenings in a sample of 23.
Findings include:
On 10/1/24 at 1:30 pm, V1 (Administrator) stated, I am unable to provide a PASARR Policy; we do not have a PASARR Policy.
R30's Physician Order Summary Report, dated 10/1/24, documents an admission dated of 12/31/23 and medication orders (Venlafaxine Hydrochloride and Aripiprazole) for diagnoses including Major Depressive Disorder, Severe Psychotic Symptoms, Bipolar Disorder, Unspecified Psychosis and Delusional Disorder.
R30's Notice of PASARR Level II Screen Outcome, dated 7/31/23, documents the date of Short-Term Approval ends on 10/29/23. The PASARR Outcome Explanation documents that this Level II evaluation is good within 90 calendar days of the Notice Date listed on the PASARR Level II Outcome and after that time, you must have an updated Level I and Level II before you to go to a Medicaid Certified Nursing Facility.
On 10/1/24 at 1:30 pm, R30's Medical Record did not document an updated PASARR, and the Facility could not produce an updated PASARR.
On 10/1/24 at 1:30 pm, V2 (Director of Nursing) stated, We need to update this PASARR. I just noticed that it was no longer effective after 10/29/23 and was for a short stay. I will get it updated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to notify the local Office of the State Long-Term Care Ombudsman and Residents/Residents' Representative in writing of resident Hospital Trans...
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Based on record review and interview, the facility failed to notify the local Office of the State Long-Term Care Ombudsman and Residents/Residents' Representative in writing of resident Hospital Transfer/Discharge for five (R2, R6, R30, R34 and R291) of five residents reviewed for transfers and hospitalizations in the sample of 23.
Findings include:
Facility Transfer and Discharge Policy and Procedure, undated, documents that transfer or discharge documentation in the Residents clinical record shall be required.
R2's Census List dated 10/1/24 documents a Hospital Paid Leave on 10/17/23, 2/26/24, 3/11/24, 4/5/24, 4/29/24, 6/4/24, 6/20/24, 7/10/24, 8/8/24 and 9/1/24.
R6's Census List dated 10/1/24 documents a Hospital Paid Leave on 6/14/24 and 8/19/24.
R30's Census List dated 10/1/24 documents a Hospital Paid Leave on 11/15/23, 12/20/23 and 7/3/24.
R34's Census List dated 10/1/24 documents a Hospital Paid Leave on 9/20/24.
R291's Census List dated 10/1/24 documents a Hospital Paid Leave on 8/24/24, 9/2/24 and 9/5/24.
1. On 10/1/24 at 12:10 pm, V9 (Social Service Manager) stated, I have never made any documentation in the medical records or sent a written notification of a hospital transfer or discharge to (V8/Ombudsman).
On 10/1/24 at 12:15 pm, V8 (Ombudsman) stated, I do not receive any notification from the facility on their hospital transfers or discharges. Sometimes, when I am in the facility, they do tell me who got admitted to the hospital. I did not know that I was supposed to be notified of all the hospital discharges or transfers in writing.
On 9/30/24 at 8:10 am, V2 (Director of Nursing) stated, We have not notified (V8/Ombudsman) of resident hospital transfers or discharges.
On 10/1/24 at 10:50 am, V1 (Administrator) stated, We do not email or notify (V8/Ombudsman) of hospital transfers or discharges. As you know, the facility has been in the middle of new ownership transition, so I cannot give you a specific policy for Transfer Discharge to hospital on notifying the Office of the State Long-Term Care Ombudsman.
2. On 10/1/24 at 12:10 pm, V9 (Social Service Manager) stated, I have never made documentation in the medical records or sent a written notification of a hospital transfer to any family or resident.
On 9/30/24 at 8:10 am, V2 (Director of Nursing) stated, We do not mail or notify residents or their Representatives in writing of a hospital transfer. There is no documentation in the residents' charts that any of these notices have been sent either. I cannot find any copies of any notification to the Resident Representatives for any of our residents that discharged to the hospital.
On 10/1/24 at 10:50 am, V1 (Administrator) stated, We do not send written notifications to the residents or the Representatives when a Resident goes out to the hospital and there is no documentation in the medical record either.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to hold Quality Assurance (QA) and Improvement Committee Meetings. This failure has the potential to affect all 40 residents who currently res...
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Based on interview and record review, the facility failed to hold Quality Assurance (QA) and Improvement Committee Meetings. This failure has the potential to affect all 40 residents who currently reside in the facility.
Findings Include:
The Facility's Quality Assurance and Improvement Agenda dated 4/19/2019 documents that the following areas will be reviewed as a Quality Assurance Team at least every quarter: Resident Concerns, Consultant/Department Reports, Policy and Procedure Review and Updates, Nursing and Quality Improvement Information, Special Unit Report (if applicable), Dietary Report, Social Service Report, Activity Department, Housekeeping and Laundry, Quality Assurance Audits/Rounds, Surveys Compliance, Life Safety Concerns, Safety Issues/Risk Management, Personnel, Environmental Improvements Planned/Made during the Quarter, Census/marketing Recruitment.
On 10/01/24 at 12:15 PM, V1 (Administrator in Training) stated I have no documentation of any QA meetings done prior to me coming in April 2024. I held one immediately upon hire because I did not see where it had been getting done.
The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to monitor infections. This failure has the potential to affect all 40 residents that currently reside in the facility.
Findings Include:
The...
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Based on record review and interview the facility failed to monitor infections. This failure has the potential to affect all 40 residents that currently reside in the facility.
Findings Include:
The Facility's Infection Control Surveillance and Monitoring policy dated 4/11/2022 documents It is the policy of the facility to do routine surveillance and monitoring of the facility to determine if compliance with infection control practices is maintained. Monitoring of the day-to-day operation of the Infection Control Program will be conducted by the DON/ICP (Director of Nursing/Infection Preventionist). Included in the duties are: Investigation and implementation of controls to prevent infections in the facility, determine and direct the correct procedures necessary for the prevention of infections. This shall be done on an individual basis, applying the concepts of isolation per infection, follow up on documentation of, and reporting of infection to physicians, through direct, random inspections of the clinical record with respect to: 1) Isolation techniques initiated and followed, 2) Evaluation of parameters involved in assessment of physical condition are evaluated and reported as appropriate (vital signs, evaluation of infection site, resident response to isolation techniques, etc.), 3 Periodic observation of infection sensitive techniques, including soaks, irrigations, catheter procedures, intravenous infusions, tracheostomy procedures and inhalation techniques
The Facility's Infection Control Monitoring Logs provided started with April 2024.
On 10/01/24 at 10:00 AM, V2 (Director of Nursing) stated, I started here (at the facility) in April 2024, I do not know where (V10/ previous Director of Nursing) kept any of her documentation of the facility's infections. I have no further documentation prior to April 2024.
The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure has the potential to affect all 40 residents that currently reside in the facilit...
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Based on interview and record review, the facility failed to implement an Antibiotic Stewardship Program. This failure has the potential to affect all 40 residents that currently reside in the facility.
Findings Include:
The facility's Antibiotic Stewardship Program Protocol dated 12/12/18 states, Purpose: To improve the use of Antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance through a set of commitments and actions designed to optimize the treatment of infections while reducing adverse events associated with antibiotic use. This will be accomplished using the Core Elements. Core Elements for Antibiotic Stewardship: 1. Leadership Commitment: Demonstrates support and commitment for safe and appropriate antibiotic use. Accountability: Identify physicians, nursing, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship activities. Action: Implement as least one policy or practice to improve antibiotic use. Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use. Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff.
As of 10/1/24, the facility was unable to provide any documentation that antibiotic tracking or infection surveillance had been completed prior to September 2024.
On 10/01/24 at 10:00 AM, V2 (Director of Nursing) stated that prior to September 2024, there was no monitoring of antibiotics or infection surveillance being completed. V2 stated V2 would have expected a McGreers Criteria Data Tool Form to be filled out on every antibiotic ordered at the facility to ensure it met Antibiotic Stewardship Protocols. V2 stated that V2 had to bring in Pharmacy to educate the nurses on what Antibiotic Stewardship even was.
The facility's Long-Term Care Application for Medicare and Medicaid dated 9/29/24 documents 40 residents currently reside in the facility.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration i...
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Based on observation, interview and record review, the facility failed to ensure resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration in a sample of three.
Findings include:
The facility's Medication Administration policy, revised 11/18/17, documents Procedure: 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be Borrowed from one resident to another.
R1's current Physician Order Sheet/POS documents an order for Zolpidem Tartrate Oral Tablet 10mg (milligrams) give one tablet by mouth at bedtime related to insomnia.
R1's current Care Plan documents a focus of (R1) is on sedative/hypnotic therapy related to insomnia, with interventions including but not limited to Administer Sedative/Hypnotic medications as ordered by physician.
On 7/9/24, at 12:36pm, R1 sat in his room and stated he did not receive his Ambien (Zolpidem) two or three times in June due to an ordering issue. R1 said I did not sleep well without it and was up in the middle of the night. I have an anxiety issue and am very regimented. They have no system in place to order meds.
R1's Medication Administration Record/MAR, dated June 2024, was signed by V8 Licensed Practical Nurse/LPN and documents R1 did not receive Zolpidem on 6/9/24 and 6/10/24 due to the drug being unavailable.
R1's Progress Notes, dated 6/9/24 and 6/10/24, document R1's medication (Zolpidem) was on order.
On 7/11/24, at 10:44am, V8 LPN stated I believe it was a weekend when (R1) didn't get his Ambien. It was not available .At the time I was not aware of the narcotic emergency box only the stock med emergency box.
On 7/11/24, at 1:30pm, V4 LPN showed this writer the facility's back up Emergency kit in the med room. This kit contained Zolpidem Tartrate (Ambien) 5mg tabs Quantity of 6. V4 confirmed that if a resident was out of Ambien, it could be taken from the kit by calling pharmacy for the code to open it.
On 7/11/24, at 2:07pm, V2 Director of Nursing/DON stated I didn't know (R1) missed the two doses until June 11 when I came in early, and the night shift nurse told me. I think what failed is that earlier that week I told (V4 LPN) to order the CIIs (Schedule 2 Controlled Substances). (V4) said she thought I meant only the meds that (V4) needed to give. I had to educate (V4) on this incident to go through the carts and order all of them. V2 confirmed that.
the pharmacy would not have provided a code for the emergency box since they needed a new signed script for R1's Ambien.
May 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure call lights were answered in a timely manner for one of three residents (R1) reviewed for call light response time in a sample of se...
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Based on record review and interview, the facility failed to ensure call lights were answered in a timely manner for one of three residents (R1) reviewed for call light response time in a sample of seven.
Findings include:
The Rehab (Rehabilitation) Resident Council Meeting Minutes dated 4/30/24 documents Slow call light reaction 2nd shift and 1st shift.
On 5/13/24 at 10:20 AM, R1 stated I came the end of December (2023). Sometimes the call light can take hours to get answered. It's not all the time. It's usually worse on day shift because the aides are so busy doing stuff.
On 5/14 24 at 11:15 AM, V14 (Agency Nurse) stated There is a wait time for the call lights to be answered. Nurses try to help as much as possible, but we have our duties too. Like, the night before (5/12-13/24) we had one aide in the whole building. Everyone called off. We tried to get staff called in, but we can only do what we can do.
On 5/14/24 at 11:45 AM, V2 (Director of Nursing) stated call light response time has been an issue and filling vacant positions and getting CNA's (Certified Nurse Aides) trained is a priority for resident safety.
On 5/14/24 at 12:40 PM, V5 (Agency Nurse) stated The call light response time could be better. Some residents are demanding. I see CNA's leave after they take someone to the restroom and the resident puts the call light right back because they are done, and need help off the toilet, but the CNA is already doing something else. The residents just have to wait. Sometimes for a very long time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure staff provided care by assessing, evaluating, and providing immediate treatment of an acute condition for one of three residents (R1...
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Based on record review and interview, the facility failed to ensure staff provided care by assessing, evaluating, and providing immediate treatment of an acute condition for one of three residents (R1) reviewed for changes in condition in a sample of seven.
Findings include:
The Notification of Change in Resident Condition or Status policy dated 7/1/12, documents 1. The nurse supervisor/charge nurse will notify the residents attending physician or on-call physician when there has been e. A significant change in the resident's physical/emotional/mental condition; g. Refusal of treatment or medications; h. A need to transfer the resident to a hospital; j. Instructions to notify the physician of changes in the resident's condition; k. Onset of temperature of a temperature two degrees higher than baseline; l. Symptoms of any infectious process; 5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
The Nursing Documentation Guidelines policy, not dated, documents vital signs are to be done every shift for three days after an admission or readmission; vital signs documentation date and time vital signs were taken, any deviations from normal pattern, all pertinent observations, oxygen start time, flow rate and rationale for use, as well as physician notification.
The General Rule of Charting policy dated 1/05, documents any vital signs other than monthly should be documented in the nurse's notes.
On 12/26/24, the record documents R1 was admitted to the facility with the following diagnoses: sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body ' s response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), type two diabetes mellitus with insulin dependence, chronic obstructive airway disease treated with inhalation medication, cellulitis (inflammation) of the buttocks and left lower limb, bilateral below the knee amputation, congestive heart failure and multiple other cardiac conditions.
On 4/3/24 and 5/6/24, The Quarterly MDS (Minimum Data Set) section C documents a BIMS (Brief Interview of Mental Status) score of 15.0, cognitively intact.
The Temperature, Heart Rate, and Blood Pressure Summary documented these vital signs were monitored on 12/27/23, 1/5/24 and 1/19/24 and the Oxygen Saturation Summary documented measurements on 12/27/23 and 1/5/24. The record lacked documentation vital signs were monitored after 1/19/24.
On 4/27/24, The Discharge Return Anticipated MDS section A documents R1 had an unplanned transfer to an acute care hospital.
On 4/27/24, the Progress Note lacked documentation of R1's condition, assessments conducted, physician notification and/or a request for interventions from the physician which led up to R1's transfer to the hospital.
On 4/27/24 at 4:40 PM, V4's (Day Shift Nurse) Progress Note documents that approximately between 4:00 PM and 5:00 PM, R1 complained of being tired. A blood pressure and heart rate were assessed and was within normal limits, although V10 (R1's friend) told R1 I want you to go to the Hospital to get checked out.
On 5/14/24 at 11:15 AM, V14 (Night Shift Nurse) stated on 4/27/24 V14 received report from V4 who said R1 was lethargic and was not acting like self-earlier in the day. R1 had slurred speech and seemed like R1 was worsening. V14 stated V2 (Director of Nursing) was notified (via text) that R1 needed to be sent to hospital. V14 tried to give R1 water to take medication but R1 couldn't hold the water and was mumbling. V14 did an assessment and R1 was oriented to name but couldn't hold arms up. V14 stated V4 was called to discuss R1's change in condition from day shift. V14 stated R1's vital signs were like 86% (oxygen saturation greater than 90% is within normal limits) I can't remember for sure. I put R1 on oxygen, notified (via text) V2 that R1 was being sent out (to hospital). I called the ambulance, sent records, called the POA (Power of Attorney) and the physician. I've worked with R1 four or five other times, and I knew there was a change, but I also asked V5 (Night Nurse) to come evaluate R1 before I sent R1 out because V5 has worked with R1 more than I have.
On 5/14/24 at 9:00 AM, V2 stated V14 texted me on 4/27/24 and stated R1's right hand was slightly swollen but was able to make a fist and didn't complain of pain. There was a reddened rash to both forearms. V2 stated V14 texted her back at 9:00 PM and stated R1 was lethargic, temperature was 99.3 degrees Fahrenheit, pulse was 89 beats per minute, blood pressure was 96/54, respirations were 14 breaths per minute, oxygen saturation was at 85%, R1 was weak, slow to respond, supplemental oxygen was administered, the ambulance was called to transfer to hospital and the physician was notified.
On 5/14/24 at 12:39 PM, V5 stated V14 wanted me to look at R1 because R1's oxygen was low. I did a sternal rub on R1 and told them to call (ambulance) and send R1 out (to hospital). It must have been around 8:30 PM.
On 5/1/24, the Hospital Records documents R1 was admitted for septic shock, probable urinary tract infection and cellulitis to the left below knee amputation site.
On 5/14/24 at 9:50 AM, V2 stated R1's vital signs should have been conducted more frequently although there was no physician's order. V2 stated It's nursing judgement but a baseline (vital signs) should be established to determine changes. R1 has a history of infections, and I would have been monitoring (vital signs) more frequently. R1 met criteria to be transferred simply for the altered mental status and decrease in oxygenation. V2 agreed that on 4/27/24, R1's Progress Note lacked documentation of V5 and V14's assessments/findings, lacked to notify the physician when change in condition started and/or a request for interventions from the physician which led up to R1's transfer to the hospital.
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
Based on record review and interview the facility failed to obtain scheduled physician prescribed medications from the pharmacy for one of three residents (R2) reviewed for medication availability in ...
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Based on record review and interview the facility failed to obtain scheduled physician prescribed medications from the pharmacy for one of three residents (R2) reviewed for medication availability in the sample of seven.
Findings include:
The facility's Conformance with Physician Medication Orders policy dated 9-27-17 documents all medications, including cathartics, headache remedies, or vitamins, etc. (etcetera) shall be given as prescribed by the physician and at the designated time. This policy also documents the resident's attending physician shall be notified to promptly renew prescription order to avoid interruption of the resident's therapeutic regimen.
R2's Order Summary Report dated 5-13-24 documents the following current medication orders: Order date 3-22-24: Atenolol 50 mg (milligrams) one tablet by mouth two times a day for the diagnosis of Hypertension. Order date 4-26-24: Zolpidem Tartrate 10 mg one tablet by mouth at bedtime daily for the diagnosis of Insomnia.
R2's Medication Administration Records dated 5-1-24 through 5-31-24 document R2 did not receive his scheduled dose of Zolpidem (Ambien) Tartrate 10 mg at 8:00 PM on 5-8-24 due to the medication being unavailable.
R2's Medication Administration Records dated 5-1-24 through 5-31-24 document R2 did not receive his scheduled dose of Atenolol 50 mg at 8:00 PM on 5-6-24 due to the medication being unavailable.
On 5-13-24 at 10:15 AM R2 stated, I did not get my Ambien one day and my Atenolol on one day. I am tired of hearing excuses from (V2/Director of Nursing/DON)) that the facility runs out of my medications. It is unacceptable.
On 5-13-24 at 10:30 AM V2 stated, (R2) did not get his scheduled dose of Zolpidem on 5-8-24 due to the pharmacy not receiving the signed prescription refill order. (R2) did not get his scheduled dose of Atenolol on 5-6-24 because the pharmacy did not get the refill to the facility in time.
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 F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Physical Therapy/Occupational Therapy (PT/OT) was provided p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Physical Therapy/Occupational Therapy (PT/OT) was provided per physician order for one of three (R1) residents reviewed for therapy services in a sample of seven.
Findings include:
The Admissions Policy, dated 10/2006, documents To admit and/or retain only those residents whose health care needs can be met through services of the facility and staff, in cooperation with outside resources under contract with the facility. Prior to admission, a thorough pre-screening of potential residents shall be done with the resident or guardian or responsible party determining appropriate placement.
The Facility assessment dated [DATE] documents Resident support/care needs the facility provided various services for the residents we care for. The resident's care is based on their individual needs and preferences and are reflected in the individuals care plan. The care and services provided are broken down by category: Therapy PT, OT .
On 12/21/23, R1's New Referral form from the transferring hospital to the facility documents Patient is bilateral BKA (Below the Knee Amputation) and gets up via (mechanical) lift. Needs SNF (Skilled Nurse Facility) placement due to inability to care for self at home. Anticipated Services needed: Physical Therapy/Occupational Therapy.
On 12/26/23, a Physician's Order documents to admit and receive skilled PT/OT services from the Skilled Nurse Facility.
On 12/27/23, R1's Skilled Charting-12 Hr. (hour) section C documents R1's ADL's (Activities of Daily Living)/Functional Status as does not weight bear, unsteady gait, impaired balance, weakness, and section L documents skilled services needed are Therapy/Rehabilitative Services, Physical Therapy and Occupational Therapy.
On 1/16/24, R1's Care plan documents R1 has bilateral BKA, R1 requires maximum assist of two staff members and the use of a mechanical lift to complete surface to surface transfers safely. R1 also requires substantial assistance from staff to complete daily tasks of dressing, grooming, toileting hygiene, and bed mobility.
R1's medical record does not include evidence of R1 receiving PT/OT services or evaluations since admission.
On 5/13/24 at 10:20 AM, R1 stated I came (to the facility) the end of December (2023). I want to go home but I need PT, but my insurance won't pay. I don't have a (mechanical lift) at home, and they haven't taught me how to use a slide board for transfer. I know other people are on Medicaid and they get therapy.
On 5/14/24 at 10:00 AM, V1 (Administrator-In-Training) stated That just must be a standardized order (R1's PT/OT order). We didn't even have therapy services back then.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure residents had fresh water available between meals for six of seven residents (R2-R7) reviewed for hydration in the samp...
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Based on observation, interview, and record review the facility failed to ensure residents had fresh water available between meals for six of seven residents (R2-R7) reviewed for hydration in the sample of seven.
Findings include:
The facility's Hydration policy dated 06/2006 documents, It is the policy of (the facility) that the facility will provide each resident with sufficient fluids to maintain proper hydration. Procedure: 1. Provide fluids (6-8 glasses per day) to residents during and in-between meals and during activities. 2. Provide fresh water and ice at the bedside except where contraindicated (example fluid restriction).
1. R2's current Physician's Orders document R2 has an order for thin liquids.
On 5-13-24 at 10:15 AM R2 was sitting on the edge of his bed. R2 stated, We (residents) do not get served fresh ice water every shift. Whenever I need water, I have to get it myself out of the tap. The ice chest is locked up so I cannot get ice. A lot of residents cannot get themselves their own water.
2. R3's current Physician's Orders document R3 has an order for thin liquids.
On 5-13-24 from 10:30 AM through 1:00 PM R3 was sitting in a chair in his room. R3 did not have fresh ice water in his room.
On 5-13-24 at 10:30 AM R3 stated, Staff never give me fresh water. If I want water, I have to get tap water out of the sink myself.
On 5-14-24 at 9:50 AM R3 was laying in his bed. R3 had no fresh water at the bedside or within reach.
3. R4's current Physician's Order Sheets document R4 has a history of urinary tract infections and has an order for thin liquids.
On 5-13-24 at 10:40 AM and 5-14-24 at 9:55 AM R4 was lying in bed in her room. R4 did not have fresh ice water in her room during these times.
On 5-13-24 at 10:40 AM R4 stated, I never get water unless it is on my meal tray. It would be great to get some.
4. R5's current Physician's Order Sheets documents R5 has history of sepsis and hypo-osmolality and has an order for thin fluids.
On 5-13-24 at 10:42 AM and 5-14-24 at 9:58 AM R5 was lying in bed in her room. R5 did not have fresh ice water in her room during these times.
On 5-13-24 at 10:42 AM R5 stated, I never have water.
5. R6's current Physician's Order Sheets document R6 has an order for thin liquids.
R7's current Physician's Order Sheets document R7 has a history of urinary tract infections and has an order for thin liquids.
On 5-13-24 at 10:45 AM R6 and R7 were both sitting in wheelchairs in their room. Neither R6 nor R7 had ice water in their room.
On 5-14-24 at 10:40 AM V2 verified R3, R4, R5, and R7 did not have water pitchers or fresh water in their rooms.
On 5-14 24 at 10:45 AM V2 (Director of Nursing) stated, All residents are supposed to get fresh ice water served to them every shift in their rooms. All residents should have a water pitcher at the bedside.
Apr 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for six residents (R5-R10) on the sample of residents reviewed for medicati...
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Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for six residents (R5-R10) on the sample of residents reviewed for medication pass. This failure resulted in medication errors out of thirty-six opportunities for error, for a 22 percent medication error rate.
Findings include:
The facility's Medication Administration policy, revised 11/18/17, documents that medications must be prepared and administered within one hour of the designated time or as ordered. (I.e., Medication time is 9:00am, The medication can be administered as early as 8:00am and as late as 10:00am. Medication is ordered as daily then medication can be given during the day at resident's preference).
On 4/22/24 at 12:40pm, V6, Registered Nurse, gave R7 his medications. V6 told R7 that his Fluticasone (steroid) 50 MCG (Microgram) nasal spray was not available.
On 4/22/24 at 1:00pm, V6 gave R9 his Gabapentin (Nerve pain) 100mg (Milligrams) one tablet. R9's MAR documents to take Cranberry tablet daily, but V6 stated that the medication was not available.
On 4/22/24 at 1:15pm, V6 performed R10's blood sugar test which was scheduled to be done before meals at 11:00am. R10's blood glucose was 400. V6 received orders to give 10 units of Humalog 10 units subcutaneous.
On 4/22/24 at 1:25pm, V6 gave R8 Aspart (antidiabetic) 7 units SQ. R8's MAR (medication administration record) documents to give Aspart 7 units SQ at 11:00am.
On 4/22/24 at 1:30pm, V6 stated that the blood sugar tests should have been done before lunch, but she was running late today. V6 stated that the facility is out of quite of few medications. V6 stated that she did order several medications a few days ago, but they have not been delivered yet.
On 4/23/24 at 10:20am, V4, Licensed Practical Nurse, stated that R5's Empagliflozin 10mg (antidiabetic), Pantoprazole (proton pump inhibitor) 40mg packet and Zinc (Supplement) 220 mg tablets are not available.
On 4/23/24 at 10:50am, V4 stated that R6 has an order for Januvia (Antidiabetic) 100mg tablet daily, but it is not in stock.
On 4/23/24 at 2:00pm, V1, Administrator, verified that there have been some issues with receiving medications in a timely manner.
Mar 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician ordered wound treatments and dressing changes were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician ordered wound treatments and dressing changes were performed as ordered for 1 resident (R1) of 3 residents reviewed for wounds in a sample of 4. This failure resulted in R1 being admitted to the hospital for wound treatments.
Findings include:
The Nursing Services policy dated 9/27/17 documents, It is the policy of (the facility) to assure sufficient qualified nursing staff is available and on duty on a daily basis to provide nursing and related services to attain or maintain each resident highest practical physical, mental and psychosocial well-being based on the comprehensive assessment of the resident and consistent with the resident's preference, needs and choices. 2. Treatments and procedures ordered by the physician shall be properly administered including enemas, irrigations, catheterizations, applications, application of dressings and/or bandages, diet supervision.
The Decubitus Care/Pressure Areas policy dated 1/2018 documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer. 6) Reevaluate the treatment for response at least every two (2) to four (4) weeks. Most pressure areas will respond to treatment in this amount of time. If no improvement is seen in this time frame, contact the physician for a new treatment order.
R1's Medical Records documents R1 was admitted to the facility on [DATE] with diagnosis Acute Infarction of Spinal Cord (Embolic) (Non embolic), Paraplegia, Monoplegia of Lower Limb Affecting Unspecified Side, Pressure Ulcer of Right Heel (Stage 4), Pressure Ulcer of Left Heel (Unstageable), Pressure Ulcer of Left Ankle (Unstageable), Pressure Ulcer of Other Site (Unstageable, Pressure Ulcer of Left Buttock (Stage 4), Pressure Ulcer of Right Buttock (Stage 4), Neuromuscular Dysfunction of Bladder, and Sepsis.
R1's Minimum Data Set/MDS assessment dated [DATE], documents R1 is a paraplegia with medically complex conditions. R1 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R1 is dependent for toileting, bed mobility, and most activities of daily living. R1 does not reject care. R1 has one stage 3 pressure ulcer, three stage 4 pressure ulcers, and three unstageable pressure ulcers. R1 did not have any of the wounds when R1 admitted to the facility. R1 has impairment on both sides of his lower extremity. R1 has an indwelling catheter and is always incontinent of bowel.
On 3/18/24 at 10:47 AM, V3 (Ombudsman) stated she had talked to the wound clinic and was told R1's wounds were dirty and smelled horrible.
On 3/18/24 at 11:03 AM, V4 (Ombudsman) stated on 3/15/24 V4 was told by R1 that R1 needed his dressing changed. V4 told a nurse (unknown) R1 wanted his dressing changed. It took over an hour to for the nurse to change R1's dressing. V4 said V4 heard the nurse say how bad it smelled.
On 3/20/24 at 10:53 AM, V5 (Wound Clinic Nurse) stated R1 was not having his wounds dressed as ordered. On 2/22/24 V5 talked to the facility about the dressing the clinic wanted the facility to use for R1's wounds. V5 was told, That dressing is too expensive, and we will not be getting it. V5 told the facility the clinic would order a less expensive dressing to see if it would work but if it did not work the facility needed to get the (antimicrobial foam) dressing. V5 said when R1 came back to the clinic on 2/29/24 R1's wounds were not getting any better so V15 (Wound Doctor) ordered the (antimicrobial foam) dressing again. A sample of the (antimicrobial foam) dressing was sent with R1 to the facility so the facility could use until the facility could get the dressing ordered. V5 said no one from the facility called to say they were not going to order the new dressing. V5 said when R1 returned to the wound clinic on 3/13/24 R1's wounds were much worse. R1's wounds were larger and deteriorating. R1 told V5 the facility ran out the sample dressing and R1 is not sure the facility will get anymore. R1 told V5, V1 (AIT) is trying to get the correct dressing ordered.
On 3/20/24 at 11:00 AM, V15 (Wound Clinic Doctor) stated R1 is alert/oriented and a good historian of his treatments. V15 said, several times R1 has come to the wound clinic from facility with incorrect dressings in place. R1 told V15 the facility has a new administrator (V1) who is working on ordering the correct dressings. R1 told V15 the facility was having staffing issues so sometimes the dressings were not being changed. V15 stated the lack of appropriate dressings being in place has caused R1's wounds to worsen. V15 said on the 3/13/24 visit R1 continued to have the incorrect dressing on, and the wounds were noted to have a foul odor and large amounts of purulent drainage indicating infection. V15 advised R1 he needed to go to the hospital and be seen because V15 felt the wounds were worsening and appeared infected. V15 stated, I feel (R1's) wounds have worsened as a result of incorrect dressings being in place from the facility. I don't understand why the facility would send (R1) to a wound clinic for an expert opinion and then not follow the treatment orders.
On 3/18/24 at 11:24 AM, V1 (Administrator in Training) stated R1 is in the hospital, and it has something to do with his wounds.
On 3/20/24 at 11:28 AM, V16 (Regional Director of Operations) was asked why R1 was not getting the dressing to his wounds as V15 (Wound Doctor) ordered. V16 stated, The ball got dropped.
On 3/19/24 at 12:30 PM, R1 stated the facility is not doing his dressing changes like they are supposed to do them. R1 must ask to have the dressings changed and if the nurses are busy the dressings are not changed. They are not using the right kind of dressing and it has caused R1's wounds to get worse.
On 3/20/24 at 11:18 AM, V1 (Administrator in Training) stated whoever the nurse was working when R1 came back from the wound clinic should have put the new orders in. V19 (Previous Director of Nursing) was monitoring wounds and orders but V19 is no longer at the facility.
On 3/20/24 at 11:30 am V17 (Licensed Practical Nurse) stated she has worked in facility for four days. V17 has observed V6 (RN) do R1s dressing change while she was in training. V17 stated V6 read the treatment came up on TAR and V6 packed the wound on R1's ischium with gauze which was soaked in solution she could not remember name of. V17 was asked if she had ever seen the (antimicrobial foam) dressing used on R1's ischium and V17 stated, I have not seen kind of dressing here.
R1's Physician Order for bilateral ischial wounds dated 2/8/24 at 4:49 PM, documents to cleanse with normal saline solution, pat dry. Apply (antimicrobial foam dressing), apply (non-adherent dressing) and cover with an abdominal pad. Cover with (clear adhesive to hold dressing in place). Change daily and as needed.
R1's Nursing Note written by V19 (Previous Director of Nursing) dated 2/9/24 at 11:47 AM, documents, (R1) came back with orders are not able to attend. May continue with (topical antiseptic) solution until next visit.
R1's Nursing Note written by V19 dated 2/16/24 at 3:17 PM, documents, New orders processed and reviewed. Call placed to wound clinic. (Antimicrobial foam dressing) is unavailable at this time as well as (biodegradable gel dressing). Orders received to continue with (topical antiseptic) at 0.5 % (percent) as well instead of 0.25%. Will continue with daily treatments. R1 agrees with current treatment plan.
R1's Wound Note dated 2/22/24 documents, (R1) did not have correct dressing on both ischial sites or on lower legs upon arrival today. Facility did not have any (antimicrobial foam dressing) on those sites today. Leg dressings were dated 2/18/24 when they should be changed daily. Poor prognosis for healing especially with additional factors of non-adherence to wound center orders.
R1's Wound Clinic note dated 2/29/24 documents R1 is alert and oriented to person, place, and time. (R1) did not have correct dressing on both ischial sites or on lower legs upon arrival today. Facility did not have any (antimicrobial foam) dressing on those sites today. (R1) advised correct dressings were not on his wounds today. (R1) states the facility has a new administrator will order the correct dressings. R1 advised regarding healing. Poor prognosis for healing especially with additional factor of nonadherence to wound center orders.
R1's Wound Orders dated 2/29/24 to bilateral ischial areas documents to pack wounds with (absorbent topical dressing), cover with (antimicrobial foam dressing), cover with (nonadherent dressing) and abdominal pad, and secure with (surgical tape).
R1's Treatment Administration Record/TAR dated 3/1 - 3/31/24 documents, bilateral ischium-(povidone iodine) to base. Apply (topical antiseptic) solution 0.5% (percent) cover with ABD (Abdominal) pad and secure with (surgical tape). The last treatment documented was on 3/17/24. The TAR was not signed the ischium treatments were done on 3/4, 3/7, 3/8, 3/12, 3/15, and 3/16/24. (There was not an order to pack wounds with absorbent topical dressing), cover with (antimicrobial foam dressing), cover with (nonadherent dressing) and abdominal pad, and secure with (surgical tape) on the TAR)
R1's Wound Clinic Note dated 3/13/24 documents, Left Ischial- Pressure ulcer stage 4 -base with pale granulation tissue. Moderate amount of yellow gray sloth at the base. Large foul-smelling drainage. Right Ischial -Pressure ulcer stage 4 - base with red granulation tissue at the base. Small amount of yellow sloth at the base. Small amount of exposed tendon and bone at the base. Moderate foul-smelling drainage. Large amounts of foul-smelling drainage from both hip sites noted today. (R1) states the facility ran out of the (antimicrobial foam) dressing a few days ago. Per RN, (R1) only had gauze packed into hip wounds. No (povidone iodine) dressing on lower extremities noted on arrival per RN. Unfortunately, wound center orders do not seem to be followed at the facility limiting options for healing. (R1) also has refused to consider negative pressure therapy in the past. (R1) has worsening infections of both hips. (R1) advised to immediately present to the nearest emergency room.
R1's Wound Clinic Measurements dated 3/13/24, documents the left ischial wound edges are open. The wound bed granulating, moist, slough, purple. Large amount of drainage. Drainage characteristics/odor serous, creamy, purulent, yellow, malodorous. Wound length 4.6 cm/centimeters, wound width 5 cm, wound surface 23 square cm, tunneling depth 6.5 cm, undermining 6.2 cm. (Compared to) R1's Wound Clinic Measurements dated 12/21/23, documents the left ischial wound bed red, slough. Moderate amount of drainage. Drainage characteristics/odor serosanguineous. Wound length 4.5 cm/centimeters, wound width 4.5 cm, wound surface 20.25 square cm, no tunneling depth or undermining.
R1's Wound Clinic Measurements dated 3/13/24, documents the right ischial wound edges are open. The wound bed moist, slough. Large amount of drainage. Drainage characteristics/odor malodorous, purulent, yellow, serous. Wound length 4.1 cm/centimeters, wound width 6.5 cm, wound depth 6.5 cm, wound surface 20.5 square cm, undermining 7 cm. (Compared to) R1's Wound Clinic Measurements dated 12/21/23, documents the right ischial wound edges are open. The wound bed red, slough. Moderate amount of drainage. Drainage characteristics/odor serosanguineous. Wound length 5 cm/centimeters, wound width 5 cm, wound depth 5.5 cm, wound surface 20.5 square cm, undermining 7 cm, no tunneling depth, or undermining.
R1's Nursing Note dated 3/13/24 at 12:46 PM, documents R1 returned from the wound clinic visit at 12:30 PM. R1 stated, They want to add me to go to the hospital again for follow up.
R1's Nursing Note dated 3/16/24 at 2:36 AM, documents R1 requested wound care be done on his buttock. More yellow exudates on the right wound, the left wound has reddened pinkish walls. There was not a strong smell from the wound as compared from before. (R1) Expresses plans of going to the Hospital today.
R1's Hospital Record dated 3/18/24 documents R1 presents to the hospital for a wound check. Worsening buttock wound with purulent discharge. History (R1) is an unfortunate [AGE] year-old male with past medical history significant for history of paraplegia with a history of chronic and multiple wounds including history of osteomyelitis with frequent admissions to the hospital. (R1) has been in a nursing home but apparently the correct wound dressing has not been applied and when the patient was last seen in the wound clinic on the 13th of this month (R1) had the wrong dressing on and was recommended to be hospitalized but at point of time (R1) would refuse. R1 was seen in the emergency room and his sacral and buttocks Decubitus appear to be worse with some purulent drainage and tunneling as well. Assessment and Plan Probable Sepsis. Secondary to infected unstageable sacral/buttocks decub (Decubitus ulcer).
R1's Nursing Note (Late entry) dated 3/20/24 at 8:02 PM written by V29 (Registered Nurse), documents, In report from AM (morning) nurse (V6/Registered Nurse) said the doctor had wanted (R1) to return to the hospital due to increased size of (R1's) ischium wounds. (V6) said administration was aware of this situation. (V25/Agency Coordinator) and (V28/Regional Nurse) we're in the Director of Nursing office and we're aware of the situation as well. I (V29) had asked if administration needed called-but since the doctor had wanted (R1) to go to the hospital per (V6) it was assumed administration knew (R1) was going. (R1) had finally agreed to go to the hospital. (R1's) packing gauze length was increased 8 (eight) inches to each ischium wound to a total length used of approximate 21 inches length of each packing gauze. The ischium wounds also had increased tunneling and increased dark yellow exudate per (V6) in report. (R1) was aware his wounds may be getting bigger and (R1) wanted them treated before they had gotten worse. (R1 was sent to the hospital on 3/17/24).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 incontinent care for 4 residents (R1, R2, R3, R4) reviewed ...
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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 incontinent care for 4 residents (R1, R2, R3, R4) reviewed for incontinent care in a sample of four.
Findings Include:
The Perennial Cleansing policy dated 12/2017 documents, To eliminate odor; to prevent irritation or infection and to enhance residents' self-esteem.
The Certified Nurse's Aide policy not dated documents the CNA job summary, Working under the direction of the staff nurses, the Certified Nurse's Aide (CNA) provides personal care and assistance to residents to assure their safety and comfort. Carries out basic hygiene measures including but not limited to the following: grooming, shaving, applying makeup, oral hygiene/dental care, cuts/cleans nails, fingers and toes, foot care, skin care, bathing/showering and cleaning incontinent residence.
On 3/18/24 at 10:47 AM, V3 (Ombudsman) stated that on 3/4/24, R3 called at 8:00 AM and said he was wet and had not been changed since night shift. V3 called V4 (Ombudsman) and asked V4 to go to the facility to check on the residents. Around 9:30 AM, R3 called V3 again and said R3 still had not been changed. V3 called the facility and told the facility receptionist V3 was not going to hang up until someone went to change R3. There was only one CNA for the whole building on day shift and management was working the floor. V3 has talked to management many times and they keeps making promises of what the facility is going to do but it is not getting done.
On 3/18/24 at 11:03 AM, V4 (Ombudsman) stated on 3/4/24 she got a call from V3 (Ombudsman) asking V4 to go to the facility to check on the residents. V3 had got a call from R3 stating he was incontinent and needed changed. R3 had the call light on when V4 got to R3's room at 9:30 AM. R3 said the light had been on for a long time, and he had not been changed since the night shift left. V4 went to R1's room which had the call light on. R1 wanted to have a nurse look at his dressing. While V4 was talking to R1 she noticed R2 (R1's roommate) was wet. R2's (disposable brief) was engorged with urine. R2 said he would like to be changed but no one had come to answer the call light and change him. R2 said R2 hated to complain because he did not want to make anyone mad at him. V4 walked the halls looking for a nurse to look at R1's dressing and a CNA to change R2 and R3. V4 found a CNA (unknown) making a bed and asked her to help R2 and R3. The CNA had an attitude and acted like making the bed was more important than changing the residents. It was 10:30 AM before R3 got changed. V4 found V1 (AIT) working the floor as a CNA. V4 stated, I walked the halls and there was only one CNA I could find. I know it was at least 30 minutes after I got to the facility before R2 was changed. I have no idea how long R2 had been waiting. V4 told V1 of her concerns about the care of the residents.
On 3/19/24 at 1:00 PM, V11 (CNA) stated, We come to work in the morning and residents are soaked or soiled and we have to change them.
On 3/19/24 at 1:30 PM, V10 (CNA) stated, Residents are not being toileted and changed.
1. R1's Medical Records documents R1 was admitted to the facility on [DATE] with a diagnosis which includes Acute Infarction of Spinal Cord (Embolic) (Non embolic), Paraplegia, Monoplegia of Lower Limb Affecting Unspecified Side, Pressure Ulcer of Right Heel (Stage 4), Pressure Ulcer of Left Heel (Unstageable), Pressure Ulcer of Left Ankle (Unstageable), Pressure Ulcer of Other Site (Unstageable, Pressure Ulcer of Left Buttock (Stage 4), Pressure Ulcer of Right Buttock (Stage 4), Neuromuscular Dysfunction of Bladder, and Sepsis
R1's Minimum Data Set/MDS assessment dated [DATE], documents R1 is a paraplegia with medically complex conditions. R1 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R1 is dependent for toileting, bed mobility, and most activities of daily living. R1 does not reject care. R1 has one stage 3 pressure ulcer, three stage 4 pressure ulcers, and three unstageable pressure ulcers. R1 did not have any of the wounds when R1 admitted to the facility. R1 has impairment on both sides of his lower extremity. R1 has an indwelling catheter and is always incontinent of bowel.
On 3/19/24 at 12:30 PM, R1 stated incontinent care is not done when needed. R1 is incontinent of bowel, and it is not good on his wounds to not get changed when needed.
2. R2's Medical Records documents R2 was admitted to the facility on [DATE] with a diagnosis of Cellulitis, Inflammatory Disorders of Scrotum, Unspecified Open Wound, Left Lower Leg, Subsequent Encounter, Unspecified Open Wound, Right Lower Leg, Subsequent Encounter, Non-Rheumatic Mitral Valve Insufficiency, and Vitamin D Deficiency.
R2's Minimum Data Set/MDS assessment dated [DATE], documents R2 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R2 requires clean up assistance for toileting. R2 is occasionally incontinent of bowel and bladder.
On 3/18/24 at 10:40 AM, R2 stated it takes staff a long time to answer call lights when R2 needs changed.
3. R3's Medical Records documents R3 was admitted to the facility on [DATE] with a diagnosis of Unspecified Sequel of Cerebral Infarction, Other Enthesopathy of Left Foot and Ankle, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Other Intravertebral Disc Degeneration, Lumbar Region, Essential (Primary) Hypertension, Abdominal Aortic Aneurysm, without Rupture, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Cervicalgia, Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb.
R3's Minimum Data Set/MDS assessment dated [DATE], documents R3 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R3 is dependent for toileting, bed mobility, and most activities of daily living. R3 is always incontinent of urine and frequently incontinent of bowel.
On 3/18/24 at 10:00 am R3 stated, They don't change us and don't get us out of bed. At bedtime they only have one CNA and we lay in feces for hours.
4. R4's Medical Records documents R4 was admitted to the facility on [DATE] with a diagnosis of Peripheral Vascular Disease, Diabetes Mellitus due to Underlying Condition with Hyperosmolality without Nonketotic Hypercalcemic-Hyperosmolar Coma, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication, Chronic Respiratory Failure, Venous Insufficiency, Chronic Diastolic (Congestive) Heart Failure, and Chronic Atrial Fibrillation.
R4's Minimum Data Set/MDS assessment dated [DATE], documents R4 has a BIMs (Brief Interview for Mental Status) of 15 (cognition intact). R4 is dependent for toileting, bed mobility, and most activities of daily living. R4 is always incontinent of urine and frequently incontinent of bowel.
On 3/20/24 at 1:00 PM R4 stated the facility has staffing issues on all shifts. Incontinent care is not done when it is needed.
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 provide required staff to assist and monitor residents during breakfast, failure to answer call lights timely, and failure to provide inco...
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Based on interview, and record review, the facility failed to provide required staff to assist and monitor residents during breakfast, failure to answer call lights timely, and failure to provide incontinent care for dependent residents. This failure has the potential to affect all 55 residents residing in the facility.
Findings include:
The Nurse Staffing policy (not dated) documents, It is the policy of (the facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by (the state agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.
The facility's Facility Assessment dated 8/18/2017, documents the average daily census is 55 residents. It does not include staffing requirements necessary to meet the needs of the resident based on the resident population and census.
On 3/18/24 at 10:00 am R3 stated that on 3/4/24 he did not get out of bed until the afternoon, however, was unable to recall exact time. The facility does not have enough staff to take care of the residents. R3 turns on his call light for help and nobody answers it. R3 also stated, They don't change us and don't get us out of bed. At bedtime they only have one CNA and we lay in feces for hours.
On 3/18/24 at 10:40 AM, R2 stated the facility is short staffed most of the time. It takes a long time to be able to get out of bed in the morning and get dressed for breakfast. R2 does not remember the date but one day last week R2 did not get breakfast until 10:00 AM due to staff not getting him up. It takes staff a long time to answer call lights when R2 needs changed.
On 3/19/24 at 12:30 PM, R1 stated that there is not enough staff and incontinent care is not done when needed. R1 is incontinent of bowel, and it is not good on his wounds to not get changed when needed.
On 3/20/24 at 1:00 PM R4 stated the facility has staffing issues on all shifts. Incontinent care is not done when it is needed.
On 3/18/24 at 10:47 AM, V3 (Ombudsman) stated that on 3/4/24, R3 called at 8:00 AM and said he was wet and had not been changed since night shift. Around 9:30 AM, R3 called V3 again and said R3 still had not been changed. V3 called the facility and told the facility receptionist that V3 was not going to hang up until someone went to change R3. V3 stated that residents were complaining they were three hours late getting breakfast because staff were not getting them to the dining room. There was only one CNA for the whole building on day shift and management was working the floor.
On 3/18/24 at 11:03 AM, V4 (Ombudsman) stated V4 got to the facility at 9:20 AM on 3/4/24 and a resident in the dining room yelled and asked if V4 was a nurse because they wanted to eat. The were several residents sitting in the dining room waiting on their breakfast. V4 asked kitchen staff (unknown) why the residents were not eating breakfast and was told they could not serve the food until there was a CNA in the dining room to monitor the residents. V4 went to find V1 so the residents could get fed. V1 was working the floor as a CNA. V4 told V1 the residents were not being fed. V4 then went to check on R3 and he was still in bed and had not had breakfast. V4 saw R1's light on and R1 and R2 (R1's roommate) were both still in bed and they both said they had not had breakfast yet. V4 also stated that on 3/4/24 she got a call from V3 (Ombudsman) asking V4 to go to the facility to check on the residents. V3 had got a call from R3 stating he was incontinent and needed changed. R3 had the call light on when V4 got to R3's room at 9:30 AM and R3 said that the light had been on for a long time, and he had not been changed since the night shift left. V4 then went to R1's room that had the call light on. R1 wanted to have a nurse look at his dressing. While V4 was talking to R1 she noticed that R2 (R1's roommate) was wet. R2's (disposable brief) was engorged with urine. R2 said he would like to be changed but no one had come to answer the call light and change him. R2 said R2 hated to complain because he did not want to make anyone mad at him. V4 walked the halls looking for a nurse to look at R1's dressing and a CNA to change R2 and R3. V4 found a CNA (unknown) making a bed and asked her to help R2 and R3. The CNA had an attitude and acted like making the bed was more important than changing the residents. It was 10:30 AM before R3 got changed. V4 found V1(AIT) working the floor as a CNA. V4 stated, I walked the halls and there was only one CNA that I could find. I know that it was at least 30 minutes after I got to the facility before R2 was changed. I have no idea how long R2 had been waiting. V4 told V1(AIT) of her concerns about the care of the residents.
On 3/18/24 at 12:49 PM, V2 (Dietary Manager) stated if a resident gets their food late it is because the facility is short staffed. Sometimes the CNAs are running behind bringing residents to the dining room. Normally the CNA's serve the meals.
On 3/19/24 at 1:00 PM, V11 (CNA) stated regarding staffing in the facility, There are not many of us. V11 stated, We come to work in the morning and residents are soaked or soiled and we have to change them.
On 3/19/24 at 1:30 PM, V10 (CNA) stated there is not enough staff on any shift. It is normal to come in and be the only CNA in the building. The staff do what they want and come to work and leave as they please. V10 stated, Residents are not being toileted and changed.
On 3/20/24 at 9:59 AM, V14 (Resident Care Coordinator) stated she started at the facility on 3/4/24. V14 stated V14 got to the facility at 9:00 AM, and it was chaos. The management team were working the floor and V14 was told to start working the floor. V14 said it was so chaotic that several residents were still in bed, call lights were on and residents needed to be gotten up for breakfast. V14 took over staffing on 3/11/24. V14 said V14 was not shown how to figure what the staffing needs were and not given any tools to use. V14 was told to staff six CNAs on days, five CNAs on evenings and four CNAs on nights. V14 said when V14 took over the staffing the daily schedule would not have all the positions covered. There were blank spaces on the sheet where a name should be. The shortage of staff was not from call offs it was because staff were not scheduled.
On 3/20/24 at 1:00 PM V18 (R4's Family Member) was at the facility visiting R4. V18 stated R4 often waits hours with her call light on before she gets assistance. V18 often comes to the facility and can hear his mom screaming for help from the desk. V18 stated the facility has staffing issues often on all shifts. V18 has come to the facility, and they only have two CNAs working in the building.
On 3/21/24 at 10:44 AM, V1 stated it's hard for her to say who or how many staff were working on 3/4/24 because there were so many changes with staffing the first week of March. V1 was shown the daily staffing sheet for 3/4/24 and she could not say who was working. V1 stated, I am not sure who was at the facility on 3/4/24 but I can't believe there was only one CNA. It is hard because we are using so much agency. The first week of March was complicated because V19 (Previous Director of Nursing) had left the facility and she was doing the schedule. Our goal is to be at six CNAs on days, five CNAs on evenings and four CNAs on nights.
On 3/21/24 at 1:58 PM, V16 (Regional Director of Operations) stated that she was unaware the Facility Assessment needed to specify the number of staff required to care for the residents. V16 thought since the Facility Assessment documents the facility staffing is based on the Staffing Calculator that was all that was needed.
The Daily Staffing Calculations were compared to the Daily Punches from 3/1/24 to 3/20/24. During that time the census ranged from 59 residents to 54 residents. The total number of hours needed for non-nursing staff ranged from 111.60 hours daily to 102.23 hours. The actual hours worked ranged from 35.10 hours to 94.01 hours.
On 3/4/24 (the day of the complaint) there were 59 residents, a need of 111.60 hours of non-nursing care, and documented punch hours worked as 31.27 hours. There were an additional 16 hours of CNA coverage documented from an agency. The documented CNA hours are as follows; (days) V23 (CNA) 6:19 AM- 7:15 AM, V21 (CNA) 7:47 AM - 8:42 PM, V22 (CNA) 11:00 AM - 1:00 PM, (evenings) V22 (CNA) 2:00 PM-10:00 PM, (nights) V30 (CNA) 10:00 PM -6:25 AM, V31 (Agency CNA) 10:00 PM - 6:00 AM, and V32 (Agency CNA) 9:52 PM - 6:00 AM.
The Long-Term Care Facility Application for Medicare and Medicaid dated 3/21/24 documents 55 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 F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility failed to complete their facility assessment to include the staffing requirements needed to care for the resident population and census. This failure ...
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Based on interview and record review the facility failed to complete their facility assessment to include the staffing requirements needed to care for the resident population and census. This failure has the potential to affect all 55 residents residing in the facility.
Findings include:
The facility's Facility Assessment dated 8/18/2017, documents the average daily census is 55 residents. It does not include staffing requirements necessary to meet the needs of the resident based on the resident population and census.
On 3/20/24 at 9:59 AM, V14 (Resident Care Coordinator/Licensed Practical Nurse) stated that she took over staffing on 3/11/24. V14 said V14 was not shown how to figure what the staffing needs were and not given any tools to use. V14 was told to staff six Certified Nursing Assistants/CNAs on days, five CNAs on evenings and four CNAs on nights.
On 3/21/24 at 9:50 AM, V1 (Administrator in Training) stated she does not know if there is a Facility Assessment that documents how the facility should staff.
On 3/21/24 at 1:58 PM, V16 (Regional Director of Operations) stated she was unaware the Facility Assessment needed to specify the number of staff required to care for the residents. V16 thought since the Facility Assessment documents the facility staffing is based on the Staffing Calculator that was all that was needed.
The Long-Term Care Facility Application for Medicare and Medicaid dated 3/21/24 documents 55 residents reside in the facility.
Feb 2024
5 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures resulted in three deficient practice statements.
A. Based on interview and record review the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures resulted in three deficient practice statements.
A. Based on interview and record review the facility failed to monitor laboratory tests results for a high-risk medication, Warfarin (anticoagulant) for one of two residents (R11) reviewed for anticoagulants in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter).
B. Based on interview and record review the facility failed to provide medications and discontinue a medication as ordered for 4 of 4 residents (R4, R8, R12 and R13) reviewed for medication administration. This failure resulted in R4 experiencing ongoing, unrelieved pain from 01/13/24 through 01/23/24.
C. Based on observation, interview and record review, the facility failed to recognize a potential ongoing life-threatening double dosage of medication from 6/24/23 when a second, similar medication was added to a resident's daily medication regime, for one of seven residents (R5), reviewed for medications, in a sample of 42.
These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/25/24, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite.
Findings include:
The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given.
The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 11/6/18, documents, It is the policy of the facility adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes and documented in the Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consult Pharmacist. This policy also documents A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered. Wrong dose administered. Medication administered by wrong route. Medication administered to wrong resident. Medication administered at wrong time. Medication not administered. A medication discrepancy report shall be completed for any of the above occurrences.
A. R11 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation and with an order for Warfarin 5mg (milligrams) every evening, with no physician ordered PT/INR labs to be drawn.
R11's MMR (medication monthly review) dated 7/31/23, 8/29/23 and 9/27/23, documents (R11) receives warfarin and the most recent INR documented in the medical record is 2.4mg/dl from 7/8/23, the date he was admitted to this facility. (R11) does not have orders stating when to draw the next PT/INR. This form documents the Rationale for Recommendation: Warfarin has a BOXED WARNING describing the potential for major, sometimes fatal, bleeding. To avoid adverse consequences (e.g., bleeding, thrombosis), individuals should be closely and continually assessed both clinically and through appropriate INR monitoring.
R11's first PT/INR, dated 10/4/23, documents an elevated PT of 25.6 seconds (normal range: 9.8-12.2 seconds) and elevated INR of 2.5 (normal range: 0.9-1.2mg/dl). R11's PT/INR dated 1/8/24, documents a high PT of 21.9 seconds and INR of 2.1mg/dl. R11's medical record has no documentation indicating R11's high PT/INR results were called to V17, (R11's Primary Care Physician).
R11's Progress Notes, dated 1/18/24 at 6:45pm, documents R11 has had three episodes of a bleeding nose. R11's Progress Notes at 9:30pm, document, R11's epistaxis episodes around 8:40pm, R11 was observed with chest covered with blood and a bloody towel in his hand. Blood was running out from R11's left nostril like a faucet. R11 reported he felt lightheaded. R11's blood pressure was 88/44 (diastolic/systolic), pulse was 72, respirations 18 and pulse oximetry was 99 percent. (V17) was notified and orders were received to send R11 to the emergency room for labs and start intravenous fluids.
R11's emergency room diagnosis, dated 1/18/24, include Hypotension Epistaxis, Acute Renal Failure, Supratherapeutic INR. R11's Hospital Problems list includes Hypovolemic Shock. On 1/18/24 R11's PT was 42.3 seconds (11.6-14.8 seconds) and INR was 4.5 mg/dl (Milligrams per deciliter). R11's hemoglobin was low at 8.8g/dl (grams per deciliter) R11's hospital notes document R11 received two units of red packed blood cells due to a diagnosis of hypovolemic shock.
R11's readmission Physician Orders, dated 1/25/24, documents Warfarin dose reduced to 5mg every evening due to elevated INR on date of admission as well as new drug interactions with antibiotics. Repeat INR in 3 days.
On 2/20/24 at 11:00am, R11 stated his labs are not drawn on a regular basis. R11 stated on 12/18/23 he had a bloody nose for most of the day. He was told to hold pressure on it. R11 stated by evening, he was seeing double and lightheaded. R11 stated his blood pressure was very low. R11 stated he was sent to the emergency room and admitted to the intensive care unit. R11 also stated he received two units of blood while in the hospital. R11 verified he has not had any labs drawn since being readmitted to the facility. On 2/23/24 at 11:30am, R11 stated he still has not had any labs drawn. On 2/26/24 at 11:30am, R11 stated he had to go the emergency room on 2/25/24. R11 verified labs were drawn at that time.
On 2/20/24 at 12:00pm, V17, R11's Primary Care Physician, verified anyone on Warfarin is to have a PT/INR drawn monthly and every 3 days if on an antibiotic. V17 stated he was not notified of R11's PT/INR results on 1/8/24, when an elevated PT/INR results were obtained. V17 also stated he was not notified of R11's bloody nose until the evening he gave the orders for R11 to be sent to the emergency room.
At 2/20/24 at 3:00pm V2, Director of Nursing, was unable to provide R11's INR results were to be drawn within the three days after readmission. V2 verified R11's INR was not drawn. On 2/21/24 at 11:00am, V2 stated the facility does not have any policy's concerning high risk medications.
B.
2. R4's Physician Order Sheet, dated February 2024, documents R4 has diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction, Pain and Neuropathy. This same order sheet documents R4 has an order to receive Pregabalin (Analgesic) 300 MG (Milligrams)two times daily for nerve pain.
R4's Medication Administration Record (MAR), dated February 2024, documents R4 did not receive the ordered medication on 2/13/24 through 2/23/24.
R4's Progress notes for February 2024 document that R4 was not given the twice daily doses of his scheduled medication due to not available.
3. R8's Physician Order Sheet, dated December 2023 and January 2024, documents R8 has diagnoses of Traumatic Hemorrhage of Right Cerebellum, Traumatic Brain Injury and Pain. These same order sheets document R8 has an order to receive Pregabalin (Analgesic) 300 MG (Milligrams)two times daily for nerve pain.
R8's Medication Administration Records (MAR), dated December 2023 and January 2024, document R8 did not receive the ordered medication from 12/14/2023 through 01/03/2024.
R8's Progress notes for December 2023 and January 2024 document R8 was not given the twice daily doses of his scheduled medication due to not available.
4. R12's Physician Order Sheet, dated February 2024, documents R12 has diagnoses of Peripheral Vascular Disease, Diabetes Mellitus, Cerebral Infarction, Polyneuropathy. These same order sheets document R12 has an order to receive Pilocarpine (Cholinergic Agonist) 5 MG three times daily.
R12's Medication Administration Records (MAR), dated February 2024, documents R12 did not receive the ordered medication on 2/13/2024, 2/14/2024 and 2/15/2024.
R12's Progress notes for February 2024 document that R12 was not given the thrice daily doses of scheduled medication due to not available.
On 2/17/24 at 11:30 A.M., V2/Director of Nurses confirmed that facility staff should notify Pharmacy immediately if a medication was unavailable.
5. R13's Monthly Medication Review, dated 1/23/24, documents R13's medical record documents the following irregularities were noted on the medication administration record (MAR)/prescriber order sheets (POS): 1/16/24 (R13) had Eliquis 2.5mg BID (twice daily) ordered but the pre-existing 5mg BID dose was not stopped.
R13's MAR (Medication Administration Record), dated 1/16/24, documents to take Eliquis 5mg tablet twice daily and Eliquis 2.5mg twice daily. R13's MAR has each medication signed out as being given on 1/19/24 through 1/23/24. R13's MAR documents that R13's Eliquis 5mg was discontinued at 1:08pm.
On 2/20/24 at 3:00pm, V2, Director of Nursing, stated that R13's Eliquis order was decreased due to a pharmacy recommendation, but the previous 5mg dose was not discontinued. V2 verified that R13 did receive the wrong dose of Eliquis for three and half days.
---
C. R5's Physician Order Sheet, dated June 2023 includes the following medications: Calcium 600 MG (Milligrams) with Vitamin D 800 MG. Give 2 tablets orally one time a day for Supplement - Start Date 06/01/2023 and Oyster Shell Calcium 500 MG. Give 3 tablets orally one
time a day for supplement -Start Date 06/24/2023.
On 2/15/2024 at 9:18 A.M., V11/Licensed Practical Nurse prepared to administer medications for R5. After adding Calcium 600 MG with Vitamin D 800 MG two tablets and Oyster Shell Calcium 500 MG three tablets to the plastic medication cup, V11/LPN stated, I don't know why (R5) gets so much calcium. That's like a double or triple dose. V11/LPN then administrated R5's pills, with the Calcium and Oyster Shell Calcium, to R5.
On 2/20/24 at 12:30 P.M., V17/R5's Physician stated, (The dosage of calcium) that (R5) receives can be toxic. (R5) should have never been given that much calcium.
The Immediate Jeopardy was identified on 2/23/24. V1 (Administrator) and V3 (Administrator in Training) were notified of the Immediate Jeopardy on 2/23/24 at 09:30 am.
The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy:
On 2/27/24, V1, Administrator, provided copies of Staff In-Services Attendance Sheets, dated 2/24/24 with indication that education in the following areas was provided to nursing staff on the facility's policy and protocol for lab monitoring of high risk medications, notifying the Physician of a change on condition on any resident and notification to physician and conformance with physician order by V18, Cooperate Director of Clinical Services.
R11's medical record was audited for completeness on 2/26/24 by V24, Regional Clinical Nurse.
The facility's Quality Assurance Audit Form have been implemented to monitor and ensure that the IDT team including a nurse will review all admissions for high risk medications during Quality Assurance meetings. The IDT team including a nurse will review all admissions for lab orders. V24 or designee will follow the quality assurance monitoring program of high risk medications and labs twice weekly for three months.
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
Notification of Changes
(Tag F0580)
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 notify physician of abnormal laboratory results, a change in conditi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify physician of abnormal laboratory results, a change in condition and a medication error for two of 13 residents (R11 and R13) reviewed for physician notification in a sample of 42. This failure resulted in R11 being admitted to the hospital with a critical PT (Prothrombin level/normal 9.8-12.2 seconds) and INR (International Normalized Ratio/normal range 0.9-1.2 milligrams per deciliter).
Findings include:
The facility's Notification for Change in Resident Condition or Status policy, revised 12/7/17, documents the facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON, (Director of Nursing), Physician, Guardian, HPOA (healthcare power of attorney) of changes in the resident's medical/mental condition and/or status.
1. R11's was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation. R11 also had an order to take Warfarin (anticoagulant) 5mg (milligrams) every evening. R11's medical record did not have an order to complete laboratory work for a PT/INR (Prothrombin International Normalized Ratio) level.
R11's PT/INR dated 1/8/24, documents a high PT of 21.9 seconds and INR of 2.1mg/dl (milligrams per deciliter). R11's medical record has no documentation indicating R11's high PT/INR results were called to V17, (R11's Primary Care Physician). R11's Progress Notes, dated 1/18/24 at 6:45pm, documents R11 has had three episodes of epistaxis (a bleeding nose). R11's Progress Notes at 9:30pm, document R11's epistaxis episodes around 8:40pm, R11 was observed with chest covered with blood and a bloody towel in his hand. Blood was running out from R11's left nostril like a faucet. R11 reported he felt lightheaded. R11's blood pressure was 88/44 (diastolic/systolic), pulse was 72, respirations 18 and pulse oximetry was 99 percent. V17 was notified and orders were received to send R11 to the emergency room for labs and start intravenous fluids.
2. R13's Monthly Medication Review, dated 1/23/24, documents (R13's) medical record documents the following irregularities were noted on the medication administration record (MAR)/prescriber order sheets (POS): 1/16/24 (R13) had Eliquis 2.5mg BID (twice daily) ordered but the pre-existing 5mg BID dose was not stopped.
R13's Medication Administration Record, dated 1/16/24, documents to take Eliquis 5mg tablet twice daily and Eliquis 2.5mg twice daily. R13's MAR has each medication signed out as being given on 1/19/24 through 1/23/24. R13's MAR documents R13's Eliquis 5mg was discontinued at 1:08pm.
On 2/20/24 at 12:00pm, V17 (R11's Primary Care Physician) stated he was not notified of R11's PT/INR results on 1/8/24, when an elevated PT/INR results were obtained. V17 also stated he was not notified of R11's bloody nose until the evening he gave the orders for R11 to be sent to the emergency room. V17 also stated he was not notified R13 received the wrong dose of Eliquis in January.
On 2/20/24 at 3:00pm, V2, Director of Nursing, stated R11's medical record does not have any documentation V17 was notified of R11's abnormal labs or bloody nose. V2 also verified V17 was not notified of R13's medication error.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R5 and R12) on the sample of residents reviewed for medi...
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Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for two residents (R5 and R12) on the sample of residents reviewed for medication pass. This failure resulted in two medication errors out of twenty- five opportunities for error, for an 8% medication error rate.
FINDINGS INCLUDE:
The facility policy, Medication Administration, dated (revised) 11/18/2017 directs staff, Medications must be administered to the right resident, right dose, right drug, right consistency, right time, right route and right documentation. If the medication is not available for a resident, call the Pharmacy and notify the physician when the drug is expected to be available.
1. R5's current Physician Order Sheet, dated February 2024 includes the following medications: Calcium 600 MG (milligrams) with Vitamin D 800 MG two tablets by mouth daily for supplementation and Oyster Shell Calcium 500 MG three tablets daily for supplementation.
On 2/15/2024 at 9:18 A.M., V11/Licensed Practical Nurse prepared to administer medications for R5. After adding Tylenol 325 MG two tablets, Vitamin E 400 MG one tablet, Calcium 600 MG with Vitamin D 800 MG two tablets, Eliquis 5 MG one tablet, Folic Acid 1 MG one tablet, Gabapentin 100 MG one tablet, Letrozole 2.5 MG one tablet, Multivitamin with minerals one tablet, Senna 8.6 MG one tablet, Protonix 40 MG one capsule, Tamsulosin 0.4 MG one tablet, Topamax 50 MG one tablet, Tricor 145 MCG (micrograms) one tablet, Effexor 37.5 MG one tablet, Effexor 75 MG one tablet, Vitamin B12 500 MCG one tablet and Oyster Shell Calcium 500 MG three tablets to the plastic medication cup, V11/LPN stated, I don't know why (R5) gets so much calcium. That's like a double or triple dose. V11/LPN then administrated R5's pills, with the Calcium and Oyster Shell Calcium, to R5.
2. R12's current Physician Order Sheet, dated February 2024 includes the following medications: Pilocarpine 5 MG one tablet daily.
On 2/15/2024 at 11:32 A.M., V10/Registered Nurse prepared to administer medications for R12. V10/RN reached into the medication cart to withdraw Pilocarpine 5 MG one tablet. At that time, V12/RN stated, I don't have any Pilocarpine to give (R12). The pharmacy will hopefully deliver it tonight.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 31 of 31 residents, (R3, R4, R5, R8 and R11-...
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Based on observation, interview and record review, the facility failed to perform the required nurse shift to shift controlled substance reconciliation for 31 of 31 residents, (R3, R4, R5, R8 and R11- R37) reviewed for controlled substances, in a sample of 42.
FINDINGS INCLUDE:
The facility policy, Controlled Substances, dated (reviewed) 3/16/23 directs staff, It is the policy of the facility that all drugs listed as Schedule II drugs are subject to specified handling, storage, disposal and record keeping. The drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. These records shall be retained for at least one (1) year.
On 02/15/24 at 9:18 A.M., a review of the facility East Hall narcotic Shift Verification of Controlled Substances Sheet for February 2024, for residents residing in the facility North East and East Wings, shows missing, nursing documentation, to confirm facility nurses performed the required shift to shift controlled substance reconciliation, on February 5, 6, 8, 9, 10, 11, 2024. On 9:20 A.M., a review of the facility [NAME] and North [NAME] Wings, shows missing documentation, to confirm facility nurses performed the required shift to shift controlled substance reconciliation, on February 1, 2, 3, 4,7, 8, 9, 10, 11, 12, 13, 14 and 15, 2024. At that time, V11/Licensed Practical Nurse confirmed the missing documentation.
A review of the facility Controlled Substances Proof of Use sheets for the facility, documents that R3, R4, R5, R8 and R11- R37 all receive a controlled substance from facility nurses.
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
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed develop and maintain policies and procedures for monthly drug regimen review and failed to act timely on pharmacy recommendations for eleven o...
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Based on interview and record review, the facility failed develop and maintain policies and procedures for monthly drug regimen review and failed to act timely on pharmacy recommendations for eleven of eleven residents (R4, R13, R19, R23, R28, R31, R38, R39, R40, R41 and R42) reviewed for pharmacy recommendations, in a sample of 42.
FINDINGS INCLUDE:
On 2/17/2024 at 1:30 P.M. the facility forms, (Pharmacy) Consultation Report, dated January 23, 2024 and signed by V19/Registered Pharmacist for R4, R13, R19, R23, R28, R31, R38, R39, R40, R41 and R42 (addressing missing diagnoses for medication, verification of correct dosages of medications, laboratory tests required for medication monitoring, duplicate pain medication therapy, parameters for blood glucose levels) were unsigned by the physician, indicating incomplete. At that time, V2/Director of Nursing stated, I'm not sure what our (facility) policy is for the monthly drug reviews. I haven't seen the recommendations from January (2024).
On 2/20/2024 at 12:00 P.M., V1/Administrator and V3/Administrator in Training stated they were told by V18/Registered Nurse/Corporate Director of Clinical Services, that the facility does not have a policy for staff to refer to, regarding monthly drug regimen reviews.
Jan 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for three residents (R1, R2 and R4) of three resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent abuse for three residents (R1, R2 and R4) of three residents reviewed for abuse in a sample of five.
Findings Include:
The Abuse Prevention policy dated 10/19/07, documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its resident, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure the facility is doing all is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. Abuse: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services are necessary to attain and/or maintain physical mental, or psychosocial well-being. This assumes all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Physical Abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment.
1. The Final Abuse Investigation Report sent to the (State Agency) dated 12/18/23, documents alleged verbal and physical abuse between R1 and R2. On 12/18/23 at 9:00 AM, R2 was in the hallway passing by R1. R1 started making delusional comments about prom to R2 and getting aggressive with his words. R1 then waved his fist at R2 and R2 threw water on R1.
R1's Medical Records documents R1 was admitted to the facility on [DATE] with a diagnosis of Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder.
R1's MDS (Minimum Data Set) dated 10/14/23 documents a BIMS (Brief Interview for Mental Status) Score of 5/15, indicating severe impairment.
R1's Behavior Note dated 12/18/23 at 9:21 AM documents R1 was threatening violence against R2 and staff and punching the walls.
R1's Behavior Note dated 12/18/23 at 9:45 AM documents R1 was in the hallway by V2 (Director of Nursing) office when R1 was speaking to R2 and began yelling at R2. R1 was then seen putting his fist up in front of his chest at R2. R1 told R2, R1 would not be going to the prom with R2 and making aggressive statements towards R2. R2 got upset and threw water on R1 and then grabbed R1's arm.
R1's Social Service Note dated 12/18/23 at 1:26 PM documents R1 was in the hallway by V2's office when he was speaking to R2 and began yelling at R2. R1 was then seen putting his fist up at R2. R2 got upset and threw water on R1 and then R2 grabbed R1's arm.
R1's Plan of Care Note dated 12/19/23 at 1:05 PM, documents the Quality Assurance Team met and reviewed the alleged abuse incident. R1 was in the hallway passing R2 when R1 started making delusional comments about prom to R2 and getting aggressive with his words to R2. R1 then waved his fist at R2 and R2 threw water on R1.
R2's Medical Records documents R2 was admitted to the facility on [DATE] with a diagnosis of Schizoaffective Disorder, Unspecified Psychosis not due to a Substance or known Physiological Condition, Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance.
R2's MDS dated [DATE] documents a BIMS Score of 8/15, indicating moderate impairment.
R2's Care Plan documents R2 is known to display and has a history of paranoid thoughts/behaviors and/or open conflict/criticism with others including false accusations. R2 is/has potential to be verbally aggressive towards staff and others related to Dementia, Ineffective Coping Skills, and Poor Impulse Control.
R2's Behavior Note dated 12/18/23 at 9:45 AM documents R2 was in the hallway by V2's office when R1 began yelling and was seen putting his fist up in front of his chest at R2. R1 told R2 he would not be going to the prom with R2 and making aggressive statements towards R2. R2 got upset and threw water on R1who was yelling at R2 and R2 then grabbed R1's arm.
R2's Social Service Note dated 12/18/23 at 1:09 PM documents R2 was in the hallway by V2's office when R1 began yelling at R2 and R1 put his fist up at R2. R2 got upset and threw water on R1 who was yelling at R2 and then R2 grabbed R1's arm.
R2's Plan of Care Note Dated 12/19/23 at 1:29 PM documents the Quality Assurance Team met and reviewed the alleged abuse incident. R2 was in the hallway passing R1 when R1 started making delusional comments about prom to R2 and R1 was getting aggressive with words to R2. R1 then waved his fist at R2 then R2 threw water on R1.
On 1/5/24 at 3:28 PM, R2 stated I told (R1) to leave me alone. (R1) kept saying I love you. I told (R1) to leave me alone. (R1) said he had a dream about me, and I threw water on (R1).
On 1/5/24 at 2:30 PM, V1 (Administrator in Training) stated R1 has dementia and delusions and R1 thinks he went to school with R2. R1 thought R2 asked him to the prom, and R1 did not want to go with R2. R2 was coming out of the dining room and R1 was standing there. R1 said to R2 he would not go to the prom with R2 because R2 was the ugliest girl in school. V1 was in V2's (Director of Nursing) office and heard R1 and R2 yelling at each other. V1 rushed out and R1 had his fist in the air like he was going to hit R2. R2 had already thrown water on R1. V1 did not see R2 throw the water but there was water on R1's shirt.
On 1/5/24 at 2:45 PM, V2 (Director of Nursing) stated V3 (R1's Power of Attorney) is furious there was any interaction between R1 and R2. Evidently there was an incident happened about a year ago when R2 stabbed R1 in the arm with a fork. V3 does not want R2 around R1 at all and wants us (the facility) to make R2 leave the facility. R2 was just leaving the dining room and R1 was the aggressor. R2 did throw a glass of water on R1, and R2 should not have done.
On 1/4/24 at 2:46 PM, V3 (R1's Power of Attorney) stated R1 has dementia, and V3 is upset the facility does not keep R2 away from R1. V3 is not sure of what happened between R1 and R2 but was told R1 had his fist raised at R2 and R2 threw water on R1.
2. The Final Abuse Investigation Report sent to the (State Agency) dated 12/15/23, documents alleged physical abuse between R2 and R4. On 12/15/23 at 2:00 PM, R2 with a BIMS score of 10 allegedly struck R4 who has a BIMs score of 13. R4 allegedly bumped into R2 with R4's motorized wheelchair instead of going around R2. When R4 struck R2, R2 allegedly struck R4 in the leg in reaction to getting bumped by R4 in R4's motorized wheelchair.
R2's Social Service Note dated 12/15/23 at 12:59 PM, documents R2 was in the front desk area when R2 asked R4 to move out of R2's way. R4 refused to move and hit R2 with R4's electric wheelchair. R2 wheeled her chair towards R4 and hit R4 twice, once in R4's knee and once in R4's stomach.
R2's Incident Investigation Form dated 12/15/23 documents R2 stated R4 hit R2 with R4's wheelchair so R2 hit R4 in the leg to get R4 to stop hitting R2.
R2's Plan of Care Note dated 12/18/23 at 8:51 AM, documents the Quality Assurance Team met to review the incident on 12/15 when R4 ran into R2 with R4's wheelchair. R2 then struck R4's leg.
On 1/5/24 at 3:28 PM, R2 stated R2 was in the TV/Television room and told R4 to go around the other way because there was not enough room for R4 to get past R2. R4 ran R4's wheelchair into R2 and hit R2's legs. R2 hit R4 with R2's fist on top of R4's leg. (R2 made a fist and demonstrated how she hit R4)
R4's Medical Records documents R4 was admitted to the facility on [DATE] with a diagnosis of Borderline Personality Disorder, Bipolar Disorder, Current Episode Manic without Psychotic Features, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side.
R4's MDS dated [DATE] documents a BIMS Score of 13/15, indicating intact cognition.
R4's MDS dated [DATE] documents verbal and physical behaviors towards others one to three days.
R4's Social Service Note dated 12/15/23 at 1:23 PM documents R4 was in the Front Desk area when R2 asked R4 to move so R2 could get through. R4 refused to move, and R4 then hit R2 with R4's electric wheelchair. R2 approached R4, hitting R4 in R4's knee and stomach.
R4's Incident Investigation Form dated 12/15/23 documents R4 stated R4 did run into R2 and R2 hit R4's leg. R4 would not say anything further as R4 stated she was upset.
On 1/5/24 at 4:40 PM, R4 stated I don't like that (R2) hit my leg. I have no idea why (R2) hit me. (R2) said I looked at her wrong. I don't remember the date, but it was in December.
On 1/5/24 at 3:10 PM, V2 stated on 12/15/23 she was doing weights in the TV (Television) room. R2 was close to the doorway and R4 was trying to come into the room in R4's electric wheelchair. V2 asked R4 to go the other way but R4 refused and ran into R2 with R4's electric wheelchair. R2 then hit R4 in the leg for running into R2. R4 has behavior problems and does things for attention.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide incontinent care for two residents (R3, R5) of three 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 incontinent care for two residents (R3, R5) of three residents reviewed for incontinent care in a sample of five.
Findings Include:
Certified Nurse's Aide Job Summary (not dated) documents that the Certified Nursing Aide/CNA provides care and assistance to residents to assure their safety and comfort. The CNA carries out basic hygiene measures includes cleaning incontinent residents.
On 1/6/24 at 3:15 PM, V1 stated the facility does not have a policy on incontinent care. The facility was hacked a few months ago and lost all the policies.
1. R3's Medical Records documents R1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Sequel of Cerebral Infarction, Perforation of Intestine (non-traumatic), Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Intervertebral Disc Degeneration, and Hypertension.
R3's MDS (Minimum Data Set) dated 12/8/23 documents a BIMS (Brief Interview for Mental Status) Score of 15/15, indicating cognition intact. R3 needs assistance with Activities of Daily Living and is always incontinent of urine.
On 1/5/24 at 2:54 PM, V2 stated she is aware of the incident when R3 was not changed, and it did happen. V2 stated (R3) has a community pass to go out of the facility. It is not uncommon for him to be gone for several hours and when he returns, he needs changed immediately. (R3) had returned to the facility around supper time on 12/27/23. V2 said V2 was in her office doing paperwork and R3 came to her office around 8:30 PM to say he had not been changed for hours and wanted to go to bed. V2 said V2 went to the hall and found the staff sitting around the desk. V2 instructed the staff to put R3 to bed and change him. V2 said V2 slept in the conference room on the couch night. Around 2:30 AM V2 went to the hall and saw staff again sitting at the desk. V2 asked if the rounds had been done at 2:00 AM and was told they had just done them. V2 told the staff she was going to do skin checks and found several residents were wet. V2 said that was the night after the Resident Council Meeting (12/27/23) when the residents complained the staff were not doing rounds.
On 1/5/24 at 8:25 AM, V4 (Ombudsman) stated she got a call from R3 because he was wet and not getting changed. R3 is alert, oriented and can make his needs known. V4 said R3 is usually in a good mood and does not complain unless there is a problem.
On 1/5/24 at 3:42 PM, R3 stated There are times it takes hours before anyone will change me. I have talked to (V4/Ombudsman) a couple of times, and she said she will take care of it for me. They never check on me. I have to put the call light on. I got mad one time and yelled, and I told them I needed changed. I have also had to get (V2/Director of Nursing) to get someone to change me.
2. R5's Medical Records documents R5 was admitted with diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia, Hypertension, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Generalized Anxiety Disorder, Acquired Absence of Right Leg Below Knee, Acquired Absence of Left Leg Below Knee.
On 1/5/24 at 4:19 PM, R5 stated she is always incontinent of bowel and bladder. Soon after she admitted to the facility, she had a problem with V5 (CNA) on the night shift. R5 said R5 had put her call light on around midnight. About 1:00 AM, V5 came into the room and shut the light off. R5 said she told V5 she needed to be changed. V5 said she was going to find a (disposable brief) and she would be back. V5 did not come back until about 6:00 AM.
On 1/5/24 at 4:25 PM, V6 (R5's Power of Attorney) stated right after R5 came to the facility V6 was talking to R5 on the phone and R5 said she was wet, waiting for her call light to be answered. About 1:00 AM, V6 heard V5 say she was going to get a (disposable brief) and would be back. V6 pulled her phone out and read a text she had sent to R5 at 2:16 AM, asking if anyone had come back to change R5. R5 had stated No. At 3:00 AM, V6 got a text from R5 Still hasn't come back. At 4:40 AM, V6 text R5 to ask if they had taken the wet (disposable brief) off and R5 replied No. V6 also stated It is not right R5 was left wet all night. I called V2 (Director of Nursing) and V5 was fired.
On 1/5/24 at 2:54 PM, V2 stated the early morning of 12/26/23 she had a complaint from V6 (R5's Power of Attorney) V5 (Certified Nursing Assistant) would not provide incontinent care for R5 during the night. V6 called V2 at home and stated at 1:00 AM she had been on the phone with R5 and heard R5 tell V5 (Certified Nursing Assistant) she needed to be changed. V5 stated she needed to go find a (disposable brief). V5 did not return until 5:56 AM to change R5. When V2 got to the facility she interviewed R5 and V6. R5 confirmed around 1:00 AM, she had put her call light on to be changed. V5 came to the room and shut the light off. V5 said she would need to find a (disposable brief) and would be back. V5 did not return until around 6:00 AM. V2 stated rounds are supposed to be done at least every two hours and as needed. It was not acceptable V5 did not do incontinent care for R5, and she was fired. V2 said the rounds are now being done correctly but it was not being done that way.
On 1/5/24 at 3:15 PM, V1 stated the last time V5 worked was 12/26/23. V5 was fired due to not providing incontinent care for R5.
An Incident Investigation Form dated 12/26/23 at 10:00 AM documents a Staff Incident. V2 (Director of Nursing) interviewed V6 (R5's Power of Attorney). V6 stated R5 turned her call light on at around 1:00 AM. A Certified Nursing Assistant came in and V6 heard (on the phone) the CNA tell R5 she had to find a (disposable brief). The CNA did not return until 6:00 AM to change R5. V2 also interviewed R5. R5 stated she turned her call light on at 1:00 AM. A CNA came and told R5 she was going to find a (disposable brief). The CNA did not return until around 6:00 AM.
A Supervisor Report of Counsel Form written by V2 (Director of Nursing) dated 12/26/23 on V5 (Certified Nursing Assistant), documents (R5) turned on her call light to be changed at 1:00 AM. (V5/Certified Nursing Assistant) returned to change (R5) at 6:25 AM. After speaking with V6 and R5, V5 will be terminated.
Resident council meeting minutes dated 12/27/23 at 10:22 AM documents, Nursing needs to get their act together. They are not doing two-hour rounds on 3rd shift.
Dec 2023
7 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pressure Ulcer Prevention
(Tag F0686)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10-17-23 R6's Initial Wound Evaluation and Management Summary signed by V19 (Wound Physician) documents R6 presented with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10-17-23 R6's Initial Wound Evaluation and Management Summary signed by V19 (Wound Physician) documents R6 presented with a wound on R6's left heel and a rash. A stage III (three) pressure wound of the left, medial heel full thickness. Wound size 2cm x 3.5cm x 0.2cm. Exudate: Light Serous-Sanguineous. Expanded Evaluation Performed: The development of this wound and the context surrounding the development were considered in greater depth today. Relevant conditions including infection considered and address through treatment changes or investigations. Dressing treatment plan: Primary dressing(s)- Xeroform gauze apply once daily for 30 days. Secondary dressing(s) ABD (Abdominal Pad) apply once daily for 30 days; Gauze roll (kerlix) 2.25 inches apply once daily for 30 days. Recommendations: Float Heels in Bed; Off-Load Wound; Reposition per facility protocol; (heel protector). Other Diagnosis: Cellulitis of the left foot. Duration: At least 1 day(s). Additional treatment information: Recommend Tetracycline 500 mg (milligrams) PO (by mouth) BID (twice a day) for 14 days. Probiotics daily for 30 days. Clinical data and material reviewed: Deep swab technique performed on stage three pressure wound of the left, medial heel on 10-17-23.
R6's current POS (Physician Order Sheet) documents R6 has diagnoses of, but not limited to, Type Two Diabetes Mellitus without Complications, Hypertension, Major Depressive Disorder, Cerebral Infarction, Paralytic Ileus, Muscle Weakness, Heart Failure, Chronic Congestive Heart Failure, and other lack of coordination.
R6's most recent completed MDS (Minimum Data Set) assessment dated [DATE] documents R6 had no pressure ulcers and is at risk for pressure ulcers. This same assessment documents R6 requires extensive assistance with one staff member for bed mobility, and dependent assistance with two staff members for transfers and toileting.
R6's Braden Scale for Predicting Pressure Ulcer Risk (completed prior to pressure sore development) dated 5-15-23 documents, Activity: 2. Chairfast- Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Mobility: Very limited- Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Skin Treatment Review: Indicate all used in last 7 days: Float Heels- No. This same assessment documents R6 has a score of 14 (high risk for developing pressure sores).
R6's Current Care Plan last revised 11-21-23 does not include a skin management or wound care management plan of care prior to wound development (to prevent pressure wound) with interventions. This same plan of care does not include the wound development with interventions (to prevent wound from worsening).
R6's MAR (Medication Administration Record) dated 10-01-23 to 10-24-23 documents an order for Tetracycline 500 mg capsule by mouth two times a day for wound infection until 11-2-23, with a start date of 10-19-23, two days after V19 Wound Physician recommended the order for an infection to the left heel on 10-17-23.
R6's TAR (Treatment Administration Record) dated 10-01-23 to 10-24-23 does not document a treatment to apply xeroform gauze daily for 30 days, ABD pad daily for 30 days, or kerlix daily for 30 days to R6's left heel as ordered per V19 Wound Physician on 10-17-23.
On 10-24-23 R6's Wound Evaluation and Management summary signed by V19, Wound Physician, documents R6 had a stage III pressure wound of the left, medial heel full thickness. Wound size 2cm x 3cm x not measurable cm. Peri-wound radius: Odor. Exudate: Moderate Serosanguinous. This same summary documents a diagnosis of Cellulitis to the left foot. Progress: Not improved. Recommend d/c (discontinue) Tetracycline and start Bactrim DS (Double strength) BID (twice daily) for 14 days. Levaquin 500 mg PO (by mouth) daily for 14 days. Probiotics daily for 30 days (based on culture report). Deep swab technique of stage III pressure wound of the left, medial heel demonstrates Pseudomonas Aeruginosa and MRSA (Methicillin-resistant Staphylococcus aureus) on 10-24-23. Dressing treatment plan: Add Gentamicin ointment daily for 30 days, Alginate Calcium daily for 30 days, ABD pad daily for 23 days, and Kerlix daily for 23 days. Discontinue Xeroform Gauze.
On 11-7-23 R6's Wound Evaluation and Management summary signed by V19 Wound Physician documents (R6's) pressure sore of the left medial heel has now worsened from a stage III to a stage IV.
R6's TAR dated 10-24-23 to 11-7-23 documents an order to apply Gentamicin Ointment BID to left heel, calcium alginate- silver BID to left heel and cover with an island dressing. These same orders were not started and signed off in the TAR until 10-25-23. From 10-25-23 to 11-07-23, five treatments were not signed as completed on R6's pressure ulcer, causing it to worsened from a Stage III to a Stage IV.
R6's TAR dated 11-16-23 to 12-12-23 documents an order to apply Gentamicin Ointment every night to left heel, calcium alginate-silver every night to left heel and cover with an island dressing. From 11-16-23 to 12-12-23, ten treatments were not signed out as completed.
R6's TARs dated 10-1-23 to 12-13-23 does not document an order for a daily skin check per policy despite having a facility acquired left heel pressure ulcer and a high-risk Braden Assessment score.
R6's progress notes dated 10-1-23 to 12-13-23 does not include any documentation of R6's facility acquired left medial heel pressure sore including size, appearance, signs and symptoms of infection, etc.
R6's MARs and TARs dated 10-1-23 to 12-13-23 does not include an order to monitor left heel pressure sore for signs and symptoms of infection.
R6's Weekly Wound Tracking documents left heel wound measurements on the following dates: 10-17-23, 10-24-23, 10-31-23, 11-7-23, 11-14-23, 11-21-23, and 11-28-23. No further measurements to R6's left heel wound were documented after 11-28-23.
On 12-13-23 at approximately 9:55 AM, V5 Agency LPN (Licensed Practical Nurse) prepared treatment for R6's facility acquired left heel wound. R6 was lying in bed with both heels elevated on a pillow. V5 LPN removed R6's dressing to the left heel with gloves. R6's left heel had a quarter-size pink area with a scant amount of light pink drainage and slight redness around the wound. V5 took off his soiled gloves and without sanitizing his hands put on new gloves before applying R6's treatment. V5 verified he did not use hand sanitizer or wash his hands between glove changes. V5 stated, I should have applied hand sanitizer in between glove changes. V5 stated he does not document any assessment anywhere on the wounds he only initials in the TAR that the treatment was completed. Immediately after R6's treatment R6 stated, My left heel has caused me severe pain. I have told the staff that I am in pain, but they won't come back to give me anything. Occasionally, they will bring me back a Tylenol, but it's not often.
On 12/13/2023 at 1:30 PM, V2 DON (Director of Nursing) confirmed there was no skin assessment completed for the month of October 2023 upon identification of wound of the left heel.
On 12-14-2023 at 9:20 AM, V14 (R6's Primary Physician) verified R6's facility acquired left heel pressure sore could have been avoidable if prior wound interventions were put into place and could have been avoidable from worsening if facility would have followed V19's Wound Physician orders, provided the treatment as ordered, and implemented/followed wound interventions. V14 stated if the facility is not following their wound care protocol and a resident's wound treatment is not completed as ordered the wound can worsen.
On 12-14-23 at 10:54 AM, V9 Assistant Director of Nursing/ Wound Nurse stated, I am unsure of the exact date R6's left heel pressure sore had developed. I know it was approximately one week prior to the (V19) Wound Physician seeing (R6). (V20, CNA) found the area to the left heel when the CNA was getting (R6) dressed and reported it to an Agency Nurse (V21) that no longer works at the facility, around 10-11-23. I can't remember who the CNA was that found it. I did not see (R6's) left heel pressure wound until that Saturday 10-14-2023. I looked at the wound but did not document on the wound or fill out any papers regarding (R6's) left heel pressure sore. (V21) who was initially made aware of (R6's) newly identified skin issue should have filled out an initial skin report, measured the wound, assessed/documented on the wound, initiated a daily skin check treatment, and notified (V14/R6's Primary Physician). V9 verified that an initial skin report had not been filled out, the wound was not initially measured, assessed/documented on, a daily skin check was not put in place, and the physician was not notified. V9 also stated that R6's left heel pressure sore was facility acquired and no treatment orders or interventions were put in place when R6's pressure wound was identified until the V19 (Wound Physician) evaluated R6 on 10-17-23. V9 stated, (V19) Wound Physician wrote treatment orders on 10-17-23 but the order did not get processed, and no treatments were performed on (R6's) left heel pressure sore during that time until (V19) Wound Physician came back on 10-24-23 and wrote new orders. We (the facility) sometimes have a delay with processing (V19's, Wound Physician) orders because we are too busy. I did wound measurements on (R6's) left heel pressure sore from 10-17-23 to 11-28-23 but have not measured (R6's) left heel wound since that date. I have been too busy over the past two weeks to keep up, sometimes I can't even get the wound physician notes and new orders processed until a week or two later.
On 12-14-23 at 3:30 PM, V2 DON verified R6's had missing treatments on the TARs dated 10-1-23 to 12-13-23. V2 verified no care plan was in place with interventions for skin breakdown and after R6's pressure sore was identified. V2 stated, The staff should always wash/sanitize their hands between glove changes.
The Immediate Jeopardy was identified on 12/14/23. V1 (Administrator in Training) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 12/18/23 at 01:35 PM.
The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy:
On 12/20/23, V2 (Director of Nursing) provided copies of Staff Inservice Attendance Sheets (dated 12/18/23) with indication that education in the following areas was provided to V1 (Administrator in Training) and V2 (Director of Nursing) by V24 (Regional Nurse): Care Plan Updating Audit, Skin Assessment Audit, Assessment of Wounds/Wound Measurements, Identification of Wounds, Physician Notification of a Change in Wound Status, and Implementation of Interventions of Pressure Ulcers.
On 12/20/23, V2 (Director of Nursing) provided copies of Shower/Abnormal Skin Report Sheets which included documentation of skin assessments completed on all facility residents on 12/18/23.
On 12/20/23, V2 (Director of Nursing) provided copies of Braden Scale Assessments, which indicate risk for pressure ulcer development, completed on all facility residents on 12/19/23.
On 12/20/23, V2 (Director of Nursing) provided a copy of the facility's Weekly Wound Tracking Log (dated 12/19/23). V2 stated this log was made current once every resident in the facility had a skin assessment and a Braden Scale Assessment completed on 12/19/23.
On 12/20/23, V2 (Director of Nursing) provided copies of Staff Inservice Attendance Sheets (dated 12/18/23) with indication that education in the following areas was provided to all licensed nurses and Certified Nursing Assistants: Assessment of Wounds, Identification of Wounds, Physician Notification of a Change in Wound Status, and Implementation of Interventions of Pressure Ulcers.
On 12/20/23, the following staff members were interviewed and were knowledgeable regarding the recent education that was administered: V17 and V22 (Registered Nurses); V5 (local agency Licensed Practical Nurse); and V8, V13 and V18 (Certified Nursing Assistants).
On 12/20/23, V2 (Director of Nursing) provided a copy of the facility's resident roster with indication of their Braden Scale Assessment scores. V2 stated residents with a score of 17 or higher receive weekly skin checks, and residents who scored 16 or below receive daily skin checks. V2 also provided a copy of the current skin check order for all facility residents dated 12/19/23.
On 12/20/23 at 09:45 AM, V1 (Administrator in Training) stated ongoing compliance will be monitored and discussed daily amongst V1 and the members of the interdisciplinary team. V1 stated the facility's Quality Assurance meeting to discuss wounds is scheduled to be conducted on 12/21/23.
On 12/20/23, V2 (Director of Nursing) provided copies of R6's current Treatment Administration Record with indication that all wound treatments have been completed as ordered as of 12/19/23.
On 12/20/23 at 1:55 PM, V2 provided a copy of the following: R6's current Care Plan, which has been revised with pressure relieving interventions; R6's Treatment Administration Record; and R6's Pain Assessment (dated 12/18/23). No pain was reported by R6 at that time. V2 stated R6's wound measurements are current on the facility's wound log and no new orders were written by V19 (Wound Physician) when R6 was seen on 11/21/23. V2 stated R6 has completed the duration of her antibiotic therapy that was prescribed for R6's wound infection.
On 12/20/23, V2 provided R6's Full Body Skin Assessment (dated 12/18/2023).
On 12/20/23, V2 provided a copy of R1's Care Plan with new revisions including pressure relieving interventions.
On 12/20/23 at 2:00 PM, V2 stated R4 is still hospitalized and indicated that upon R4's return to the facility, R4's Pressure Ulcer Care Plan will be updated, and the physician orders accompanying R4 from the hospital will be entered into R4's medical record immediately.
On 12/21/23, V2 provided a copy of the facility's Quality Assurance Audit Form. This form documents the following: A weekly audit is in place to ensure the Wound Log is current, and it was completed 12/19/23; A weekly Quality Assurance meeting is in place, and the first meeting was conducted the morning of 12/21/23; A daily audit of all resident TAR's (Treatment Administration Record) is in place and has been conducted daily since 12/19/23.
Based on interview, observation and record review, the facility failed to identify, assess, report and treat a facility-acquired pressure ulcer for one resident (R6); failed to administer wound treatment as ordered using proper infection control technique; failed to develop and implement pressure relieving interventions or care plan; failed to conduct a pressure ulcer development risk assessment for a resident identified as high risk for pressure ulcer development; and failed to develop a pressure ulcer care plan after a pressure ulcer developed for three of three residents (R1, R4, R6) reviewed for pressure ulcers in the sample of nine.
These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/19/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice training and Quality Assessment oversite.
Findings include:
The facility's Skin Care-Wound Care- Teaching Protocols dated 4/07 document, CNAs (Certified Nursing Assistants): Skin check with ADLs (Activities of Daily Living) and 100% (percent) Skin check with bath/shower. Report any changes in skin to the charge nurse. Report problems noted with wound or treatment coverings to charge nurse. Float heels while in bed. Document interventions on CNA Flow Sheet. Read care plan-Report interventions not on care plan to Care Plan Coordinator. Charge Nurse: Complete Interventions as listed for Prevention Protocols: Report wound area to physician during same shift discovered whenever possible. Obtain order for treatment of wound. Order to include: Method of Cleansing, type of treatment, specific location of area to be treated, type of dressing or leave open to air, frequency of how treatment is performed, treatment ending date. Assess for pain, notify physician as necessary and intervene as necessary to minimize pain, Initiate daily skin check on TAR (Treatment Administration Record) per score risk, Complete weekly assessment of wound to include wound locations, size in cc (centimeters), shape, color, depth, and presence of drainage, necrotic tissue granulation present, Initiate nursing intervention and place on TAR as necessary (Door Flag, specialty mattress, specialty chair, float heels, elevate legs, apply lotion, barrier cream ), Communicate new interventions and orders obtained to nursing office via the New Acquired Skin Condition Report, Document on Nurses' Note notification, interventions and current condition/wound description, Notify the physician of any changes in skin integrity or lack of progress. MDS (Minimum Data Set) Coordinator: Ensure Braden completed on newly acquired wound and PRN (as needed), Ensure care plan completed for presence of wound and new interventions including treatment, Ensure CNAs and nurse understand C/P (Care plan) interventions and documentation supports MDS and C/P. Director/Assistant Director of Nursing: Ensure inclusion of necessary interventions for prevention and treatment based on standards of practice and P&P (Policy and Procedure), Ensure completion and documentation of daily skin checks on TAR, Insure completion of weekly progress note includes wound location, size in cc, shape, color, depth and presence of drainage, necrotic tissue, granulation present, Ensure treatment completed as ordered, Ensure proper infection control technique is observed, Ensure physician notification of changes in skin integrity, presence of signs and symptoms of infection and/or lack of healing progress, Ensure completion of care plan and coordination of care by interventions listed. Administrator: Ensure above parties listed complete tasks as delegated, Review TARs to determine compliance with above tasks, Review MDS, Care Plans and charting to determine compliance with regulation.
The facility's Skin Care Prevention-Teaching Protocols, dated 04/07, documents to complete Braden Risk Assessment on admission. Inspect skin head to toe first three shifts after admission-document results in nurse's notes. Complete Nursing admission Assessment. Obtain order for prescriptions as needed for prevention (Vitamin/Mineral Supplements, antibiotic creams/ointments, prescription creams .)
The facility's Treatment Protocol Guidelines Policy undated documents, Always maintain a clean field- Sterile if ordered, Wash hands after removing old dressings, cleansing and before applying new dressings, Sanitizer should be rubbed in for at least 30 seconds, Document the treatment on the TAR immediately upon completion, Document treatment progress at least weekly, Notify the Physician if a treatment is not producing progress within 2 weeks of starting. This protocol also documents to follow the Treatment Administration Record for all cleansing, medication application and dressings.
1. R1's TAR, dated 9/17/23, documents a new order to cleanse R1's left gluteal wound, then apply Santyl External Ointment (debridement ointment) topically, cover with calcium alginate (medicated dressing) and secure with a border gauze every day and night shift. This treatment is not signed out as being completed on 9/23/23. This treatment was not signed out as being done 9/28/23 through 10/8/23.
R1's TAR, dated 10/8/23, documents to cleanse R1's right and left buttock wounds with normal saline, dry the wound, then apply Santyl ointment, cover with calcium alginate and a dry dressing. This treatment is not signed out as being done on 10/11/23, or from 10/16/23 through 10/27/23.
R1's Weekly Wound Tracking, dated 9/17/23, documents both R1's left and right buttocks wounds are stage III facility acquired wounds. R1's right buttock wound measuring 5.2cm (centimeters) x 3.7cm x 0.1cm (no treatment ordered for the right buttocks wound) and left buttock wound 5.5cm x 5.0cm.
On 9/26/23, R1's right buttock wound measured 6.0cm x 6.0cm x 0.0 cm and left buttock wound 5.5cm x 5.0cm x 0.0cm. On 10/5/23, R1's right buttock wound measured 6.0 cm x 5.5. cm x 1.0 cm and R1's left buttocks measured 5.5 cm x 4.5 cm x 0.5 cm. Both wounds documented as increasing in size.
R1's Weekly Wound Tracking, dated 10/10/23, documents R1's right buttock wound measured 6.0cm x 6.0cm x 1cm and left buttocks wound 6.0cm x 6.0cm x 2cm. R1's right buttocks wound measured 6.0 cm by 6.0 cm by 3.0 cm on 10/17/23, and his left buttocks wound measured 6.0 cm by 6.0 cm by 3.0 cm. On 10/24/23, R1's right buttocks measured 6.0 cm by 6.0 cm by 5 cm and the left buttocks wound measured 6.0 cm by 6.0 cm by 4 cm. Both wounds increasing in size.
R1's Progress Notes, dated 10/27/23 at 6:06 PM, document R1 has a temperature of 102.2 degrees Fahrenheit, 117 heart rate, and was sent to hospital for suspected sepsis.
R1's re-admission order sheet, dated 11/22/23, documents R1 was being treated for lower extremity paralysis, history of opioid abuse, infected ulcer of the skin, undifferentiated connective tissue disease, normocytic anemia, acute osteomyelitis of calcaneus, osteomyelitis of left side of pelvis, positive blood culture, hyponatremia, hypoalbuminemia. R1's admission orders document to cleanse R1's right and left gluteal/ischial wounds with normal saline and gauze, protect the perineal wound with a no sting barrier spray, then apply Sodium Hypochlorite moist gauze to the wound bed, cover with an ABD (abdominal gauze) and bordered dressing. Change twice a day and PRN (as needed).
On 12/11/23 at 1:00 PM, R1 stated the facility does not have the Sodium Hypochlorite (Dakin's) solution for his wound care. R1 stated his wounds on his bottom are not being done twice a day as ordered. R1 stated he just returned from a hospital stay because of his wounds being infected. R1 stated he is now on a long term intravenous antibiotic treatment because of the wound infections. R1 stated his wounds on his buttocks had to be surgically debrided.
On 12/12/23 at 1:15 PM, V17, Registered Nurse, washed her hands, then applied gloves. V17 un-taped R1's incontinent brief, soiled with a small amount of soft mushy BM (bowel movement). V17 removed the dressing from R1's right ischial wound. V17 sprayed the wound bed with wound cleanser, then used a gauze pad to wipe the inside of the wound. V17 soaked a roll of gauze in a glass of sterile water. V17 took the end of the sterile water-soaked gauze and packed it into R1's wound. V17 covered R1's wound packing with a calcium alginate and a foam dressing. V17 did not change her gloves or perform hand hygiene during this part of R1's wound care. V17 left, removed her gloves, then went to the bathroom to perform hand hygiene. V9, Licensed Practical Nurse/Wound Nurse, was assisting R1 to roll over on his side. V9 left R1 lying on the side of the bed and R1 rolled out of bed to the floor. V17 and V9 assisted R1 back to bed with the mechanical lift. V17 applied gloves and pulled back on R1's soiled brief. V17 attempted to place the calcium alginate dressing back in place, after it was out sitting on the soiled brief. V17 discarded the soiled calcium alginate dressing, applied a new calcium alginate to R1's wound, then covered the wound with a foam dressing. V17 performed hand hygiene then applied clean gloves. V17 removed the dressing on R1's left ischial wound. V17 cleansed R1's wound with wound cleanser, then wiped the wound out with gauze. V17 then soaked a roll of gauze in a cup of sterile water. V17 packed R1's wound with the sterile water-soaked gauze and covered it with calcium alginate, then a foam dressing. V17 and V9 then cleaned R1's BM covered buttocks.
On 12/12/23 at 2:10 PM, V17 verified she did not perform hand hygiene when moving from a soiled area to clean. V17 stated incontinence care should have been done prior to the wound care. V17 stated she did not do R1's wound care as they were ordered. V17 verified the facility has been out of Sodium Hypochlorite for some time. V17 stated V9, Assistant Director of Nursing/Wound Nurse, told her to apply the calcium alginate over the gauze packing.
On 12/13/23 at 3:00 PM, V2, Director of Nursing, verified the only wound R1 had on admission was the burn to his left lateral lower leg. V2 also verified the facility is unable to get Sodium Hypochlorite (Dakin's) solution. V2 stated sterile water is not a substitute for the Dakin's solution. V2 stated all the Sodium Hypochlorite orders were to be changed to normal saline but were not. V2 verified R1's wound is to be cleansed with wound cleanser then the Sodium Hypochlorite-soaked gauze is to be packed in the left and right buttocks wounds, then covered with an ABD (Abdominal Pad). V2 stated she does not know where the calcium alginate or sterile water came from. V2 stated R1's incontinent care should have been done, prior to wound care being started. V2 stated hand hygiene is to be done when going from a dirty area to a clean area.
2. R4's admission Skin Assessment, dated 11/30/23, documents upon admission to the facility (11/30/23) an unstageable pressure injury to her coccyx, measuring 4.8 cm (centimeter) by 7.2 cm and a depth of 0.3 cm. The wound bed has slough with purulent drainage, with an odor.
R4's admission orders, dated 11/30/23, documents to cleanse R4's right gluteal wound with Sodium Hypochlorite (Dakin's) 0.125% solution, apply moist to dry gauze dressing using 0.125% Sodium Hypochlorite (Dakin's) solution.
R4's TAR (Treatment Administration Record), dated 11/30/23, does not have any pressure ulcer treatments documented as ordered.
R4's TAR, dated 12/1/23 through 12/6/23, does not have wound care or pressure ulcer orders transcribed or documented as being done as ordered.
R4's Skin Check weekly, based on Braden, one time daily every Tuesday and Friday was not completed on 12/5/23.
R4's TAR, dated 12/7/23, documents to cleanse R4's left buttock wound with Dakin's (1/2 strength) then cover with a wet normal saline gauze and a dry dressing.
R4's Progress Notes, dated 12/8/23, at 12:05 PM, R4 was lethargic and vomiting, blood pressure is 69 (systolic)/59 (diastolic) and a pulse of 120 beats per minute.
R4's Progress Notes, dated 12/10/23, documents R4 is being admitted for wound debridement, intravenous fluids and unable to eat.
R4's hospital admission diagnosis, dated 12/8/23, documents sepsis secondary to infected sacral ulcer/urinary tract infection, urothelial metastatic cancer, physical deconditioning and encephalopathy.
On 12/13/23 at 3:00 PM, V2, Director of Nursing, stated R4's skin assessment was completed on admission, but the pressure ulcer and fall risk assessments were not completed as required. V2 stated R4 did not have an interim pressure ulcer care plan implemented. V2 also stated R4's admission wound care orders were not transcribed onto the TAR's. V2 verified R4's wound care was not done from 11/30/23 through 12/7/23. V2 stated if the TARs are not initialed, then the wound care is considered to not be done as ordered. V2 verified the wound measurements are not being done weekly as required. V2 stated she was not aware the skin issues were so bad until the state agency came in to investigate.
On 12/14/23 at 9:20 AM, V9, Assistant Director of Nursing/Wound Care, stated she is having a hard time keeping up with the wound care duties because she is getting pulled to the floor to work all the time. V9 verified the floor nurses are responsible for doing treatments expect for when V19, Wound Physician, is in the building.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. On 12/12/23 at 01:15 pm, V17 (Registered Nurse) and V9 (Assistant Director of Nursing/Wound Nurse) were performing wound car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
2. On 12/12/23 at 01:15 pm, V17 (Registered Nurse) and V9 (Assistant Director of Nursing/Wound Nurse) were performing wound care to R1's right and left buttocks wounds. V17 left R1 lying on the side of the bed, while V17 performed hand hygiene. V9 was assisting R1 with maintaining his position on his left side, and R1 was lying along the edge of the bed. V9 asked R1 if he was ok in that position, and then proceeded to walk away from him. R1 then fell off the side of the bed, onto the floor, landing on his knees. V17 and V9 assisted R1 back to bed with the mechanical lift. Neither V17 nor V9 performed a full body assessment on R1 after he had fallen.
R1's current care plan documents that R1 is as risk for falls, due to gait/balance problems, history of falls, monoplegia of lower limb, musculoskeletal impairment. R1's current electronic medical record does not contain a fall risk assessment.
On 12/13/23 at 3:00 pm, V2, Director of Nursing, stated R1 should not have been left lying on the side of the bed alone.
On 12/14/23 at 9:20 am, V9 stated she should not have left R1 on the side of the bed unattended. V9 verified R1 does have a history of falls.
3. R4's Progress Notes document R4 was admitted to the facility on [DATE], and documents that on 12/01/23, R4 verbalized reports of feeling, so weak. R4's medical record does not have a fall risk assessment or an interim fall risk care plan in place. On 12/7/23, R4's Progress Notes document R4 was visualized on the floor next to her bed near the window with range of motion within normal limits and no visible pain. R4 was assisted back to bed.
On 12/13/23 at 3:00 pm, V2 (Director of Nursing) verified R4 did not have a fall risk assessment completed upon admission. V2 stated R4 did not have an interim fall prevention care plan.
Based on interview and record review, the facility failed to conduct a fall risk assessment and implement fall interventions for two of three residents (R1 and R4) and failed to ensure a resident (R2) was properly transferred with a mechanical lift. This failure resulted in the mechanical lift tipped over while R2 was in the sling resulting in fracture of the right distal tibia and required a surgical repair.
Findings include:
The facility's (mechanical lift) Owner's Manual (dated 2017) documents the following: Please note that the (mechanical lift) is designed to perform all types of lifts. It can be used as a bath lift in many situations. When used as a bath lift, we recommend using a (mechanical lift mesh bath sling). This same manual also documents, Lift Legs Position. Legs should be opened at the following times: To allow access around chairs, toilets or other impediments; To increase stability particularly with heavier patients; So, it is recommended to have legs open when lifting or lowering if possible though not required except as set forth below; Legs must be opened at the following times: For use with a walking harness; For patients who are active or swing around in the lift.
The facility's Fall Prevention policy (revised 11/10/18) documents to conduct a fall risk assessment on the day of admission, quarterly and with a change in condition. Identify, on admission, the risk for falls. All staff must observe residents for safety. If a resident with a high-risk code are observed up or getting up, help must be summoned or assistance must be provided to the resident. Assessment of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be high risk at the time of admission for up to 72 hours. The admitting nurse will determine the temporary risk category.
1. R2's current medical record documents R2's current diagnoses to include: Hemiplegia and Hemiparesis following cerebral infarction affecting right non-dominant side; and Muscle Weakness.
R2's current care plan documents the following focus: Alteration in transfer ability. Unable to transfer independently related to diagnosis of CVA (stroke) with right-sided Hemiparesis as evidenced by dependent on staff for all transfers. Resident Specific Information: (R2) requires the use of (mechanical lift) and staff assist of two to complete all transfers.
On 12/11/23 at 02:40 PM, V3 (Certified Nursing Assistant) stated she was present during the 12/06/23 transfer when R2 was injured. V3 stated, We had just given (R2) a shower, and we were transferring (R2) from the shower bed back into her bed. She transfers with a (mechanical lift), and we just left the sling underneath her during her shower, so it was really, really wet. (R2) was moving when she was lifted, and the entire lift tipped over in the middle of the transfer. She did hit her head and the entire right side of her body struck the wall pretty hard. The position of the sling was not centered, and it was very, very wet since she just had the shower. V3 stated the mechanical lift's legs were not opened to increase stability at the time of R2's fall. V3 added R2 has a deficit on her right side, and R2's right arm lost positioning during the transfer. V3 stated, She (R2) cannot hold her right arm across her chest for the entire transfer, so her arm did slide down, but she remained still enough for me to guide the sling.
On 12/11/23 at 04:05 PM, V4 (Certified Nursing Assistant) stated she was one of the staff members present when R2 sustained an injury during a mechanical lift transfer on 12/06/23. V4 stated, (V3, Certified Nursing Assistant) and I had just given (R2) a shower. We had transferred her to a shower bed for the shower, and we were transferring her back into her bed once her shower was completed. We did leave the mechanical lift sling underneath (R2) while we gave her the shower. It was not a shower sling, so it absorbed a lot of water, and there was water everywhere. I operated the controls, and (V3) was guiding (R2) while she was lifted in the sling. I had to leave the (stabilizing) legs closed because there just wasn't enough room to open them. When I pushed the mechanical lift toward (R2's) bed, the sling began swinging and then the entire lift tipped over. The top of the lift struck the wall. (R2) hit her head and her body struck the wall pretty hard. At that point, (V2, Director of Nursing) came in and took over. We put her back in bed once lifting help arrived. (R2) has a strong right sided deficit. She was adjusting her arms during the transfer because she cannot maintain her right arm positioned across her chest for very long. She was not flailing around. She was still enough for us to transfer. What made the lift fall was the momentum created from us moving the lift. I think they called 911 for additional lifting assistance. She was still in the facility when I left at the end of my shift.
R2's Incident Investigation (dated 12/06/23) documents the following: (R2) in (mechanical lift) following shower. (R2) was active in (mechanical lift) sling causing the (mechanical lift) to sway. Water dripping from sling during the transfer. The momentum and legs were not fully extended, caused the (mechanical lift) to tip over. 911 activated to assist with returning resident to bed. Again, assessed for injury by staff nurse. Neurological checks intact. Pain 3/10 in lower back. Later in shift resident noted to have increased swelling of extremity. V14 (R2's Physician) made aware and orders received for X-ray. (Local mobile X-ray provider) at facility to perform X-ray (fracture observed). Resident transferred to (local hospital) for evaluation. X-rays there confirmed closed fracture of the proximal fibula. This same investigation documents, Resident scheduled for surgery at this time. During surgery an open reduction internal fixation using intramedullary nail in distal tibia, and five screws to secure the fibula. Root Cause: Resident moving around in the (mechanical lift). Interventions: Resident will be educated about behavior in the (mechanical lift) upon return from the hospital. Nursing staff will be in-serviced on proper use of the (mechanical lift), which (mechanical lift) slings are appropriate for the transferring situation, weight limits for (mechanical lifts), and resident behavior in a (mechanical lift).
R2's (local hospital) medical record (dated 12/07/23) documents the following: R2 had an X-ray of her right tibia and fibula with the following impression: Distal Right Tibial Fracture. These same records document R2 had surgery on 12/08/23, and an intramedullary nail with five locking screws were inserted into R2's right tibia to stabilize R2's fracture.
On 12/12/23 at 03:50 PM, V2 (Director of Nursing) stated, The only correct thing that occurred with (R2's) transfer (on 12/06/23) was the correct (mechanical lift) was utilized, it was appropriate for her weight. The legs of the (mechanical lift) should have been fully expanded and locked for stability, and they were not. Never take the center of gravity away, or someone is going to get hurt. (V3 and V4, Certified Nursing Assistants) did not use the correct sling for the situation. Using a regular sling in the shower is going to absorb excess water weight, and water was dripping everywhere creating a fall hazard. They (V3 and V4) knew to use a shower sling but did not because they could not locate one. V2 then confirmed R2 has right-sided weakness and may not be able to maintain her arm across her chest for the duration of a mechanical lift transfer. V2 verified the newly implemented intervention of, Resident Education was not an appropriate intervention to implement for R2's mechanical lift transfers and indicated the failure came from the two staff members transferring R2. V2 stated, (R2) initially reported her pain at 3/10 around 04:00 PM on 12/06/23. At 06:00 PM, increased swelling was noted R2's right leg, and she was reporting increased pain. We ordered a mobile X-ray, and they were at the facility around 06:30 PM. As soon as the X-ray was taken, you were able to see an obvious break, so (R2) was sent to (local hospital) at 06:40 PM and is still hospitalized . She has not yet returned to the facility. The hospital identified a fracture in her right tibia. She had to have surgery to repair the fracture, and she had some hardware to stabilize the fracture.
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
Based on observation and interview, the facility failed to ensure call lights were answered in a timely manner for two of five residents (R5 and R9) reviewed for call lights in the sample of nine.
Fin...
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Based on observation and interview, the facility failed to ensure call lights were answered in a timely manner for two of five residents (R5 and R9) reviewed for call lights in the sample of nine.
Findings include:
On 12/11/2023 at 10:45 AM, V15 (Regional Administrator) verified facility does not have a policy regarding call light response times for staff to access.
1. On 12/12/2023 from 11:28 AM to 12:01 PM, R9's call light was observed to be on during this time. At 11:51 AM, V10 CNA (Certified Nursing Assistant) entered R9's room, shut R9's call light off, and then exited R9's room and left the hallway. At 11:52 AM, R9 was lying in bed covered up with a bed sheet. R9 stated, (V10) CNA came in and shut my call light off and said she would be right back. This happens all the time. Sometimes the staff member forgets to come back. I have had my call light on for around 25 to 30 minutes. I used the bed pan to have a bowel movement and needed assistance getting off the bed pan and cleaned up. It hurts and causes me pain to sit on a bed pan this long, but it is a constant thing. It takes staff one to two hours most of the time to answer my call light.
On 12/12/2023 at 12:01 PM, V10, CNA, confirmed she shut off R9's call light and told R9 she would be right back. V10 stated, We are short-staffed and have a hard time getting to the call lights timely. Sometimes we must shut off the resident's call light and come back to assist them when we get time.
2. On 12/12/2023 at 10:25 AM, R5 stated, It takes CNAs 30 minutes to two hours most of the time to answer my call light, especially on second shift. I must sit that long and wait to request my pain medication when I am in severe pain. The nurses are short-staffed as well, so that's why it takes them so long to get to all of us.
On 12/13/2023 at 3:10 PM, V2, DON (Director of Nursing), stated that call lights should be answered within two to five minutes and anyone in the building can answer a call light. V2 stated waiting 25 to 30 minutes for a call light is too long.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview, observation and record review, the facility failed to revise a care plan after a resident fall for one of three residents (R3) reviewed for falls in the sample of nine.
Findings in...
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Based on interview, observation and record review, the facility failed to revise a care plan after a resident fall for one of three residents (R3) reviewed for falls in the sample of nine.
Findings include:
The facility's Fall Prevention policy (revised 11/10/18) documents the following: Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.
R3's Fall Investigation (dated 12/08/23) documents R3 fell while trying to transfer himself off the toilet. This same investigation documents the following fall prevention intervention was implemented after R3's fall: Placed Call Don't Fall sign in (R3's) bathroom.
R3's current care plan has no mention of the fall prevention intervention that was implemented after R3's 12/08/23 fall.
On 12/13/23 at 03:10 PM, V2 (Director of Nursing) stated R3's care plan has not been updated with the fall prevention intervention from R3's 12/08/23 fall. V2 then added that due to the facility currently not having a Minimum Data Coordinator employed at the building, Care Plans haven't been getting updated as often as they should.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure showers were completed as scheduled and hygiene assistance was provided to a dependent resident for one of four reside...
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Based on observation, interview, and record review, the facility failed to ensure showers were completed as scheduled and hygiene assistance was provided to a dependent resident for one of four residents (R7) reviewed for ADL (Activities of Daily Living) assistance in the sample of nine.
Findings include:
The facility's Bath/Shower Policy dated 1/2018 documents, Policy: To ensure adequate hygiene needs are met. A bath/shower is scheduled for all resident in the facility at least weekly. Responsibility: All nursing personnel.
The facility's Shaving-Male or Female Policy undated documents, Policy: Resident will be free of facial hair- male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan. Responsibility: All nursing assistants, monitored by the charge nurse.
The facility's A.M. (Morning) Policy, undated, documents Policy: A.M. care will be given to all residents daily. Responsibility: All Nursing Assistants. Equipment: 7. Nail clippers, orange stick. 8. Razor, shaving cream, basin of warm water. Procedure: 12. Provide nail care. 13. Provide/assist with shaving (male and female) as needed.
The facility's Weekly Shower List indicates R7 receives showers on Monday and Thursday mornings.
The facility's Shower Tracking Log documents R7's last shower was given 11/18/2023.
On 12/11/23 at 12:37 PM, R7 was sitting in a wheelchair. R7's hair was unkempt and sticking up everywhere. Both of R7's hands had long fingernails extending past her fingertips with brown matter under her fingernails, and R7's chin was full of long white hairs. R7 was still in her pajamas and had a strong urine odor smell. R7 stated, I would like cleaned up in the mornings. They have not changed my clothes, combed my hair, cleaned, or clipped my fingernails, and have not shaved my chin today. I wanted it done this morning, but they say they don't have time. I don't remember the last time I even had a shower.
On 12/11/23 at 2:40 PM, V3 CNA (Certified Nursing Assistant) stated, We have been short staffed for the past couple of months. Day shift CNAs say they don't have time to do showers and want us second shift CNAs to do them. We haven't been able to do a lot of showers lately because of staffing needs.
On 12/12/23 at 2:20 PM, V5 LPN (Licensed Practical Nurse) and V9 Assistant Director of Nursing/Wound Nurse verified they had not received any shower sheets indicating resident's showers had been completed for that day so far. V5 LPN stated, When CNAs perform a shower on a resident, they fill out a shower sheet stating the shower was completed, Us nurses will sign them and then turn them in to (V2) DON (Director of Nursing.) I have not noticed any showers being given today.
On 12/12/23 at 2:23 PM, V2 DON stated, I track shower sheets to ensure residents are receiving showers. The last shower sheet I have received was on 11/18/2023 right around when COVID-19 Virus hit.
On 12/13/23 at 2:05 PM, V18 CNA confirmed R7's fingernails were dirty, hair was not combed, and white long hair was present on R7's chin. V18 stated, (R7) now receives extensive assistance by one staff member for hygiene and grooming needs. (R7) should have been shaved and had her fingernails cleaned out this morning.
On 12/13/2023 at 9:41 AM, V2 DON confirmed residents' fingernails should be clipped during showers if needed. V2 stated fingernails should be cleaned daily (if dirty), a resident's face should be shaved, and a resident's hair should be combed every morning with cares. V2 stated, The weekly shower list is correct. It is noted when residents should receive their showers.
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, observation and record review, the facility failed to ensure sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 55 residents...
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Based on interview, observation and record review, the facility failed to ensure sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 55 residents currently residing at the facility.
Findings include:
The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial wellbeing of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The division of nursing needs by shift will be calculated based on resident census and needs.
The Facility Assessment (reviewed 11/16/23) documents the following: Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.
On 12/12/2023 from 11:28 AM to 12:01 PM, R9's call light remained on during this time. R9 stated, (V10) Certified Nursing Assistant, came in and shut my call light off and said she would be right back. This happens all the time. Sometimes the staff member forgets to come back. I have had my call light on for around 25 to 30 minutes. I used the bed pan to have a bowel movement and need assistance getting off the bed pan and cleaned up. It hurts and causes me pain to sit on a bed pan this long, but it is a constant thing. It takes staff one to two hours most of the time to answer my call light.
On 12/12/2023 at 12:01 PM, V 10 CNA (Certified Nursing Assistant) confirmed she shut off R9's call light and told R9 she would be right back. V10 CNA stated, We are short staffed and have a hard time getting to the call lights timely. Sometimes we must shut off the resident's call light and come back to assist them when we have time. I have been busy and haven't even got my showers completed for the day.
On 12/12/2023 at 10:25 AM, R5 stated, It takes CNAs 30 minutes to two hours most of the time to answer my call light, especially on second shift. I must sit that long and wait to request my pain medication when I am in severe pain. The nurses are short staffed as well so that's why it takes them so long to get to all of us.
On 12/12/23, V1 (Administrator in Training) provided copies of the facility's Daily Staffing Assignment sheets (dated 12/01/23 - 12/11/23), which indicate the length of time and location of the staff members working for each day. V1 also noted the facility's census with a breakdown of the census into skilled and intermediate residents. V1 stated the facility determines their minimum requirements based on the numbers stated in their staffing policy.
The Daily Staffing Assignment Sheets (dated 12/2/23 and 12/3/23) both document a census of 58, with two residents determined to be skilled care, and 56 residents determined to be intermediate care. Based on the calculations in the facility's staffing policy, the facility should have had 152.60 hours of total direct care hours, 38.15 of licensed nurses working, and 15.26 hours of Registered Nursing hours. The Daily Staffing Assignment Sheet (dated 12/2/23) documents the following: the facility had a total of 100 total direct care hours, 24 hours of licensed nurses, and 12 hours of Registered Nursing hours. The Daily Staffing Assignment Sheet (dated 12/3/23) documents the following: the facility had a total of 118 total direct care hours, 14 hours of licensed nurses, and 24 hours of Registered Nursing hours.
On 12/13/2023 at 11:45 AM, V2 DON (Director of Nursing) confirmed that the daily staffing sheets were accurate for 12/2/23 and 12/3/23 and staffing was below their minimum requirements based off the staffing calculator utilized to determine staffing needs.
The facility's Daily Census form (dated 12/11/23) indicates that 55 residents are currently residing 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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide oversight and leadership to Administrator in T...
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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 oversight and leadership to Administrator in Training and nursing staff to ensure implementation of its policy and procedures regarding pressure ulcers, staffing, assessments, care plans, and employee education. In addition, Administrator in Training is practicing without any type of license. These failures have the potential to affect all 55 residents residing at the facility.
Findings include:
The facility's Administrator Job Description documents the following: Job Summary: The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting and the physical management of the facility, residents & equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The administrator will manage and conduct the business of the facility in the manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical mental and social wellbeing. Administrator Qualifications: Must have successfully completed all educational requirements as required by federal and state regulations; Must possess a current, unencumbered Nursing Home's Administrator license or meet the licensure requirements of this state; Must possess the ability to work harmoniously with and supervise other people.
On 12/19/23 at 09:30 AM, V1 (Administrator in Training) stated she cannot provide a copy a current license of any type, because she has yet to receive one. V1 stated, I have applied for a temporary Administrator's license, but haven't received anything yet. I cannot see anything when I try to look it up either. V1 stated she is the individual overseeing the facility on a daily basis, and she reaches out to corporate support when she has a question or needs assistance. V1 then stated she took over the facility at the end of June 2023, and confirmed that her application for temporary Administrator was submitted on 08/04/23. V1 stated the facility did not have a Director of Nursing hired for approximately six months. V1 stated, V9 (Licensed Practical Nurse/Assistant Director of Nursing) assisted with attempting to maintain several of the roles of the Director of Nursing, such as the facility's pressure ulcers, supervising and scheduling the Certified Nursing Assistants, and participating in morning Quality Assurance meetings.
On 12/12/23 at 10:30 AM V2 (Director of Nursing) stated she recently hired on full time at the facility with a start date of 11/01/23. V2 stated she's been finding, Some things that need addressed. I opened the Pressure Ulcer Logbook yesterday and there were a lot of blanks and things that were not current. A lot of wound measurements were missing.
On 12/14/23 at 10:55 AM, V9 (Assistant Director of Nursing/Licensed Practical Nurse) stated that prior to V2's recent hire, the facility did not have a Director of Nursing for, quite some time. V9 stated she had assumed several roles typically handled by the Director of Nursing when the facility did not have one hired. V9 stated, I do the wounds. Once (V2) hired on, I took a break and went on vacation. Then I got COVID-19, so I was off sick for a while. V9 stated she was not aware of anyone temporarily filling in on the roles that she'd been assuming while she was off. V9 then stated she has been assigned to work on the floor recently, which has not allowed her to keep up on some of her assigned duties, including wounds/pressure ulcers.
On 12/19/23 at 03:35 PM, V1 (Administrator in Training) stated she did not delegate responsibility of the facility's pressure ulcer task to another staff member while V9 was off work.
On 12/19/23 at 03:40 PM, V2 (Director of Nursing) stated she was not aware of anyone assuming responsibility to care for the facility residents with pressure ulcers while V9 was off work.
R4's medical record documents R4 was admitted to the facility on [DATE] with treatment orders for an unstageable pressure ulcer on her sacrum. On 12/08/23, R4 had a change in condition and was sent to a local hospital for evaluation. R4's wound orders were never processed or completed during her nine days stay at the facility. R4 was admitted to the hospital with a diagnosis of sepsis, and subsequently required surgical debridement to her sacral pressure ulcer.
R6's medical record documents R6 developed a Stage III pressure ulcer on her left heel at the facility. No assessment, interventions or treatment was implemented for approximately one week after it was discovered. R6 was seen by V19 (Wound Physician) on 10/17/23 and treatment orders were written at that time. R6's treatment orders were not implemented until 10/25/23. From 10/25/23 to 11/07/23, five treatments were not completed on R6's pressure ulcer, causing it to worsen from a Stage III to a Stage IV. R6 verbalized increased pain and required antibiotic administration due to her pressure ulcer developing an infection.
R1's medical record documents R1 was admitted to the facility on [DATE] with a left lateral lower leg wound, and six wound treatments were not completed from 08/24/23 - 10/27/23. On 09/17/23, R1 also developed a Stage III right buttocks pressure ulcer and a Stage III left buttocks pressure ulcer. From 09/17/23 - 10/27/23, multiple wound treatments were not completed, and R1 was subsequently admitted to the hospital with a diagnosis of sepsis of his wounds.
On 12/14/23 at 9:20 am, V9, Assistant Director of Nursing/Wound Care, stated she is having a hard time keeping up with the wound care duties because she is getting pulled to the floor to work all the time. On this same date at 10:54 AM V9 stated, I have been too busy over the past two weeks to keep up, sometimes I can't even get the wound physician notes and new orders processed until a week or two later.
R3's Fall Investigation (dated 12/08/23) documents R3 fell while trying to transfer himself off the toilet. This same investigation documents the following intervention was implemented after R3's fall: Placed Call Don't Fall sign in (R3's) bathroom.
R3's current care plan has no mention of the fall prevention intervention that was implemented after R3's 12/08/23 fall.
On 12/13/23 at 03:10 PM, V2 (Director of Nursing) stated R3's care plan has not been updated with the fall prevention intervention from R3's 12/08/23 fall. V2 then added that the facility currently does not have a Minimum Data Set Coordinator employed at the building and stated, Care Plans haven't been getting updated as often as they should.
On 12/19/23 at 11:15 AM, V1 (Administrator in Training) stated the facility does not have a Minimum Data Set Coordinator staffed at the building and hasn't had one employed full-time in over four months. V1 stated, Our corporate Minimum Data Set Coordinator has been helping us try to stay current. Our care plans have not been getting updated as frequently as they should.
On 12/11/23, V4 (CNA/Certified Nursing Assistant) was interviewed and indicated the facility is frequently short-staffed.
On 12/12/2023 from 11:28 AM - 12:01 PM, R9's call light remained on and unanswered. R9 stated, (V10, Certified Nursing Assistant) came in and shut my call light off and said she would be right back. This happens all the time. Sometimes the staff member forgets to come back. I have had my call light on for around 25 to 30 minutes. I used the bed pan to have a bowel movement and need assistance getting off the bed pan and cleaned up. It hurts and causes me pain to sit on a bed pan this long, but it is a constant thing. It takes staff one to two hours most of the time to answer my call light. R9 then stated the facility needs more staff every day.
On 12/12/2023 at 10:25 AM, R5 stated, It takes CNAs 30 minutes to two hours most of the time to answer my call light, especially on second shift. I must sit that long and wait to request my pain medication when I am in severe pain. The nurses are short-staffed as well so that's why it takes them so long to get to all of us.
On 12/11/23 at 12:37 PM, R7 was sitting in a wheelchair. R7's hair was unkempt and sticking up everywhere. R7's bilateral hands had long fingernails extending past her fingertips with brown matter under her fingernails and R7's chin was full of long white hairs. R7 was still in her pajamas and had a strong urine odor smell. R7 stated, I would like cleaned up in the mornings. They have not changed my clothes, combed my hair, cleaned, or clipped my fingernails, and have not shaved my chin today. I wanted it done this morning, but they say they don't have time. I don't remember the last time I even had a shower.
On 12/11/23 at 2:40 PM, V3 (CNA/Certified Nursing Assistant) stated, We have been short-staffed for the past couple of months. Day shift CNAs say they don't have time to do their showers and want us second shift CNAs to do them. We haven't been able to do a lot of showers lately because of staffing needs.
On 12/13/2023 at 11:45 AM, V2 (Director of Nursing) confirmed the facility's daily staffing sheets dated 12/02/23 and 12/03/23 were accurate and staffed below the facility's minimum requirements based off the staffing calculator utilized to determine their daily staffing needs.
R4's Progress Notes document that R4 was admitted to the facility on [DATE]. On 12/1/23, R4's Progress Note, documents that R4 is, so weak. R4's medical record does not have a fall risk assessment or an interim fall risk care plan in place. On 12/7/23, R4's Progress Notes document that R4 was visualized on the floor next to her bed.
R4's medical record does not have a fall risk assessment or fall prevention interventions in place.
On 12/13/23 at 3:00 PM, V2 (Director of Nursing) verified R4 did not have a fall risk assessment completed upon admission. V2 stated R4 did not have an interim fall prevention care plan.
On 12/13/23 at 10:25 AM, water temperatures were taken in both facility's shower rooms with V16 (Maintenance). V16 was questioned about the acceptable range of temperature of the shower water, and stated, I don't really know how warm it should be. I just started here a few weeks ago, and I haven't had any training on that. I am not really sure what the temperature should be.
On 12/19/23 at 03:55 PM, V15 (Regional Administrator) stated she is the Administrator assigned to oversee the facility. V15 stated, I was here full time until June 2023 when (V1, Administrator in Training) took over. I have several buildings assigned to me that I oversee. I haven't been here (facility) much since June. I've been at one of our special focus facilities quite a bit, and I've also been at another facility where they needed some help. They send me wherever I am needed.
The facility's Daily Census Form (dated 12/11/23) documents 55 residents currently reside at the facility.
Nov 2023
4 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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R2, R6 and R7) on the sample of residents reviewed for...
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Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R2, R6 and R7) on the sample of residents reviewed for medication pass. This failure resulted in four medication errors out of twenty- seven opportunities for error, for a 14.81% medication error rate.
FINDINGS INCLUDE:
The facility policy, Medication Administration, dated (revised) 11/18/2017 directs staff, Medications must be administered to the right resident, right dose, right drug, right consistency, right time, right route and right documentation. If the medication is not available for a resident, call the Pharmacy and notify the physician when the drug is expected to be available.
1. R2's current Physician Order Sheet, dated November 2023 includes the following medication: Pregabalin (Lyrica) Oral Capsule Give 75 mg (milligram) by mouth one time a day for nerve pain.
On 11/29/2023 at 9:33 A.M., V13/Licensed Practical Nurse (LPN) prepared to administer medications for R2. After adding Baby Aspirin one tablet, Orphenadrine ER 100 MG one tablet, Clonidine 01.2 MG one tablet, Calcium Acetate 667 MG one tablet, Hydralazine 100 MG one tablet, Losartan Potassium 100 MG one tablet, Eliquis 2.5 MG one tablet and Pantoprazole DR 40 MG one tablet to the plastic medication cup, V13/LPN stated, I don't have any (Pregabalin) Lyrica (for R2). There isn't any in the cart. I guess (R2) won't get that one today. V13/LPN then administrated R2's pills, without the Lyrica to R2.
2. R6's current Physician Order Sheet, dated November 2023 includes the following medications: Aspirin 81 MG one tablet daily.
On 11/29/2023 at 9:42 A.M., V7/LPN prepared to administer medications for R6. V7/LPN placed Enteric Coated Aspirin 81 MG, one tablet; Oyster Shell Calcium, one tablet and Multivitamin, one tablet in a plastic sleeve and crushed all medications together, added the powdered mixture to a plastic medication cup, placed applesauce in the mixture and administered the mix to R6. At that time, V7/LPN verified the enteric coated aspirin and the contraindication of crushing the medicine.
3. R7's current Physician Order Sheet, dated November 2023 includes the following medications: Ativan (anti-anxiolytic) 1 MG two times daily, Folic Acid 1 MG daily.
On 11/29/2023 at 9:44 A.M., V13/Licensed Practical Nurse prepared to administer medications for R7. V13/LPN placed one tablet of Metoprolol 25 MG and One tablet of Multi Vitamins with minerals in a plastic medication cup. At that time V13/LPN stated, I don't know where (R7's) Ativan or Folic Acid is. (R7) doesn't have any on the cart or in the med (medication) room. V13/LPN went into R7's room, handed R7 the medication cup with only the Metoprolol and Multi Vitamin with minerals to R7. R7 swallowed both pills with a cup of water, laid back down on the bed and V13/LPN exited the room.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to keep medications secure for thirteen residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) of fifteen resid...
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Based on observation, interview and record review, the facility failed to keep medications secure for thirteen residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) of fifteen residents reviewed for medication storage, in a sample of 16.
FINDINGS INCLUDE:
The facility policy, Procurement and Storage of Medications, dated (reviewed) 11/6/18 directs staff, All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart.
On 11/29/2023 at 8:40 A.M., four gold/tan-colored plastic tubs with 120 different medication punch cards for 13 facility residents (R2, R3, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15 and R16) were present, unattended, on top of nurse's station counter, readily accessible to any resident or facility staff. Multiple residents, including R1, R2 and R3 walked/wheeled past the unsecured medications, as well as V3/SSD (Social Survives Director), V4/Maintenance Director, V8/Housekeeping Supervisor, V11/Medical Records/Receptionist, V7/Licensed Practical Nurse, V12/Registered Nurse and V13/Licensed Practical Nurse. At no time from 8:40 A.M. through 9:33 A.M. any staff member secure the medications.
On 11/29/2023 at 9:33 A.M., V7/Licensed Practical Nurse confirmed the presence of the medications and stated, They have been there since I came into work at 6:00 (A.M.) this morning.
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 F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide the services of a registered nurse, as required. This failure has the potential to affect all 59 residents currently in the facilit...
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Based on interview and record review, the facility failed to provide the services of a registered nurse, as required. This failure has the potential to affect all 59 residents currently in the facility.
FINDINGS INCLUDE:
Facility Nursing Schedule staffing sheets, dated 11/4/2023 document no Registered Nurse in the facility for 8 hours out of 24 hours, on that day.
On 11/29/2023 at 1:15 P.M., V2/Director of Nursing stated, We don't have many RN's (registered nurses) on staff. At that time, V2/Director of Nurses confirmed no Registered Nurses were present in the facility on 11/4/2023.
The facility Room Roster/Census, dated 11/29/2023 confirms 59 residents currently 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
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to remove soiled PPE (Personal Protective Equipment) and apply clean PPE upon exiting the facility COVID-19 Unit, failed to apply...
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Based on observation, interview and record review, the facility failed to remove soiled PPE (Personal Protective Equipment) and apply clean PPE upon exiting the facility COVID-19 Unit, failed to apply the correct PPE upon entrance into the facility COVID-19 Unit and failed to ensure a COVID-19 positive resident exited the facility COVID-19 Unit with correct PPE. These failures have the potential to affect all 59 facility residents.
FINDINGS INCLUDE:
The facility policy, COVID-19 Control Measures, dated (revised) 5/19/2023 directs staff, To prevent transmission of the COVID -19 Virus and to control outbreaks. Healthcare workers must use proper PPE (Personal Protective Equipment) when exposed to a resident with suspected or confirmed COVID-19. The Healthcare worker must wear an N95 respirator, eye protection, gown and gloves. Soiled (contaminated) PPE must be removed, disposed of, hand hygiene performed and a clean N-95 mask reapplied upon exit from a COVID-19 Unit.
On 11/29/2023 at 8:59 A.M., V11/Medical Records/Receptionist exited the facility COVID-19 Unit wearing a soiled, disposable, yellow gown and gloves, with a cloth mask dangling around her neck. V 11 walked past multiple facility residents and staff members, up the facility main hall to the reception desk at which time V11 removed her soiled, disposable gown and gloves. Without performing hand hygiene, V 11 sat down at the facility receptionist desk and answered the telephone. At that time, V11 confirmed she had failed to remove the soiled PPE, apply a clean mask and perform hand hygiene.
On 11/29/2023 at 9:29 A.M.,V13/Licensed Practical Nurse exited the facility COVID-19 Unit wearing a soiled, contaminated N95 mask, walked to the facility nurse's station, past residents and staff and began passing medications. At that time, V13/LPN confirmed he had failed to remove the contaminated mask and reapply a clean mask.
On 11/29/2023 at 9:36 A.M.,V3/Social Services Director entered the facility COVID-19 Unit after applying a disposable yellow gown, and an N-95 mask. V3/SSD did not apply gloves or eye protection when entering the unit.
On 11/29/2023 at 9:48 A.M., R4 (COVID-19 positive resident) exited the facility COVID-19 Unit with no N95 mask, propel his wheelchair to the East nurse's station, and sat next to R5 and R6, without interference from any staff. At 9:54 A.M., upon notification from a State Surveyor, V13/Licensed Practical Nurse confirmed R4's COVID-19 positive status and placed R4 back in the facility COVID-19 Unit.
The facility Room Roster/Census dated 11/29/2023 and provided by V1/Administrator documents 59 current facility residents.
Oct 2023
4 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to revise a care plan with a new fall prevention intervention following a fall for one of three residents (R4) reviewed for falls in the sampl...
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Based on interview and record review, the facility failed to revise a care plan with a new fall prevention intervention following a fall for one of three residents (R4) reviewed for falls in the sample of six.
Findings include:
The facility's Fall Prevention policy (revised 11/10/18) documents the following: Report all falls during the morning Quality Assurance Meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.
R4's Fall Investigation (dated 10/22/23) documents R4 was sent to a local hospital for evaluation and treatment after she was found on the floor next to her bed on 10/22/23.
R4's Progress Note (dated 10/23/22) documents the following regarding R4's 10/22/23 fall: IDT (Interdisciplinary Team) Note: QA (Quality Assurance) team met this morning to discuss resident's unintentional change of plane. Resident fell out of bed while reaching for call light. Care plan reviewed and updated. Glow in the dark tape placed on call light for resident to see at night.
R4's Current Care Plan has no mention of the newly implemented intervention of glow in the dark tape placed on R4's call light.
On 10/30/23 at 01:30 PM, V1 (Administrator in Training) stated that R4's care plan has not been updated with the intervention implemented after R4's fall.
On 10/30/23 at 01:45 PM, V6 (Regional Minimum Data Set Coordinator) stated, R4's care plan was not updated with the intervention put in place after her 10/22/23 fall and it should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 conduct a fall risk assessment and ensure the assessme...
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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 conduct a fall risk assessment and ensure the assessment was thoroughly completed, as directed in their Fall Prevention policy, for one of three residents (R4) reviewed for falls in the sample of six.
Findings include:
The facility's Fall Prevention policy (revised 11/10/18) documents the following: Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Conduct fall assessments on the day of admission, quarterly, and with a change in condition.
R4's Face Sheet (undated) documents R4 was admitted to the facility on [DATE].
R4's medical record documents R4's most recent Fall Risk Assessment was completed on 05/14/23, the day R4 was admitted to the facility. This assessment documents a score of 9 (10 points or more equals High Risk Score). This assessment is compiled of the following criteria: Age; Elimination; Visual Impairment (1 point for wears glasses, and this section was blank and not assessed on 05/14/23); Confinement; Gait and Balance; Medication, History of Falls in the Last Three Months; and Diagnostic/Health Condition Predisposing for a Fall.
On 10/31/23 at 10:40 AM, R4 was lying in bed. R4's bed had two upper ½ side rails attached and secured in the upright position. R4 was wearing glasses at this time. R4 confirmed that she did fall recently at the facility and stated, I was on the floor for a long time. These people are worthless. R4's call light had a bright yellow wrap adhered around the base of the call light and approximately eight inches of the cord.
On 10/30/23 at 11:30 AM, V6 confirmed R4's medical record does not document a Fall Risk Assessment has been completed since R4's date of admission to the facility on [DATE].
On 10/30/23 at 01:30 PM, V1 (Administrator in Training) stated a Fall Risk Assessment should be completed upon admission, quarterly and after a resident has fallen. V1 verified that R4's Fall Risk Assessment was incomplete, and stated another Fall Risk Assessment should have been completed at the time of R4's quarterly assessment and again after R4's fall at the facility on 10/22/23. V1 then stated additional fall prevention interventions are implemented for a resident assessed as a high risk for falls.
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, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 54 resi...
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Based on interview, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. This failure has to potential to affect all 54 residents currently residing at the facility.
Findings include:
The facility's Nurse Staffing policy (undated) documents the following: It is the policy of (facility) to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nursing staff shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (State Agency). Each skilled care resident shall receive at least 3.8 hours of nursing and personal care each day, and 2.5 hours of nursing and personal care each day for a resident needing intermediate care. A minimum of 25% of nursing and personal care time shall be provided by licensed nurses, with at least 10% of nursing and personal care time by Registered Nurses. Registered Nurses and Licensed Practical Nurses employed by a facility in excess of these requirements may be used to satisfy the remaining 75% of the nursing and personal care time requirements. The division of nursing needs by shift will be calculated based on resident census and needs.
The Facility Assessment (reviewed 09/20/23) documents the following: Staffing Plan: The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.
On 10/26/23 at 09:30 AM, V1 (Administrator in Training) stated the facility currently does not have a Director of Nursing working. V1 stated, We have hired one but she doesn't start until sometime in November.
On 10/30/23 at 12:10 PM, R1 was lying supine in a bariatric bed with two upper ½ side rails attached to R1's bed and secured in the upright position, and a trapeze was hanging in place above R1. A colostomy bag was adhered to R1's left knee area, and R1 pointed to the bag and explained that he currently has an infection in his knee in which the colostomy bag was collecting the drainage. A strong, bitter odor was noted throughout R1's room and R1 explained his infection has a foul odor. R1 then stated the following: There is not enough staff here. I often wait for over an hour to get help. My call light is rarely answered quickly, and if it is, someone comes in and shuts it off, tells me that they will be back shortly, leaves the room and then I don't see them again for several hours. I am a big guy, and I need someone to hold a urinal in place for me to urinate. I cannot physically do it myself. There have been several instances when I have just had to lay here and pee in the bed because no one comes to help me, and then it will be several hours that I have to lay here soiled before someone comes in to change my bed and clean me up. I can only hold it for so long. My bottom is red and irritated because I have laid in a soiled bed for so long. I have this terrible infection in my knee, and it smells horrible. I think a lot of the staff avoid coming to help me due to the smell. There is very limited staff here during third shift, and I have waited for help for several hours. It is the worst feeling laying here waiting knowing you are helpless and at the mercy of two or three people. I can't tell you how many times I have been told by a staff member that the wait was long because they were on break. I think they all must take their breaks together at the same time. A couple weeks ago, I missed my afternoon medications that were due at 4:00 PM. The nurse told me they were short staffed, and that she will not work in the current environment of this place, and then she quit the next day.
On 10/30/23 at 12:15 PM, V5 (Certified Nursing Assistant) entered R1's room to assist him to roll onto his left side. Once R1 was rolled over, R1's buttocks was exposed, and red, excoriated skin was covering his bottom.
On 10/31/23 at 10:40 AM, R4 was lying in bed. R4's bed had two upper ½ side rails attached and secured in the upright position. R4 stated she did fall at the facility recently and stated, I was on the floor for a long time. I laid there with vomit in my hair. These people are worthless. They rarely come and check on you. There aren't enough people working, and there have been several instances where I have hit my call light and they don't come for hours. It doesn't matter if you need help, because you're not going to get it. This is constant and ongoing. There is never a day that I get help timely.
On 10/30/23, V1 (Administrator in Training) provided copies of the facility's Daily Staffing Assignment sheets (dated 10/01/23 - 10/25/23), which indicate the length of time and location of the staff members working for each day. V1 also noted the facility's census with a breakdown of the census into skilled and intermediate residents. V1 stated the facility determines their minimum requirements based on the numbers stated in their staffing policy.
The Daily Staffing Assignment Sheets (dated 10/15/23 and 10/16/23) both document a census of 56, with four residents determined to be skilled care, and 52 residents determined to be intermediate care. Based on the calculations in the facility's staffing policy, the facility should have had 142.5 hours of total direct care hours, 36.3 hours of licensed nurses working, and 14.5 hours of Registered Nursing hours. The Daily Staffing Assignment Sheets (dated 10/15/23 and 10/16/23) both document the following: the facility had a total of 132 total direct care hours, 36 hours of licensed nurses, and 12 hours of Registered Nursing hours.
On 10/31/23 at 11:45 AM, V1 (Administrator in Training) confirmed that the facility was short on their minimum staffing requirements noted in their Nurse Staffing policy for 10/15/23 and 10/16/23.
The facility's Resident Census and Conditions of Residents form, provided by V1 on 10/30/23, indicates that 54 residents are currently residing 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
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview observation and record review, the facility failed to post signage with indication to maintain isolation precautions for a resident with suspected Shingles, failed to apply PPE (per...
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Based on interview observation and record review, the facility failed to post signage with indication to maintain isolation precautions for a resident with suspected Shingles, failed to apply PPE (personal protective equipment) prior to entering a resident's room with isolation precautions in place for Shingles and a resident with Enhanced Barrier Precautions in place for two of six residents (R1 and R2) reviewed for improper nursing care in the sample of six. This failure has the potential to affect all 54 residents residing in the facility.
Findings include:
According to the CDC (Centers for Disease Control and Prevention), In 2019, CDC introduced a new approach to the use of personal protective equipment called Enhanced Barrier Precautions (EBP). This new approach recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO (multi drug resistant organisms) transmission. CDC interim guidance recommends EBP as a strategy in nursing homes to interrupt the spread of novel or targeted MDROs (e.g., carbapenem-resistant organisms or C. auris). Based on available evidence and expert opinions, this white paper aims to provide a consideration for broader use of EBP beyond targeted MDROs, including pathogens that affect every nursing home in the United States such as S. aureus (both methicillin sensitive and resistant). Enhanced Barrier Precautions can be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO. Consistent with 2019-2020 CDC EBP interim guidance, examples of indwelling medical devices include central line, urinary catheter, feeding tube, and tracheostomy/ventilator; examples of high contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. (https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html).
According to the CDC's Infection control precautions based on patient's immune status and rash localization chart: Immunocompetent patients with localized Herpes Zoster: Completely cover lesions and follow standard precautions until lesions are dry and scabbed. Immunocompetent patients with Disseminated Herpes Zoster: Airborne and contact precautions until lesions are dry and scabbed. Immunocompromised patients with localized Herpes Zoster: Airborne and contact precautions until disseminated infection is ruled out. After dissemination is ruled out, completely cover lesions and follow standard precautions until lesions are dry and scabbed. Immunocompromised patients with disseminated Herpes Zoster: Airborne and contact precautions until lesions are dry and scabbed. (https://www.cdc.gov/shingles/hcp/hc-settings.html).
The facility's Transmission Based Precautions policy (revised 12/14/09) documents, Transmission Based Precautions are designed for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission. Airborne Precautions: Are designed to reduce the risk of airborne infectious agents. Contact Precautions are designed to reduce the risk of epidemiologically important microorganisms by direct or indirect contact.
On 10/31/23 at 10:50 AM, V1 (Administrator in Training) stated the above mentioned policy is the only policy the facility must reference regarding isolation precautions procedure.
1. On 10/30/23 at 09:05 AM, V4 (Registered Nurse) stated that R2 has a daily treatment in place for a dressing change to her left heel pressure ulcer. V4 then stated R2 was placed in isolation precautions on 10/29/23 and was ordered medication for the treatment of suspected shingles.
R2's Progress Note (dated 10/29/23) documents the following: Resident has small blisters on right hip. (V11, Medical Director) contacted via text and confirmed resident has shingles. Isolation has begun and a new order for Valtrex (antiviral) has been entered.
R2' s Physician's Orders document the following medication order (date of order 10/29/23): Valtrex Oral Tablet 500 milligrams (Valacyclovir HCl) Give 1 tablet by mouth four times a day for shingles until 11/06/2023.
On 10/30/23 at 02:20 PM, No signage was posted for any type of isolation precautions on R2's door. A small bin containing PPE supplies was in the hallway next to the doorway of the room beside R2's room. R2 was lying in bed positioned on her back with the head of her bed raised to approximately 45 degrees. An indwelling urinary catheter drainage bag was hanging on the lower aspect of R2's bed. V4 (Registered Nurse) entered R2's room to provide a dressing change R2's left heel pressure ulcer. V2 (Assistant Director of Nursing) and V7 (Certified Nursing Assistant) entered R2's room at this time as well. V2 stated, I haven't had a chance to take a look yet, so I'm going to look at her blisters. V2 then proceeded to unfasten R2's incontinence brief to evaluate R2's right groin area. A raised, red blister and a linear area of redness was present in R2's right groin area. At this same time, V4 removed the current dressing in place on R2's left heel, and a round, open area approximately 2.5cm (centimeters) x 2cm covered with slough tissue was observed on R2's left heel. V4 cleansed the area, applied the ointment currently ordered, and then applied a new, clean dressing. No gowns or masks were worn by any staff members in R2's room while cares were administered.
On 10/30/23 at 03:15 PM, V11 (Medical Director) stated he expects staff to apply the recommended PPE when a resident is being treated for suspected Shingles.
On 10/30/23 at 03:20 PM, V2 (Assistant Director of Nursing) verified there was no signage posted on R2's door indicating isolation precautions are in place and stated, There should have been a sign posted on the door and we should have been wearing gowns. We moved her roommate out of the room. When asked, V2 could not explain what type of isolation precautions should be currently maintained for R2.
On 10/30/23 at 03:25 PM, V1 (Administrator in Training) stated the facility does not have a policy to reference regarding isolation precaution procedures for Shingles. V1 could not explain what type of isolation precautions should be implemented for a resident with a case of suspected Shingles.
On 10/31/23 at 09:15 AM, V1 (Administrator in Training) stated, I talked to my corporate support this morning, and they told me about a person with a suspected case of shingles should have their lesions covered and should be placed in Contact and Airborne Precautions until the lesions are scabbed over. V1 stated a sign should be placed on the resident's door with indication of these isolation precautions, and a mask, gown and gloves should be worn prior to entering a resident's room.
2. R1's current Diagnoses List documents R1 diagnoses to include: Chronic Osteomyelitis, Right tibia, and Fibula; Muscle Weakness; and Need for Assistance with Personal Care.
R1's Physician's Order Sheet documents the following medication and treatment orders: Calcium Alginate-Silver External Pad apply to left posterior calf topically every day shift. For wound care, cleanse wound, apply Calcium Alginate-Silver, and cover with guaze island with border; Vancomycin 125mg give one capsule by mouth one time a day for infections; Change drainage bag to right lower extremity every week on Thursday; Drain wound bag to right lower extremity every day shift for wound drainage collection.
On 10/30/23 at 11:55 AM, a sign was posted on R1's door indicating Enhanced Barrier Precautions, with instruction to apply PPE (personal Protective equipment) prior to administering direct care. A plastic bin containing PPE was in place in the hall near the doorway to R1's room. V3 (local agency Licensed Practical Nurse) and V5 (Certified Nursing Assistant) entered R1's room to perform a dressing change to R1's left calf. V3 and V5 applied gloves after entering R1's room but did not apply a gown. R1 was lying supine in a bariatric bed with two upper ½ side rails secured in the upright position, and a trapeze was hanging in place above R1. A colostomy bag was adhered to R1's left knee area, and R1 explained that he currently has an infection in his knee in which the colostomy bag was collecting the drainage. A strong, bitter odor was noted throughout R1's room and R1 explained his infection has a foul odor. V5 then lifted and held R1's left leg above the pillow it was positioned on while V3 removed the current dressing on R1's left calf, cleaned R1's left calf wound, and applied a new, clean dressing. Once cares were completed, V3 and V5 exited the room, and R1 stated staff providing direct care are usually not wearing a gown.
On 10/30/23 at 12:15 PM, V5 (Certified Nursing Assistant) entered R1's room to assist him to roll onto his left side. V5 did not apply gloves or a gown prior to entering R1's room. R1 applied gloves once inside R1's room prior to assisting R1 to roll over. Once R1 was rolled over, R1's buttocks was exposed, and red, excoriated skin was covering his bottom. R1 stated, They are putting some cream on it. V5 then assisted R1 with positioning of urinal for R1 to void. Once R1 was finished, V5 cleansed R1's perineal area and emptied the urinal.
On 10/30/23 at 03:20 PM, V2 (Assistant Director of Nursing) could not explain the protocol of placing a resident in Enhanced Barrier Precautions. V2 stated she did not know why R1 was currently being maintained in Enhance Barrier Precautions, and the reason R1 is currently maintained in Enhanced Barrier Precautions is, because the previous DON (Director of Nursing) hung the sign on his door.
On 10/31/23 at 09:15 AM, V1 (Administrator in Training) stated the facility does not have a policy to reference regarding the criteria of placing a resident in Enhanced Barrier Precautions, or a policy in place regarding the procedure of caring for resident maintained in Enhanced Barrier Precautions. V1 staff should apply a gown and gloves prior to providing cares to a resident who is maintained in Enhanced Barrier Precautions.
On 10/30/23 at 03:15 PM, V11 (Medical Director) stated he expects staff to apply the recommended PPE when a resident is being maintained in Enhanced Barrier Precautions.
On 10/31/23 at 10:30 AM, V1 stated all staff members can go anywhere in the building to provide assistant to residents when needed. V1 stated R1 prefers to stay in bed, but it is easier for multiple staff members to provide assistance when getting him up to sit in his chair.
The facility's Resident Census and Conditions of Residents form, provided by V1 on 10/30/23, indicates that 54 residents are currently residing in the facility.
Jul 2023
28 deficiencies
CONCERN
(D)
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 a wheelchair to a resident (R197) who was dep...
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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 a wheelchair to a resident (R197) who was dependent on a wheelchair for mobility for one of two residents (R197) reviewed for accommodation of needs in the sample of 37.
Findings include:
The Facility Assessment Tool, dated 3/29/23, documents, Other medical diagnoses or conditions may be considered for admission. For other possible admissions or continuing care decisions the QA (Quality Assurance) team will meet and identify any new needs or resources needed to provide care and support for the person. QA will make the decision that appropriate care can or cannot be provided to the individual and the services required are within the scope of the license for the facility. Once the decision is made the appropriate department will obtain the needed resources (training, equipment, etc.).
On 07/18/23 at 08:43 AM, R197 was lying in bed. R197 stated, I was in the hospital for six weeks for the infection in my foot. I was home and took care of myself before that happened, and that is my goal to get back home. However, with being in the hospital for so long, I'm not able to walk. I came here with the understanding that I would be doing therapy to get back home, but I haven't received any therapy since I've been here. I just got a wheelchair yesterday (7/17/23). The facility told me they didn't have one that would fit me. I haven't left this room since I got here because of it.
R197's Hospital Discharge information, dated 7/8/23, documents, Diagnosis Problem List: Principal physical deconditioning.
R197's Order Summary report, dated 7/19/23, documents that R197 was admitted to the facility on [DATE].
On 07/19/23 at 09:48 AM, V1 (Administrator in Training) stated, (R197) needs a 26 wheelchair due to his size, and we don't have that size of wheel chair in this facility. We knew he needed that size when he was admitted , but we didn't have one when he got here. V1 confirmed (R197) did not get a wheelchair until 7/17/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. R195's MDS tracking, dated 7/18/23, documents R195 was admitted to the facility on [DATE]. The tracking has no documentation ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. R195's MDS tracking, dated 7/18/23, documents R195 was admitted to the facility on [DATE]. The tracking has no documentation of a comprehensive admission MDS assessment being completed.
On 07/19/23 at 11:19 AM, V7 (MDS/Care plan Coordinator) stated R195's admission MDS has not been completed.
7. R196's MDS tracking, dated 7/20/23, documents R196 was admitted to the facility on [DATE]. The tracking has no documentation of a comprehensive admission MDS assessment being completed.
On 07/19/23 at 11:19 AM, V7 stated R196's admission MDS has not been completed. V7 also stated, I'm so far behind with MDSs and care plans. Anyone who was admitted after 6/1/23 I don't have their MDSs or care plans done.
On 7/18/23 2:23 PM, V7 (Licensed Practical Nurse/ MDS coordinator) stated, I have been doing MDS assessments since February of this year and there wasn't anyone prior to me. I am not sure for how long they were without someone. I have been pulled to work the floor and I fell behind on MDS's with the facility's switch to (electronic records).
Based on interview and record review, the facility failed to complete comprehensive admission and annual MDS (Minimum Data Set) assessments for 7 of 23 residents (R4, R11, R12, R18, R27, R195, R196) reviewed for MDS completion in the sample of 37.
Findings include:
The facility's Comprehensive Assessment/MDS policy, dated 11/1/17, documents, It is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history, and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The policy also documents, Each resident residing in this facility for a full 14 days shall have a MDS initiated by the 13th day after admission, and a RAI (Resident Assessment Instrument) completed by the 14th day after 'admission.' The MDS shall be re-evaluated according to the following schedule: Annually within 366 days of previous comprehensive ARD (Assessment Reference Date)/MDS.
1. R4's Profile Face Sheet documents R4 was admitted to the facility on [DATE].
R4's electronic record documents R4's last comprehensive Minimum Data Set assessment (MDS) was completed on 5/7/22.
R4's Assessment look up screenshot, provided by V1 (Administrator in Training) on 7/20/23, documents all Minimum Data Set assessments have been submitted since February 2023 to present for R4. This record does not document R4 has had an annual comprehensive assessment.
On 7/20/23 at 11:20 AM, V7 (Licensed Practical Nurse/ MDS coordinator) confirmed R4 has not had an annual comprehensive assessment submitted and it was due in May of 2023.
2. R11's MDS Assessment Lookup (printed 7/20/23) documents R11's third Quarterly MDS assessment was completed on 3/6/23. R11's last comprehensive MDS assessment was completed on 6/3/22.
On 7/20/23 at 10:05 AM, V7 confirmed R11 was due for a comprehensive MDS assessment, but it has not been completed.
3. R12's MDS Assessment Lookup (printed 7/20/23) documents R12's third Quarterly MDS assessment was completed on 3/11/23. R12's last comprehensive MDS assessment was completed on 6/8/22.
On 7/20/23 at 10:05 AM, V7 confirmed R12 was due for a comprehensive MDS assessment, but it has not been completed.
4. R18's MDS Assessment Lookup (printed 7/20/23) documents R18's third Quarterly MDS assessment was completed on 3/3/23. R18's last comprehensive MDS assessment was completed on 7/18/22.
On 7/20/23 at 10:05 AM, V7 confirmed R18 was due for a comprehensive MDS assessment, but it has not been completed.
5. R27's MDS Assessment Lookup (printed 7/20/23) documents R27's third Quarterly MDS assessment was completed 3/8/23. R27's last comprehensive MDS assessment was completed on 6/5/22.
On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) stated she has been working the floor as a nurse and got behind on the assessments. V7 confirmed R27 was due for a comprehensive MDS assessment, but it has not been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change minimum data set assessment for a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a significant change minimum data set assessment for a resident admitted to hospice for one of 23 residents (R9) reviewed for significant change in the sample of 37.
Findings include:
The facility's Comprehensive Assessment / Minimum Data Set (MDS) policy, dated 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goal, life history and preferences to develop a comprehensive plan of care for each resident with the goal of attaining or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This same policy documents The MDS shall be re-evaluated according to the following schedule. c. Significant change in status- The interdisciplinary team shall determine the presence or absence of significant change based on the resident's status during the previous assessment reference period compared with the current assessment reference period. Within 14 days of determination that a significant change in a resident's status: Within enrollment or discontinuation of Hospice services.
R9's Physician Order sheet, dated 7/19/23 documents R9 was admitted to the facility on [DATE]. R9's Physician Order dated 1/16/23 documents, Discontinue occupational therapy, patient Hospice.
R9's Minimum Data Set assessment dated , 4/16/23 does not document R9 is receiving Hospice services.
R9's Assessment look up screenshot, provided by V1 (Administrator In Training) on 7/20/23, lists all Minimum Data Set assessments that have been submitted since admission for R9 and does not document any significant change MDS assessment has been submitted.
On 7/20/23 at 11:20 AM, V7 (Licensed Practical Nurse/ Minimum Data Set (MDS) coordinator) stated, (R9) never had a significant change MDS assessment when he went to Hospice care. It should have been done but none of his assessments document that he receives Hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
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 complete a quarterly MDS (Minimum Data Set) assessment for three of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a quarterly MDS (Minimum Data Set) assessment for three of 23 residents (R1, R23, R24) reviewed for MDS completion in the sample of 37.
Findings include:
The facility's Comprehensive Assessment/Minimum Data Set (MDS) policy, dated 11/1/17, documents, The MDS shall be re-evaluated according to the following: Quarterly-within 92 of previous ARD (Admission, Review, and Dismissal)/MDS.
1. R1's MDS Assessment Lookup (printed 7/20/23) documents R1's admission MDS assessment was dated 2/6/23 the next Quarterly assessment was dated 5/22/23.
On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) confirmed that R1's quarterly MDS assessment was not completed on 5/22/23.
2. R23's MDS Assessment Lookup (printed 7/20/23) documents R23's admission MDS assessment was dated 4/2/23. This is the last assessment documented.
On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) confirmed that R2's has no quarterly MDS assessment after R23's admission MDS.
3. R24's MDS Assessment Lookup (printed 7/20/23) documents R24 had a Significant Change MDS assessment dated [DATE]. This is the last assessment documented.
On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) confirmed that R24 has no quarterly MDS assessment following R24's Significant change MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a baseline care plan within 24 hours of admi...
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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 complete a baseline care plan within 24 hours of admission for one of one resident (R197) reviewed for baseline care plans in the sample of 37.
Findings include:
On 07/18/23 at 08:43 AM, R197 was lying in bed. R197 stated, I was in the hospital for six weeks for the infection in my foot. I was home and took care of myself before that happened, and that is my goal to get back home. However, with being in the hospital for so long, I'm not able to walk. I came here with the understanding that I would be doing therapy to get back home.
R197's Hospital Discharge information, dated 7/8/23, documents, Diagnosis Problem List: Principal physical deconditioning.
R197's Order Summary report, dated 7/19/23, documents R197 was admitted to the facility on [DATE].
R197's Care Plan Detail, dated 7/20/23, has no documentation of an initial baseline care plan being completed for R197.
07/19/23 11:19 AM, V7 (MDS-Minimum Data Set/Care plan Coordinator) stated, I'm so far behind with MDS and care plans. Anyone who was admitted after 6/1/23 I don't have their MDSs or care plans done. (R197) does not have an interim care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to revise a care plan for the use of an antipsychotic medication for one of four residents (R10) reviewed for antipsychotics in ...
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Based on observation, interview, and record review, the facility failed to revise a care plan for the use of an antipsychotic medication for one of four residents (R10) reviewed for antipsychotics in the sample of 37.
Findings include:
The facility's Psychotropic Medication policy, dated 6/17/22, documents, Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches, and goals to address these behaviors.
On 07/19/23 at 10:38 AM, R10 was aimlessly self-propelling himself in the hallway. R10 was pleasantly confused, smiling, and not displaying any behaviors.
R10's Order Summary Report, dated 7/19/23, documents R10 has an order to receive Seroquel (antipsychotic) 25 mg (milligrams) half tablet (12.5 mg) by mouth in the evening for the diagnosis of dementia.
R10's Psychotropic care plan, dated 5/15/23, documents, R10 requires use of psychotropic medication to manage mood and/or behavior issues. Class of drug: Antidepressant. Related diagnosis: Major Depressive Disorder. Behaviors exhibited: Withdrawn, little to no interest in doing things. R10's care plan is not revised to include R10's use of an antipsychotic, diagnosis for the use of an antipsychotic, nor the behaviors indicated for the use of an antipsychotic.
On 07/19/23 at 11:19 AM, V7 (MDS-Minimum Data Set/Care plan) confirmed (R10's) care plan is not revised to include the use of his antipsychotic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to obtain an appropriate treatment order upon development and progression of a pressure ulcer for one of one resident (R30) revie...
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Based on observation, interview and record review, the facility failed to obtain an appropriate treatment order upon development and progression of a pressure ulcer for one of one resident (R30) reviewed for pressure ulcers in the sample of 37.
Findings include:
The facility's Decubitus Care/ Pressure Areas policy, dated 1/2018, documents, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer.
The facility's Skin Condition Monitoring policy, dated 3/16/23, documents, It is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities.
R30's Skin Only Evaluation, dated 7/12/23, documents at 6:25 PM V23 (R30's Physician) was notified R30's skin contained bruising on the coccyx measuring 12 centimeters (cm) by 12 cm. This evaluation documents, Deep red and Purple bruising on coccyx, (V23) contacted at 6:30 PM.
R30's Nursing Progress Note, dated 7/16/23, documents at 1:09 PM, Red non-blanchable area present to coccyx. Measures 14 by 9 cm and UTD (undetermined depth). Boarder foam dressing applied. Medical Director, Power of Attorney and Hospice aware.
R30's Treatment Administration record, dated 7/1-7/31/23, documents a treatment order, Red area to coccyx: Apply boarder foam dressing daily and as needed. Monitor and report any changes to medical doctor and hospice. Every day shift for pressure area. Start Date 07/17/2023. This same treatment record does not document any other coccyx pressure area treatment or that a coccyx treatment was put into place before 7/17/23.
On 7/19/23 at 3:15 PM (R30) was in her room lying in bed with her eyes closed. V6 (Registered Nurse) stated R30 has been asleep most of the day. V15 (Wound Doctor) stated, If the area has no open spots, the secondary dressing like a boarder foam that is currently ordered is fine. However, if the wound has any open portions to any degree like shearing or the first layer of skin is disrupted, then the wound needs a primary dressing like a collagen or hydrocolloid to help heal the open layer, or another medication, then follow with a secondary dressing such as the boarder foam. V6 stated he did R30's dressing change several times on 7/18. V6 stated, The wound looks to be discovered on 7/16 because that's when the order was placed. When it was discovered, they documented the area was reddened over the coccyx and hospice gave the order for the boarder foam. Yesterday (7/18) when I changed the dressing, it had an area of shearing or peeling of skin under the boarder foam dressing.
On 7/19/23 at 3:20 PM, V6 (Registered Nurse) and V2 (Licensed Practical Nurse/ Resident Care Coordinator) went in R30's room for wound care. V6 pulled back the old dressing from R30's coccyx to reveal a large, reddened area that spanned the entire upper portion of R30's buttocks and coccyx. The area contained two sheared areas that were moist with red granulation in the center. One was approximately nickel sized and one approximately larger than a quarter. The coccyx wound also contained purple edges and a blackened scabbed area approximately quarter sized with some swirling of yellow areas in the center. V6 confirmed the wound needs a new order that provides a primary dressing like V15 discussed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to supervise smoking residents and keep smoking materials in a safe place for three of three residents (R3, R23, R95) reviewed for...
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Based on observation, interview and record review the facility failed to supervise smoking residents and keep smoking materials in a safe place for three of three residents (R3, R23, R95) reviewed for smoking in the sample of 37.
Findings include:
The Safe Smoking and Vaping Policy dated 10/27/22, documents, The facility works to provide appropriate care for residents keeping safety and comfort in mind. Residents may have the desire to smoke/vape and accommodations will be provided as the facility deems appropriate.
The Smoking Policy (not dated) documents, It is the policy of (the facility) smoking is only permitted outside the facility according to the following guidelines. There will be no smoking inside the facility by either resident or staff. Guidelines 2. Residents must always be accompanied by a staff member to smoke and may not keep his/her own smoking materials.
On 7/18/23 at 9:32 AM, R3 and R95 were sitting on a bench in front of the facility smoking. There were no staff supervising the residents.
On 7/19/23 at 11:48 AM, V9 (Ombudsman) stated she has seen residents out front of the facility smoking with no staff being present.
On 7/19/23 at 3:47 PM, V2 (Licensed Practical Nurse/Resident Care Coordinator) stated the residents are to be supervised during smoking, but she has seen some residents smoking in front of the facility unsupervised.
On 7/20/23 at 10:45 AM, R23 pulled a pack of cigarettes out of his front pant pocket. There were two lighters in the top drawer of the nightstand. R23 stated, I keep my cigarettes and lighter with me. The cigarettes are in my pocket and the lighter is in my top drawer of the nightstand. I go out to smoke whenever I want. Sometimes I go out after midnight if I cannot sleep. The staff do not go out with me.
On 7/20/21 at 11:00 AM, V1 (Administrator in Training) stated she was not aware that it was in the smoking policy that the residents needed to be supervised while smoking and could not keep the smoking materials with them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to cleanse a resident's perineal area during incontinence care for one of one resident (R30) reviewed for incontinence care in th...
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Based on observation, interview and record review, the facility failed to cleanse a resident's perineal area during incontinence care for one of one resident (R30) reviewed for incontinence care in the sample of 37.
Findings include:
The facility's Perineal Cleansing policy, dated 12/2017, documents, To eliminate odor; to prevent irritation and to enhance resident's self-esteem. This same policy documents Procedure: Female without catheter. 4. Wet washcloth with cleansing agent chosen. 5. Wash pubic area including upper and inner aspect of both thighs and frontal portion of perineum. a. Using long strokes from the most anterior down to the base of the labia. b. After each stroke refold the cloth to allow use of another area. 6. Follow same sequence for rinsing area, if applicable. 7. Place soiled items in plastic bag. 8. Dry thoroughly.
R30's Current care plan, dated 1/13/23, documents R30 has an Alteration in Bowel and Bladder elimination as related to incontinence.
On 7/19/23 at 3:20 PM, V6 (Registered Nurse) and V2 (Licensed Practical Nurse/ Resident Care Coordinator) went in R30's room to complete incontinence care and wound care. V6 removed R30's urine soiled brief and then proceeded to care for R30's coccyx wound. V6 and V2 then placed a clean incontinence brief under R30 and fastened it. No perineal care or cleansing of the perineum was completed after removing or before placing a new incontinence brief.
On 7/19/23 at 3:35 PM V6 and V2 both confirmed that R30's brief contained urine and that they didn't use any cleaning agent or wipes to cleanse R30's perineal area. V2 stated, We use (perineal cleansing agent) during incontinence care, normally.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a physician ordered supplement, obtain a weig...
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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 a physician ordered supplement, obtain a weight upon admission, and obtain weekly weights following admission for one of two residents (R195) reviewed for weight loss in the sample of 37. These failures resulted in R195 having a significant weight loss of 11.2 lbs. (pounds)/6% in one month.
Findings include:
The facility's Resident Weight Monitoring policy, dated 9/08, documents, New admission weight is obtained within 24 hours of admit. All new admissions and readmissions will be weighed weekly for at least four weeks. If the monthly weight shows a significant change (i.e., 5% +/- in 30 days, 7.5%+/- in 90 days, or 10% +/- in 180 days) the resident will be re-weighed.
On 07/18/23 at 09:31 AM, R195 was alert sitting up in his bed. R195 stated he is of Islamic religion and is not able to have any food with any kind of pork or pork product in it. R195 stated, However, the kitchen doesn't care. They send me things all the time with pork in it. When I tell them I can't eat what they are serving, all I get for a substitute is a grilled cheese sandwich. They tell me (R195) that a grilled cheese sandwich is a nutritive exchange for the protein. I'm losing weight, and I get a sandwich that is no more than 300 calories. I've never been weighed in this facility. If they have a weight in the computer they are lying.
R195's Hospital discharge exam, dated 6/18/23, documents that R195's discharge weight was 186 lbs.
R195's Order Summary Report, dated 7/18/23, documents that R195 was admitted to the facility on [DATE], and received an order on 6/19/23 to receive Boost (liquid supplement) daily.
R195's electronic weight, dated 7/20/23, documents the only weight obtained for R195 was on 6/29/23 with his weight being 167.2 lbs.-pounds (18.8 lbs. lost-10.1% since hospital discharge weight in less than one month). Weight was documented by V16 (CNA-Certified Nursing Assistant), and no reweigh was completed.
On 07/20/23 at 09:00 AM, V16 stated, I don't know if I weighed (R195). I know my name is documented that I did, but I don't know if I did or not.
R195's Dietician note, dated 6/29/23, documents, Nurse reports resident's physician added Boost order. Administration spoke with resident about facility not providing Boost - resident willing to receive Med Pass (liquid supplement) provided by facility. Nurse to change order from Boost to Med Pass.
R195's Order Summary report, dated 7/18/23, documents R195 received an order on 7/4/23 to receive 2.0 calorie supplement one time daily.
On 07/20/23 at 09:11 AM, V3 (Dietary Manager) stated, When a resident is admitted they should be weighed within the first three days and then monthly after that. The dietician reviews the weights each time she is here to look for significant weight loss. I know our policy says weekly weights when they are admitted , but we do monthly. (R195) came with an order to get Boost daily. We don't provide Boost; the family has to provide that. I know his family didn't provide it so we switched him to our Medpass (supplement) on 7/4/23. He didn't receive any kind of supplement before the Medpass was ordered since the family didn't provide the boost. V3 confirmed R195 was not weighed upon admission nor weekly.
On 07/20/23 at 08:42 AM, V1 (Administrator in Training) stated, I just went to weigh R195 and he weighs 174.8 lbs. (11.2 lbs. lost-6% in one month).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure oxygen tubing and oxygen humidity were dated for one of one resident (R30) reviewed for oxygen administration in the sa...
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Based on observation, interview and record review, the facility failed to ensure oxygen tubing and oxygen humidity were dated for one of one resident (R30) reviewed for oxygen administration in the sample of 37.
Findings include:
The facility's Oxygen Therapy policy, dated 3/2019, documents Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. 13. Change oxygen tubing/mask/cannula/ and/or tracheostomy mask on a weekly basis. Date tubing changes and document on treatment sheet.
R30's current care plan, dated 3/16/23, documents, (R30) requires the use of Oxygen related to diagnosis of COPD (Chronic Obstructive Pulmonary Disease) and SOB (Shortness of Breath).
On 7/17/23 at 10:50 AM, R30 was in her room sitting in high-back wheelchair with Oxygen on via nasal cannula at four liters and connected to a humidity bottle. R30's Oxygen tubing and humidity bottle were both undated.
On 7/19/23 at 9:15 AM, R30 was in her room lying in bed sleeping. R30 had Oxygen on via nasal cannula at 4 liters and connected to a humidity bottle. R30's Oxygen tubing and humidity bottle did not have a date. V6 (Registered Nurse) confirmed there was no date on R30's oxygen tubing and humidity. R30 stated, Night shift changes that so I'll have to see when it got changed. They should be dated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to document justification to warrant the use of an antipsychotic, monitor for behaviors, perform a gradual dose reduction, and c...
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Based on observation, interview, and record review, the facility failed to document justification to warrant the use of an antipsychotic, monitor for behaviors, perform a gradual dose reduction, and complete an AIMs (Abnormal Involuntary Movement) assessment for two of three residents (R10, R12) reviewed for antipsychotics in the sample of 37.
Findings include:
The facility's Psychotropic Medication policy, dated 6/17/22, documents, It is the policy of this facility that residents shall not be given unnecessary drugs. Unnecessary drug is any drug used: Without adequate indications for its use. Any resident receiving such medications shall have a psychiatric diagnosis or documented evidence of maladaptive behavior, which can be considered harmful to themselves or others, destructive to property, or if emotional problems exist which cause the resident frightful distress. Residents who use antipsychotic drugs hall receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to discontinue the drugs. Reductions shall be attempted at least twice in one year, unless the physician documents the need to maintain the resident regimen according to the regulatory guidelines for such. Any resident receiving any psychotropic medication will have certain aspects of their use and potential side effects addressed in the resident's care plan at quarterly. The care plan will identify target behaviors causing the use of psychotropic medications. The care plan will address the problem, approaches, and goals to address these behaviors.
1. On 07/18/23 at 09:54 AM, R10 was alert sitting up in a wheel chair sitting at the nurses' desk. R10 was pleasantly confused and smiling. R10 was not displaying any behaviors.
On 07/18/23 at 11:24 AM, V24 (R10's Family) stated, The only behaviors I know of that he has is being verbally abusive at times and flirting with the nurses. He's generally pretty pleasant. He's a social guy and likes to be out an about with other residents at activities just to socialize.
On 07/19/23 at 10:38 AM, R10 was aimlessly self-propelling himself in the hallway. R10 was pleasantly confused, smiling, and not displaying any behaviors.
R10's Order Summary Report, dated 7/19/23, documents that R10 has an order to receive Seroquel (antipsychotic) 25 mg (milligrams) half tablet (12.5 mg) by mouth in the evening for the diagnosis of dementia.
R10's Psychotropic care plan, dated 5/15/23, documents, R10 requires use of psychotropic medication to manage mood and/or behavior issues. Class of drug: Antidepressant. Related diagnosis: Major Depressive Disorder. Behaviors exhibited: Withdrawn, little to no interest in doing things. R10's care plan is not revised to include R10's use of an antipsychotic, diagnosis for the use of an antipsychotic, nor the behaviors indicated for the use of an antipsychotic.
R10's Behavior Monitoring and Interventions, dated 7/19/23, documents from the date range of 6/1-7/19/23, R10 had zero episodes of behaviors.
On 07/19/23 at 01:13 PM, V2 (Resident Care Coordinator-RCC) stated, He was admitted to the facility on the Seroquel. The diagnosis we have for (R10's) Seroquel is Dementia with behaviors. The only behaviors he has are being loud and combative with the staff, but this is normally after around 3 or 4 p.m. with his sun-downing. He doesn't ever direct his behaviors at other residents or try to hurt them. I don't do the psychotropic monitoring. That is one of the jobs that the Director of Nursing would do if we had one. I am the RCC so my responsibilities are schedules and managing the CNAs (Certified Nursing Assistants). (R10) does not have an AIMs assessment.
2. R12's Physician Order, dated 7/20/23, documents that R12 has an order to receive Haloperidol 2 milligrams (mg), give one tablet orally one time a day for mood disorder.
R12's Consultation Report dated 3/17/23, documents that R12 has been taking Haldol 2 mg by mouth every evening since 9/30/22. The report also documents, Please attempt a gradual dose reduction (GDR) of Haloperidol to 2 mg q o (every other) pm (evening) alternating with 1 mg q o pm. V23 (R12's Primary Care Physician) declined the recommendation due to severe Post Traumatic Stress Disorder with hallucinations.
R12's current medical record has no documentation of a GDR of R12's Haldol since it was started on 9/30/22 nor is there documentation of behavior tracking.
On 7/19/23 at 3:47 PM, V2 (Licensed Practical Nurse/Resident Care Coordinator) stated there is no Behavior Tracking for R12 and there has not been a Gradual Dose Reduction for R12 due to R12's family not wanting the Haldol reduced.
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 observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two of two residents (R9, R10) reviewed for medication erro...
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Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for two of two residents (R9, R10) reviewed for medication errors in the sample of 37.
Findings include:
The facility's Medication Administration policy, dated 11/18/17, documents, Drug administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given.
The facility's Adverse Drug Reactions and Medication Discrepancy policy, dated 11/6/18, documents, It is the policy of the facility that adverse drug reactions and drug errors are to be reported to the resident's physician, documented in the nursing notes and documented in the Adverse Drug Reaction or Medication Discrepancy Report. These reports are to be completed in coordination with the Director of Nursing and filed with the Administrator and reviewed by the Medical Director and Consult Pharmacist. This policy also documents A medication discrepancy/error has been made when one of the following occurs: Wrong medication administered. Wrong dose administered. Medication administered by wrong route. Medication administered to wrong resident. Medication administered at wrong time. Medication not administered. A medication discrepancy report shall be completed for any of the above occurrences.
1. R9's Physician Order Sheet, dated 7/19/23, documents R9 has diagnoses of Cognitive Communication Deficit and Schizophrenia. This same order sheet documents R9 has an order to receive Divalproex Sodium Delayed release (anticonvulsant medication) 125 milligrams by mouth daily for Schizophrenia with a start date of 1/31/23, Nuedexta (central nervous system agent) 20-10 milligrams by mouth every 12 hours for Schizophrenia with a start date of 11/11/22, and Quetiapine (antipsychotic medication) 50 milligrams by mouth at bedtime for Schizophrenia with a start date of 11/30/22.
R9's Medication Administration Record (MAR), dated 5/1/23-5/31/23, documents the 8:00 PM dose of Nuedexta and the 8:00 PM dose of Quetiapine for the entire month are circled administrations, meaning they were not given for the month of May.
R9's Progress notes for May 2023 do not document why R9 was not given the evening doses of his scheduled medication.
R9's MAR, dated 6/1/23-6/30/23, documents that on 6/13, 6/14, 6/17 and 6/18, R9 was not given his daily dose of Divalproex for a reason of other/see progress notes.
R9's Nursing progress notes for 6/13,14,17 and 18, document Divalproex Sodium Delayed release 125 milligrams, Give 1 tablet orally one time a day for Schizophrenia, not given; not available
R9's MAR, dated 7/1/23-7/31/23, documents that on 7/5, 7/6 and 7/7, R9 was not given his daily dose of Quetiapine for a reason of other/see progress notes.
R9's Nursing progress notes for 7/5,6 and 7, document Quetiapine 50 milligrams, Give 1 tablet orally at bedtime for Schizophrenia, medication not available.
On 7/19/23 at 2:10 PM, V2 (Licensed Practical Nurse/ Resident Care Coordinator) confirmed that there are several times in May, June and July R9 did not receive his scheduled medications for schizophrenia. V2 stated, When the MAR has medication administration circled like that, it means the medication was not given. They should be documenting in the nurses notes why the medication wasn't given. I do not have any discrepancy reports to show what happened or that the physician was ever notified. Maybe the resident refused, or the medication was out of stock. We shouldn't be running out of medications but it sometimes happens or maybe the resident was sleeping and the nurse didn't want to wake him up. But nurses should be waking (R9) up to take scheduled medications. The entire month of May (R9) was not given the 8:00 PM doses. There is no way we were out of the medication all month long.
2. On 07/18/23 at 09:54 AM, R10 was alert sitting up in a wheel chair sitting at the nurses' desk. R10 was pleasantly confused and smiling.
R10's Post Acute Care Transition Document, dated 12/23/22, documents R10 was discharged from the hospital with physician orders to receive Seroquel (antipsychotic) 25 mg (milligrams) 1/2 tablet (12.5 mg) by mouth at night.
R10's Physician's orders, dated 12/24/23, document R10's Seroquel admission order was transcribed for R10 to receive Seroquel 25 mg by mouth every evening.
R10's Pharmacy Consultation Report, dated 1/26/23, documents, During the review of R10's medical record, the following irregularities were noted on the medication administration record/prescriber order sheet: The dose of Quetiapine on the admission orders was 12.5 mg (half tab of 25 mg) but it was transcribed to the POS (Physician Order Sheet) as a dose of 25 mg (full tab).
R10's MAR (Medication Administration Record), dated 12/24-12/31/23, documents that R10 received Seroquel 25 mg by mouth at night from 12/24-12/31/23.
R10's MAR, dated 1/23, documents that R10 received Seroquel 25 mg by mouth at night from 1/1-1/31/23. R10's Physician's orders, dated 1/23, document that an order clarification was received on 1/31/23 for R10 to receive Seroquel 12.5 mg by mouth every evening.
On 07/19/23 at 01:13 PM, V2 (Resident Care Coordinator) stated, (R10) receiving double the dose of Seroquel would be a significant medication error, and I can tell you we didn't do a medication error report on it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident understood the arbitration agreement and failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident understood the arbitration agreement and failed to inform a resident of their ability to rescind the agreement for one of three residents (R197) reviewed for arbitration in the sample of 37.
Findings include:
R197's Order Summary Report, dated 7/19/23, document that R197 was admitted to the facility on [DATE].
On 07/18/23 at 10:53 AM R197 stated, I did my admission contract with (V11 Social Services Director) She went over arbitration with me, and I signed the arbitration agreement. However, she did not explain to me that I was giving up my rights to legal action. If I had known that I would have never signed it. I want to revoke that now! She never told me I could revoke it either.
R197's Agreement to Resolve Disputes by Binding Arbitration, dated 7/8/23, documents that R197 signed the contract himself as well as V11.
On 07/20/23 at 10:08 AM, V11 (Social Service Director) stated, I do the (admission) contract and the arbitration agreement with the residents. I haven't had any residents decline signing the agreement. I read the agreement to them so they should understand it. I tell the residents that they can revoke it, but I don't even know how long they have to revoke the agreement.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on record review, interview, and observation the facility failed to follow their water temperature policy to maintain water temperatures between 100 to 110 degrees Fahrenheit for five of 37 resi...
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Based on record review, interview, and observation the facility failed to follow their water temperature policy to maintain water temperatures between 100 to 110 degrees Fahrenheit for five of 37 residents (R5, R14, R33, R42, R96) reviewed for water temperature in the sample of 37.
Findings include:
The facility's Water Temperature Control policy (undated) documents, It is the policy of (the facility) to maintain water temperature available to residents between 100- and 110-degrees Fahrenheit (F).
On 7-19-23 at 12:25 PM V12 (Maintenance Director) tested R42's bathroom sink water temperature using a thermometer after the water was running for five minutes. The water was cold to touch and tested at 76 degrees F.
On 7-19-23 at 12:35 PM V12 tested R5's, R14's, R33's, and R96's bathroom sink water temperature using a thermometer after the water was running for two minutes. The water was cold to touch and tested at 72 degrees F.
On 7-19-23 at 11:20 AM R96 stated, My sink water has been cold for months. The CNA's (Certified Nursing Assistants) wash me up with freezing cold water.
On 7-19-23 at 12:40 PM R5 stated, The water here is always cold. I have complained and complained, and nothing changes.
On 7-19-23 at 12:50 PM R42 stated, The sink water is cold. I want it fixed.
On 7-19-23 at 12:35 PM V12 stated, I do not know why these bathroom sinks (R5, R14, R33, R42 and R96 sinks) have cold water. It could be from lime or rust build-up.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R195's Care plan tracking, dated 7/20/23, documents R195 was admitted to the facility on [DATE]. The tracking has no document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R195's Care plan tracking, dated 7/20/23, documents R195 was admitted to the facility on [DATE]. The tracking has no documentation of a comprehensive care plan being completed.
On 07/19/23 at 11:19 AM, V7 (MDS/Care plan Coordinator) stated R195's admission comprehensive care plan has not been completed.
4. R196's Care plan tracking, dated 7/20/23, documents R196 was admitted to the facility on [DATE]. The tracking has no documentation of a comprehensive care plan being completed.
On 07/19/23 at 11:19 AM, V7 stated R196's admission comprehensive care plan has not been completed. V7 also stated, I'm so far behind with MDSs and care plans. Anyone who was admitted after 6/1/23 I don't have their MDSs or care plans done.
Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a smoker, a resident receiving hospice services, and within 21 days of admission to the facility for four of 15 residents (R9, R23, R195, R196) reviewed for care plans in the sample of 37.
Findings include:
The facility's Comprehensive Care Planning policy, dated 7/20/22, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining resident strengths, needs, goals, life history and preferences to develop a comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The following procedures shall be utilized in the development and maintenance of care plans: The Comprehensive Care Plan (CCP) shall be developed within 7 days of the completion of the RAI (Resident Assessment Instrument). A. The CCP shall be reviewed after each annual, significant change and quarterly MDS (Minimum Data Set assessment) and revised as necessary to reflect the resident's current medical, nursing, and mental and psychosocial needs as identified. B. The care plan shall be revised as necessary when the needs/problems and care and services specified in the plan of care no longer reflect those of the resident. C. The IDT (Interdisciplinary Team) may determine a comprehensive revision of the Plan of Care may warrant a significant change MDS. Documentation of such a decision shall be contained in the resident record.
1. R9's Physician Order Sheet, dated 1/16/23 documents Discontinue occupational therapy, Patient Hospice.
R9's current care plan does not document a plan of care for Hospice services.
On 7/20/23 at 10:45 AM V7 (Licensed Practical Nurse/ MDS Coordinator) stated she does the care plans in the facility. V7 stated, (R9) doesn't have a Hospice care plan and should. He went Hospice in January 2023 and I started in February, so it should've been on there in January when he switched to Hospice.
2. R23's current Medical Record, documents R23 was admitted to the facility on [DATE].
R23's Smoking assessment dated [DATE], documents R23 can smoke independently.
On 7/20/23 at 10:45 AM, R23 pulled a pack of cigarettes out of his front pant pocket. There were two lighters in the top drawer of the nightstand. R23 had the smell of smoke on his clothing. R23 stated he goes out to smoke whenever he wants.
R23's current Care Plan does not document a smoking care plan for R23.
On 7/20/23 at 10:05 AM, V7 (Minimum Data Set Coordinator/MDS) stated there was not a Care Plan for R23 because she did not know he was a smoker until he was seen smoking with a family member.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on record review, interview, and observation the facility failed to date multi-dose insulin pens once opened for four of eight residents (R2, R13, R39, R198) reviewed for insulin medication stor...
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Based on record review, interview, and observation the facility failed to date multi-dose insulin pens once opened for four of eight residents (R2, R13, R39, R198) reviewed for insulin medication storage in the sample of 37.
Findings include:
The facility's Procurement and Storage of Medications policy dated 03/2017 documents, All medication containers shall be labeled with the date opened by the person breaking the container seal.
On 07/18/23 at 11:35 AM R2's open Lantus Insulin Flexpen100 u (units) per ml (milliliter), R13's open Lantus Insulin Flex pen 100 u per ml, R39's open Lispro Insulin Kwik pen 100 u per ml, and R198's open Novolin R Insulin Flex pen three ml/100 u per ml were all located in the top drawer of the east hallway medication cart. These same insulin pens for R2, R13, R39 and R198 were opened and not labeled with the date the insulin pens were opened.
On 07/18/23 at 11:41 AM V5 (LPN/Licensed Practical Nurse) stated, All insulin pens should be dated when opened.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
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 to provide activities to meet the needs and interests of...
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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 activities to meet the needs and interests of all the residents. This had the potential to affect all 45 residents residing within the facility.
Findings include:
The Facility's Activity Director Job Summary (undated) documents, The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the resident's plan of care. The Activity Director completes the activity assessment for each resident and participates in developing the interdisciplinary care plan. Responsibilities: 1. Plan, organize, and coordinate an activity program according to established policies. 2. Plan group and individual activities designated to restore self-care and well-being and geared to the individuals needs and interest. 3. Develop and appropriate plan of activities for and visit residents who are bedfast, unwilling, or unable to participate in group activities. 4. Group and individual activities will be based on interdisciplinary care plans and assessments. 5. Within 48 hours of admittance, he/she will complete the new resident interim assessment. 6. Within 14 days of admittance, and quarterly thereafter, the activity director will assess and attend the care plan conference to develop/review an interdisciplinary plan of care. 7. Charts monthly activity progress notes for each resident. 11. Prepares and posts a monthly activities calendar indicating schedules activities and their times for the coming month.
The facility's Activity Policy, undated, documents, It is the policy of (facility) to provide an ongoing program of activities, designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. Residents shall have the opportunity to contribute to planning, preparation, conducting, clean up and critiquing of programs.
On 7/17/23 at 9:45 a.m., upon entrance to the facility no activities were occurring. There was no calendar of activities posted within the facility.
On 7/17/23 at 10:30 AM, R246 was in her room sitting in a wheelchair with mechanical lift sling under her. R246 was asked if she is watching television. R246 stated, Yes, there's nothing else to do.
On 7/17/23 at 10:44 a.m., V1 (Administrator in Training) stated the facility has not had an Activity Director for at least two weeks.
On 07/17/23 at 11:14 AM, R23 was lying in bed watching television (TV). R23 stated he leaves his room to smoke, goes to meals, and watches TV and that's about it.
On 07/17/23 at 01:29 PM R196 was sitting on the side of the bed in his room. R196 stated, We don't have anything to do around here. They don't have an activity director right now. Heck we would even like to just play some bingo or go on some outings.
On 07/18/23 at 09:31 AM, R195 was alert sitting up in his bed. R195 stated, We don't have any activities here. I've never been given anything about any activities even occurring. I would socialize and do things, but there's no activities for us to even do.
R195's Online MDS (Minimum Data Set) tracking, dated 7/18/23, documents R195 was admitted to the facility on [DATE].
On 07/18/23 at 08:43 AM, R197 was lying in bed. R197 stated, I've been here a little over a week, and I haven't heard of any activities going on. I'd love to be active and socialize with other residents. I'm a very social person. It would be nice if there were outings outside of the facility, but there isn't any activities period. I haven't left this room since I've been here.
R197's Order Summary report, dated 7/19/23, documents R197 was admitted to the facility on [DATE].
On 07/18/23 at 09:54 AM, R10 was alert sitting up in a wheel chair sitting at the nurses' desk with no activities occurring within the facility. R10 was pleasantly confused and smiling.
R10's Activity Care plan, dated 5/15/23, documents interventions of: Provide monthly activity calendar and newsletter; Invite, remind, and escort to and from activities of choice and praise involvement.
On 07/18/23 at 10:40 AM, the dining room was empty, and the Activity room was locked and empty. The assist dining room was dark and empty. No activities were taking place within the facility.
On 07/19/23 at 10:38 AM, R10 was aimlessly self-propelling himself in the hallway. R10 was pleasant smiling and not displaying any behaviors. There were not activities occurring within the facility at the time.
On 07/19/23 at 11:21 AM during the resident council meeting R3, R4, R10 R95, R96, R196, and R201 all stated they have not had any activities offered for over a month
On 07/19/23 at 03:32 PM, no activities were occurring within the facility. V13 (Registered Nurse) stated, They don't have any activities ever going on here.
On 07/20/23 at 10:25 AM, V25 (LPN-Licensed Practical Nurse) stated, The facility does not have activities ever, and the residents are bored.
On 7/17/23 - 7/20/23 random observations were made of R12 walking the halls of the facility.
On 7/20/23 at 9:50 AM, R12 stated, They don't have any activities. I would like them, I get bored. It's depressing, it is not a good use of time.
On 07/20/23 at 10:33 AM, V23 (CNA-Certified Nursing Assistant) stated, The biggest issue for the residents right now is activities. They are going stir crazy without having any activities. The behaviors have increased. Residents are irritable with each other and we've had more falls. (R9) is one that his behaviors have significantly increased. He wasn't active when he went to activities, but he loved being a part of the activity being present. His favorite thing was just sitting in the activity room during coffee time and having a cup of coffee. Now he has nothing to do and he acts out.
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to employ a full-time Activity Director. This failure had the potential to affect all 45 residents residing in the facility.
Fin...
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Based on observation, interview, and record review, the facility failed to employ a full-time Activity Director. This failure had the potential to affect all 45 residents residing in the facility.
Findings include:
The Facility's Activity Director Job Summary (undated) documents, The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the resident's plan of care. The Activity Director completes the activity assessment for each resident and participates in developing the interdisciplinary care plan. Responsibilities: 1. Plan, organize, and coordinate an activity program according to established policies. 2. Plan group and individual activities designated to restore self-care and well-being and geared to the individuals needs and interest. 3. Develop and appropriate plan of activities for and visit residents who are bedfast, unwilling, or unable to participate in group activities. 4. Group and individual activities will be based on interdisciplinary care plans and assessments. 5. Within 48 hours of admittance, he/she will complete the new resident interim assessment. 6. Within 14 days of admittance, and quarterly thereafter, the activity director will assess and attend the care plan conference to develop/review an interdisciplinary plan of care. 7. Charts monthly activity progress notes for each resident. 11. Prepares and posts a monthly activities calendar indicating schedules activities and their times for the coming month.
The facility's Activity Policy, undated, documents, It is the policy of (facility) to provide an ongoing program of activities, designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests.
On 7/17/23 at 9:45 a.m., upon entrance to the facility no activities were occurring. There was no calendar of activities posted within the facility.
On 7/17/23 at 10:44 a.m., V1 (Administrator in Training) stated the facility has not had an Activity Director for at least two weeks.
The Facility's Assessment Tool dated 3-29-23 does not include any documentation of the facility having a current Activity Director.
Throughout the survey, 7/17-7/20/23, no Activity Director was observed in the facility.
On 07/19/23 at 11:21 AM during the resident council meeting R3, R4, R10 R95, R96, R196, and R201 all stated they have not had any activities offered for over a month
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review, interview, and observation the facility failed to employ a full time Director of Nursing (DON) to oversee nursing services and failed to ensure a Registered Nurse (RN) worked a...
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Based on record review, interview, and observation the facility failed to employ a full time Director of Nursing (DON) to oversee nursing services and failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 45 residents residing within the facility.
Findings include:
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
The facility's Director of Nursing Job Description undated documents, Job Summary: To plan, organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. Qualifications: 3. Must possess a current, unencumbered, active license to practice as a registered nurse in this state.
The facility's Nurse Staffing policy (undated) documents, It is the policy of (the facility) to provide sufficient licensed and nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. A minimum of 25 percent of nursing and personal care time shall be provided by licensed nurses, with at least ten percent of nursing and personal care time provided by registered nurses.
The Facility's Assessment Tool dated 3-29-23 documents, Part Three: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Nursing Services-DON (Director of Nursing). This same assessment does not include any documentation of the facility having a current DON.
The facility's Nurse Schedule dated July 1 to July 31, 2023, documents the facility did not have the services of a registered nurse at least eight hours a day on 7-3-23, 7-7-23, 7-8-23, and 7-9-23.
On 7-17-23, 7-18-23, 7-19-23, 7-20-23 from 9:45 AM through 2:45 PM there was no Director of Nursing present within the facility.
On 07/19/23 at 11:21 AM during the resident council meeting R3, R4, R10 R95, R96, R196, and R201 all stated they have not had a Director of Nursing so when they have concerns with cares they have no one to go to.
On 07/19/23 at 01:13 PM, V2 (Resident Care Coordinator/RCC) stated, I don't do the psychotropic monitoring. That is one of the jobs that the DON would do if we had one. I am the RCC so my responsibilities are schedules and managing the CNAs.
On 07/19/23 at 03:00 PM V2 (Resident Care Coordinator) stated, I am responsible for scheduling the nurses. There was no registered nurse scheduled in the facility on 7-3-23, 7-7-23, 7-8-23, and 7-9-23. The facility did not have enough nurses to have a registered nurse work every day.
On 07/20/23 at 9:45 AM V1 (Administrator-In-Training) stated, The facility has not had a full-time Director of Nursing since February 2023. (V17/Former DON) last day worked was 2-21-23.
On 07/20/23 at 10:25 AM, V25 (LPN) stated, I work agency, but I can tell that there isn't a DON. (V2/Resident Care Coordinator) cannot get everything done that a DON would do.
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to provide food substitutions of equal nutritive value. This had the potential to affect all 45 residents residing in the facility.
Findings i...
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Based on interview and record review, the facility failed to provide food substitutions of equal nutritive value. This had the potential to affect all 45 residents residing in the facility.
Findings include:
On 07/17/23 at 01:29 PM R196 was alert sitting on the side of his bed. Clean well kempt. R196 stated, We don't get any kind of choices if we don't like the meal they are serving except grilled cheese, peanut butter and jelly, or lunch meat sandwiches. Normally it's only lunch meat sandwiches.
On 07/18/23 at 08:43 AM, R197 stated, I've never been offered any kind of substitute since I've been here. I just take what they've given me.
On 07/18/23 at 09:31 AM, R195 was alert sitting up in his bed. R195 stated, I'm of Islamic religion, and I'm not able to have any food with any kind of pork or pork product in it. However, the kitchen doesn't care. They send me things all the time with pork in it. When I tell them I can't eat what they are serving, all I get for a substitute is a grilled cheese sandwich. Tell me that a grilled cheese sandwich is a nutritive exchange for the protein. I'm losing weight, and I get a sandwich that is no more than 300 calories. I voiced this concern to (V1 Administrator in training) last night and all she said was she would have (V3 Dietary Manager) send me two grilled cheeses. I told her no; I want other choices of food to eat besides just grilled cheese.
On 07/19/23 at 11:21 AM, during the resident council meeting R3, R4, R10 R95, R96, R196, and R201 all stated the substitutes offered are lunch meat sandwiches and they never get offered lettuce salads or warm food as a substitute.
On 07/20/23 at 09:00 AM, V16 (CNA-Certified Nursing Assistant) stated, The only substitutes the residents are offered are peanut butter and jelly, lunch meat sandwiches, and grilled cheese.
On 07/20/23 at 10:33 AM, V23 (CNA), stated, The kitchen only offers peanut butter and jelly, grilled cheese, and cold cut sandwiches. It really depends on who is working as to which option of those you even get. They don't offer anything else for substitutes regardless of what they say.
On 07/19/23 at 09:48 AM, V1 (Administrator in Training) stated, We are a small facility so we aren't able to serve buffet style to have multiple options for the residents. However, the kitchen can always get them a grilled cheese or lunch meat sandwich.
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
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 record review, interview, and observation the facility failed to label and date 21 containers of mixed fruit and 12 deli-meat sandwiches when prepared and stored in the refrigerator. These fa...
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Based on record review, interview, and observation the facility failed to label and date 21 containers of mixed fruit and 12 deli-meat sandwiches when prepared and stored in the refrigerator. These failures have the potential to affect all 45 residents who reside within the facility.
Findings include:
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
The facility's Refrigerator and Freezer Storage policy dated 10/2009 documents, It is the policy of (the facility) that any item to be placed in the refrigerators and freezers must be covered, labeled, and dated with a date-marking system that tracks when to discard perishable foods. Procedure: 2. [NAME] container with name of item. [NAME] the date that the original container is opened or date of preparation.
On 07/17/23 at 10:14 AM there were 21 small containers with lids that contained mixed fruit and 12 deli-meat sandwiches located inside a two-door refrigerator. These containers of fruit and sandwiches were not labeled or dated when prepared. V4 (Cook) stated, These are mixed fruit cups and ham sandwiches. They are not labeled. All food should be labeled and include dates of when the food was prepped. I guess the staff did not have time to label the fruit and sandwiches. The fruit and sandwiches are given to all residents whenever residents request them.
On 07/17/23 at 11:30 AM V3 (Dietary Manager) stated, All food should be dated and labeled when it is prepared and put into the refrigerator.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to employ a full-time Administrator to manage, plan, organize, staff, direct, coordinate, report, and provide physical management...
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Based on observation, interview, and record review the facility failed to employ a full-time Administrator to manage, plan, organize, staff, direct, coordinate, report, and provide physical management to the facility. This failure has the potential to affect all 45 residents residing within the facility.
Findings include:
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
The facility's Job Description Administrator dated and signed by V1 (Administrator-In-Training) on 11-21-22 documents, Job Summary: The Administrator is responsible for managing, planning, organizing, staffing, directing, coordinating, reporting, budgeting, and the physical management of the facility, residents, and equipment in a way that the purpose of the facility shall be maintained in accordance with all established practices, policies, laws, and applicable State Regulations. The Administrator will manage and conduct the business of the facility in a manner that protects the facility license and certification at all times. The major goal of the Administrator is to provide an atmosphere in which residents may achieve their highest physical, mental, and social well-being. Qualifications: The Administrator must be qualified through a combination of education, experience, and training to manage a nursing facility. Knowledge of business administration, nursing care, and human relations is necessary, He/she must hold, or be eligible for, a nursing home administrator's license in the state which he/she is practicing. Responsibilities: 1. Operate the facility in compliance with all Federal and State rules and regulations. 2. Operate the facility in accordance with established policies and procedures. 3. Assist in developing and establishing a budget and managing within it. 4. Appoint a Director of Nursing and other department heads. 5. Supervise department heads. 6. Assure proper facility and department operation through the implementation of the specified Quality Assurance Program. 7. Responsible for maintaining good business practices. 8. Establish and conduct annual public relations program promoting the facility.
On 07/19/23 at 11:21 AM during the resident council meeting R3, R4, R10 R95, R96 R196, and R201 all stated they have not had any activities offered for over a month and have also not had a Director of Nursing. These same residents stated that when they have concerns with cares, they do not know who to report to. These residents also stated the substitutes offered are lunch meat sandwiches and they never get offered lettuce salads or warm food as a substitute.
On 7-17-23, 7-18-23, 7-19-23, 7-20-23 from 9:45 AM through 2:45 PM there was no licensed Administrator present within the facility.
On 7-20-23 at 9:45 AM V1 (Administrator in Training) stated, I have a bachelor's degree in Therapeutic Recreation/Leisure Services. I have not applied for a temporary Administrator's license yet. I am waiting on the college to send me the information I need to apply for a temporary Administrator's license. (V14/Administrator) has her license hanging in the facility. I took over for (V14) the end of June 2023. (V14) was here for one hour yesterday and five hours last Friday (7-14-23). That is the only time (V14) has been here since the end of June 2023. I have not had a DON (Director of Nursing) in the building since 2-21-23. I have not had an activity director in the building since 4-27-23. We (the facility) have not identified or developed any plans of action during the QAA meeting to address the facility not having a Director of Nursing, not having registered nurse eight hours daily, not having an activity director or activities, having late MDS assessments, or not having food substitutes.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the Governing Body failed to be consistently involved in the management and operation of the facility, failed to implement policies related to facilit...
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Based on observation, interview and record review the Governing Body failed to be consistently involved in the management and operation of the facility, failed to implement policies related to facility operations and resident care, including, Accommodation of Needs, Comfortable Homelike conditions, MDS (Minimum Data Set) assessments and care plans being completed timely and accurately, Psychotropics, Activities, Pressure Ulcers, Significant Weight Loss, Significant Medication Errors, Smoking supervision, Staffing, Medication storage, Incontinence Care, and Infection control. The Governing Body failed to ensure Director of Nursing and Activity Director responsibilities were completed. This failure has the potential to affect all 45 residents residing in the facility. Cross reference to F558, F584, F636, F637, F638, F655, F656, F657, F679, F680, F686, F689, F690, F692, F695, F727, F732, F758, F760, F761, F806, F812, F825, F867, F868, and F880.
Findings include:
The facility's Corporate Compliance & Ethics Program Overview (5/2021) documents Corporate's management staff (Directors, Regionals' and Administrators') are responsible for monitoring the compliance and ethics program. The Corporate Compliance & Ethics Program was reviewed, and the Code of Conduct was revised and distributed to all employees. Corporation Operation and Nursing Policies and Procedures are in place and cover areas related to Corporate Compliance and Ethics. A Mandatory In-service List is provided to all Administrators to ensure education is conducted at least annually. Regional Directors conduct audits throughout the year during visits on areas of risk as identified. The Regional Teams and others identified by the Regional Teams conduct mock surveys annually. External Audits are conducted periodically. The following documents are incorporated within the Corporate Compliance and Ethics Program. This list is not all inclusive: Operational Policies and Procedures; Nursing Policies and Procedures; New Administrator Training Manual; New DON (Director of Nursing) Training Manual, Resident Admissions Packet, SWAT Programs; Quality Improvement Programs, Quality Assessment and Assurance Committee Policy Abuse Prevention Program, Employee Handbook, Employee and Resident Satisfaction Surveys, Equal Employment Opportunity policy False Claims, Whistle Blower & Drug Free Workplace Policy.
Upon entering the facility on 7/17/23 at 9:45 am, V1 (Administrator in Training) explained that V2 (Licensed Practical Nurse/Resident Care Coordinator) was Acting DON (Director of Nursing). V1 indicated this was the facility's current Administrative Staff. V14's (Administrator for another facility in the cooperation) Nursing Home Administrator's license is hanging on the wall of the facility. V1 stated the facility has not had someone in the position of DON for a length of time, but V2 has been filling in until the new DON can start. V1 stated the facility does not have an Activity Director.
On 7-20-23 at 9:45 AM V1 stated, I have not applied for a temporary Administrator's license yet (V14/Administrator) has her license hanging in the facility. I took over for (V14) the end of June 2023. (V14) was here for one hour yesterday and five hours last Friday (7-14-23). That is the only time (V14) has been here since the end of June 2023. The governing body of this facility is (V14) and (V20/Regional Director of Clinical Operations). I answer to (V14 and V20). I have not had a DON (Director of Nursing) in the building since 2-21-23. I have not had an activity director in the building since 4-27-23.
On 7-17-23, 7-18-23, 7-19-23, 7-20-23 from 9:45 AM through 2:45 PM there was no licensed Administrator present within the facility.
1. The Facility's Director of Nursing job description (no date) documents, Job Summary: To plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility and as may be directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times.
On 07/19/23 at 01:13 PM, V2 (Resident Care Coordinator) stated, I am the RCC so my responsibilities are schedules and managing the CNAs (Certified Nursing Assistant). V2 confirmed V2 does not do any of the actual DON duties, such as overseeing resident care that is delivered by the licensed nursing staff and CNAs.
During the survey, numerous issues regarding, accommodating a resident's need for a wheelchair, significant weight loss, psychotropic monitoring, infection control, significant medication errors, completion of MDSs and care plans timely and accurately, pressure ulcer treatments, smoking supervision. staffing, medication storage, and incontinence care have been identified.
Cross reference findings at F558, F636, F637, F638, F655, F656, F657, F686, F689, F690, F692, F695, F727, F732, F758, F760, F761, and F880.
2. The Facility's Activity Director Job Summary (undated) documents, The Activity Director plans, schedules, and implements an ongoing program of activities designed to meet the physical, mental, and psychosocial needs of each resident. Residents are engaged in a meaningful, varied program of activities that meets the individual residents. The activities are conducted with individuals or in groups, according to the resident's plan of care. The Activity Director completes the activity assessment for each resident and participates in developing the interdisciplinary care plan. Responsibilities: 1. Plan, organize, and coordinate an activity program according to established policies. 2. Plan group and individual activities designated to restore self-care and well-being and geared to the individuals needs and interest. 3. Develop and appropriate plan of activities for and visit residents who are bedfast, unwilling, or unable to participate in group activities. 4. Group and individual activities will be based on interdisciplinary care plans and assessments. 5. Within 48 hours of admittance, he/she will complete the new resident interim assessment. 6. Within 14 days of admittance, and quarterly thereafter, the activity director will assess and attend the care plan conference to develop/review an interdisciplinary plan of care. 7. Charts monthly activity progress notes for each resident. 11. Prepares and posts a monthly activities calendar indicating schedules activities and their times for the coming month.
The facility's Activity Policy, undated, documents, It is the policy of (facility) to provide an ongoing program of activities, designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The program is under the direction of an Activity Director, who shall have a specific planned program of group and individual activities based upon the resident's needs and interests. Residents shall have the opportunity to contribute to planning, preparation, conducting, clean up and critiquing of programs.
During the time of this survey, 7/17-7/20/23, no activities were occurring within the facility. Multiple staff and residents complained about no activities occurring within the facility resulting in a lack of socialization, residents being bored, and an increase in behaviors.
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to develop and implement plans of action through their Quality Assurance and Assessment (QAA) Committee to address a lack in prov...
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Based on observation, interview, and record review the facility failed to develop and implement plans of action through their Quality Assurance and Assessment (QAA) Committee to address a lack in providing meaningful activities, providing equal nutritive value food substitutes, employing a full-time activity director and Director of Nursing, employing at least eight hour of registered nurses daily, and ensuring MDS (Minimum Data Set) Assessments were completed timely. These failures have the facility to affect all 45 residents residing within the facility.
Findings include:
The facility's Quality Assurance Plan (undated) policy documents, (The facility) works to continuously improve the way residents are cared for, safety, and operations within the facility through the Quality Assurance process. Quality assurance activities are to be completed continuously and objectively to provide a comprehensive review of the facility's activities. The purpose of the Quality Assurance Plan is: To help identify problems or potential problems. To provide information upon which corrective action can be planned. To help analyze the need for policy or procedural changes or in-service training. To act as a record that, when analyzed, will prevent similar mishaps or injuries. To improve quality of resident care and overall safety in the facility. The responsibilities of the Quality Assurance Committees are: Quarterly Assurance Committee reviews all the activities of the daily Quality Assurance Team. The Quarterly Committee will review any patterns or trends, areas identified for improvement, and make recommendations as needed.
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
On 07/18/23 at 02:23 PM V7 (MDS/Minimum Data Set) Coordinator stated, I have been doing MDS's since February 2023 and there wasn't anyone prior to me. I have been pulled to work the floor and I fell behind on MDS's with the switch to (electronic medical records). I am waiting to submit about 15 MDS's right now.
On 07/19/23 at 11:21 AM during the resident council meeting R3, R4, R10 R95, R96, R196, and R201 all stated they have not had any activities offered for over a month and have also not had a Director of Nursing. These same residents stated that when they have concerns with cares, they do not know who to report to. These residents also stated the substitutes offered are lunch meat sandwiches and they never get offered lettuce salads or warm food as a substitute.
On 07/18/23 at 10:40 AM the dining room was empty and the activity room door was locked and quiet. There were no activities taking place.
On 07/18/23 at 09:54 AM, R10 was alert sitting up in a wheel chair sitting at the nurses' desk with no activities occurring within the facility.
On 07/19/23 at 10:38 AM, R10 was aimlessly self-propelling himself in the hallway. There were no activities occurring within the facility at the time.
On 07/19/23 at 03:32 PM, no activities were occurring within the facility. V13 (Registered Nurse) stated, They don't have any activities ever going on here.
On 7-17-23, 7-18-23, 7-19-23, 7-20-23 from 9:45 AM through 2:45 PM there was no Director of Nursing present within the facility.
On 07/18/23 at 11:00 AM V1 (Administrator) stated, We (the facility) do not have an activity director. The activity director quit in June. We do not have an activity calendar or schedule of activities. We also have not had a Director of Nursing since February 2023. We have not identified or developed any plans of action during the QAA meeting to address the facility not having a Director of Nursing, not having registered nurse eight hours daily, not having an activity director or activities, having late MDS assessments, or not having food substitutes. I was only able to find one plan of action and it was regarding falls. The facility did not keep logs/minutes of anything that was reviewed in the QAA meetings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on record review and interview the facility failed to ensure the Infection Preventionist and Director of Nursing (DON) attended all quarterly QAA (Quality Assessment and Assurance) meetings. The...
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Based on record review and interview the facility failed to ensure the Infection Preventionist and Director of Nursing (DON) attended all quarterly QAA (Quality Assessment and Assurance) meetings. These failures have the potential to affect all 45 residents who reside within the facility.
Findings include:
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
The facility's List of Quality Assessment and Assurance (QAA) members (undated) and provided on 7-17-23 at 10:45 AM by V1 (Administrator-In-Training) documents the DON and Infection Preventionist (V2) should be members of the QAA committee.
The facility's QAA Meeting Attendance Forms dated 7-20-22, 10-26-22, 1-12-23, and 4-25-23 do not include attendance of a Director of Nursing or Infection Preventionist.
07/19/23 09:36 AM V1 (Administrator In Training) stated, A Director of Nursing did not attend any of the Quality Assessment and Assurance (QAA) meetings from 7-20-22 through 4-25-23. An Infection Preventionist did not attend the QAA Meetings on 1-12-23, 10-26-22, and 7-20-22.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
B. The facility's Standard Precautions policy, dated 4/3/23, documents Standard precautions will be instituted to prevent the spread and contamination of pathogenic microorganisms in a manner that voi...
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B. The facility's Standard Precautions policy, dated 4/3/23, documents Standard precautions will be instituted to prevent the spread and contamination of pathogenic microorganisms in a manner that voids transfer to residents, personnel and environment. Standard precautions are designed to reduce the risk of transmission of pathogens from moist body substances and applies them to all residents receiving care in health facilities regardless of their diagnosis or presumed infection status. Standard Precautions apply to: Blood, all body fluids, secretions, and exertions except sweat; regardless of whether or not they contain visible blood, non-intact skin, Mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in facilities. Handwashing: Wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed between resident contacts and when otherwise indicated to avoid transfer of microorganism to other residents or environments. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves: Wear gloves (clean, non-sterile gloves are adequate) when touching blood, body fluids, secretions, excretions and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.
R30's Treatment Administration Record (TAR), dated 7/1-7/31/23, documents a treatment order Red area to coccyx: Apply boarder foam dressing daily and as needed. This same TAR documents a treatment order Calmoseptine ointment (skin barrier ointment), Apply to abdominal folds/under breasts topically every day and night shift for skin barrier.
R30's Current care plan, dated 1/13/23, documents R30 has an Alteration in Bowel and Bladder elimination as related to incontinence.
On 7/19/23 at 3:20 PM, V6 (Registered Nurse) and V2 (Licensed Practical Nurse/ Resident Care Coordinator) went in R30's room for wound and incontinence care. After removing R30's soiled incontinence brief and placing gauze over R30's wound, V6 fastened R30's incontinence brief and without changing gloves or performing hand hygiene, V6 then applied barrier ointment to the same gloves and rubbed it onto R30's abdomen under the breast area.
On 7/19/23 at 3:35 PM V6 confirmed he did not change gloves or perform hand hygiene between site cares for R30.
These failures resulted in two deficient practices.
A. Based on record review and interview the facility to monitor and test for Legionella and other opportunistic waterborne pathogens within the facility's water system. This failure has the potential to affect all 45 residents residing within the facility.
B. Based on observation, interview and record review, the facility failed to perform hand hygiene and a glove change between cares for one of 16 residents (R30) reviewed for infection control in the sample of 37.
Findings include:
A. The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
The facility's Annual Risk Assessment (undated) and Legionella Policy and Procedure (undated) does not include any evidence of the facility testing their water system for Legionella or other opportunistic waterborne pathogens.
On 07/19/23 at 03:05 PM V12 (Maintenance Director) stated, I am not aware of the facility testing for Legionella. I do not test the water for Legionella.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on interview, record review, and observation the facility failed to post nurse staffing for the last 18 months. This failure has the potential to affect all 45 residents residing within the faci...
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Based on interview, record review, and observation the facility failed to post nurse staffing for the last 18 months. This failure has the potential to affect all 45 residents residing within the facility.
Findings include:
The facility's Census dated 7-17-23 and signed by V1 (Administrator-In-Training) documents 45 residents currently reside within the facility.
On 07/18/23 from 10:02 AM to 10:15 AM a tour of the facility was conducted. During the tour there was no nursing staffing posted that included the name, date, census, or total number and actual hours worked per shift of licensed and unlicensed staff responsible for resident care.
On 07/18/23 at 11:01 AM V1 (Administrator-In-Training) stated, I am not aware of nurse staffing getting posted anywhere in the facility. I do not think nurse staffing has been posted within the last 18 months.
Jun 2023
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to notify a physician of an
change in resident's condition for one of three residents (R2) reviewed for notification of change in a sample of ...
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Based on record review and interview, the facility failed to notify a physician of an
change in resident's condition for one of three residents (R2) reviewed for notification of change in a sample of 9.
Findings Include:
A notification for Change in Resident Condition or Status policy, (No date), documents the following, Policy: The facility and/or facility staff shall promptly notify appropriate individuals
Administrator, DON, Physician, Guardian, HCPOA, etc.) of changes in the resident's medical/mental condition and /or status.
R2's Progress Note, dated 6/15/2023, documents the following,4:10PM Registered Nurse (RN) was called by V14/Certified Nurse Aide (CNA) because R2 was on their knees and laying across the bed. Upon entering room patient appeared very sweaty. R2 was assessed before moving and appeared to be able to be moved. Moved R2 to chair and full assessment performed. 2CM (Centimeter) laceration to the great toe on the right foot. Bandage applied. Bleeding was stopped prior to bandaging. Patient stating, 'I got really hot.' R2 was moved out of the room and into a cooler room. V1 (Administrator) was called into the room, and V1 called V2 to examine the air conditioner. Vital signs stable.
On 6/17/2023 at 11:30AM R2 stated, My room has been warm. The air conditioner must be repaired by maintained. It is an old system. I became sick last week. It was very hot in the hallways and in my room. I was taken to a cooler area after I started feeling better. I must have passed out from the heat. I only remember I was in the bathroom and then they found me halfway on my bed with my knees on the floor. Injured my great toe somehow.
On 6/17/2023 at 1:23PM V9/RN stated, It was a horrible evening. I was down the hall passing medicines when I was summons to (R2's) room. When I entered the room, (R2) was laying across the bed. (R2) was so hot and sweaty. I was able to move (R2) to a chair to assess him. (R2) said, 'Last thing I remember was in the bathroom. I don't remember how I got here. I was so hot.' I assessed (R2) and moved him to a cooler area, the front. (R2's) Vital signs were stable. I notified V1 and she had V2 come down and check the air conditioner. It doesn't work. It hasn't worked, if it does, it only works for a short time then it's off again. (R2) needs a new air conditioner. Most of the residents need a new air conditioner in their rooms.
On 6/19/2023 at 2:45PM V9/RN stated, No, I did not notify the physician for (R2's) incident of passing out.
On 6/19/2023 at 10:52AM V16 (Physician) stated, No, I was not notified that (R2) passed out due to the heat in the facility.
On 6/19/2023 at 2:50PM V15/Licensed Practical nurse (LPN), RCC (Resident Care Coordinator) stated, Any change in a resident's condition. The doctor needs to be notified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to monitor a resident during a day of excessive heat in the facility. This failure caused one resident (R2) to pass out for one of three reside...
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Based on record review and interview the facility failed to monitor a resident during a day of excessive heat in the facility. This failure caused one resident (R2) to pass out for one of three residents reviewed for resident injury in a sample of 9. This also failure resulted in a laceration to right great toe.
Findings Include:
The facility policy, named Hot Weather, dated, May 2011, from the State Agency, documents, Some residents in long term care facilities may be more susceptible to adverse health effects of hot weather then others. These residents should be identified and monitored closely during periods of extreme temperatures
R2's Progress Note, dated 6/15/2023, documents the following,4:10PM Registered Nurse (RN) was called by V14/Certified Nurse Aide (CNA) because R2 was on their knees and laying across the bed. Upon entering room, R2 appeared very sweaty. R2 was assessed before moving and appeared to be able to be moved. Moved R2 to chair and full assessment performed. 2CM (Centimeter) laceration to the great toe on the right foot. Bandage applied. Bleeding was stopped prior to bandaging. R2 stating, 'I got really hot.' R2 was moved out of the room and into a cooler room. V1 (Administrator) was called into the room, and V1 called V2 to examine the air conditioner. Vital signs stable.
On 6/17/2023 at 1:23PM V9/RN stated, It was a horrible evening. I was down the hall passing medicines when I was summons to (R2's) room. When I entered the room, (R2) was laying across the bed. (R2) was so hot and sweaty. I was able to move (R2) to a chair to assess him. (R2) said, Last thing I remember was in the bathroom. I don't remember how I got here. I was so hot. V9 said, I assessed (R2) and moved him to a cooler area, the front. (R2's) vital signs were stable. I notified (V1) and she had (V2) come down and check the air conditioner. It doesn't work. It hasn't worked, if it does, it only works for a short time then it starts blowing hot air. (R2) needs a new air conditioner. Most of the residents need a new air conditioner in their rooms. (R2) sustained a cut on his right great toe when passing out.
On 6/19/2023 at 8:55AM V12/R2's daughter stated, I was not told that (R2) had a spell and blacked out due to the heat. I was just told that he fell and injured his foot. It is always hot in (R2's) room. I don't think the air conditioner works.
On 6/19/2023 at 9AM V13/R2's son in law stated, The air conditioner in (R2's) room does not blow cool air. It is always hot in his room. They need to replace these old air conditioners.
On 6/19/2023 at 8:40AM V14/CNA stated, I came around the corner and noticed (R2) half on the floor and halfway on the bed. (R2) was bleeding from his foot. The room was very hot. I went to get the nurse. (R2) was just not acting right. (R2) was disoriented. (R2) kept repeating 'I am really hot.' The air conditioner wasn't working, it was blowing hot air.
On 6/17/2023 at 11AM R1 stated, My air conditioner in my room doesn't always work. Last week I was moved to another room because it was so hot. I asked them to move me back to my room. It was pretty hot in the facility last week I was sweating a lot.
On 6/17/2023 at 11:30AM R2 stated, My room has been warm. It needs to be repaired by maintenance. It looks like an old system. I became sick last week. It was very hot in the hallways and in my room. I was taken to a cooler area after I started feeling better. I must have passed out from the heat. I was in the bathroom and then they found me halfway on my bed. I cut my great toe somehow. I don't remember anything.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
Based on observation, record review and interview the facility failed to follow the hot water policy to maintain water temperature between 100-110 degrees Fahrenheit and failed to ensure air condition...
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Based on observation, record review and interview the facility failed to follow the hot water policy to maintain water temperature between 100-110 degrees Fahrenheit and failed to ensure air conditioners are in good working order to maintain a comfortable temperature for the residents. This failure has the potential to affect all 52 residents residing in the facility.
The facility policy, (Not dated), titled Water Temperature Control, documents the following: It is the policy of (the facility) to maintain water temperature available to residents between 100- and 110-degrees Fahrenheit. To maintain these parameters, the maintenance department shall schedule and perform these functions. Water temperature monitoring: two times a week each week a maintenance person will take and record temperatures from two taps supplied by each water heater (supply area).
The facility policy, titled Hot Weather, dated May 2011, is a bulletin from the State Agency, documents, During the approaching hot weather of summer, when outdoor temperatures climb into the 80's, 90's and 100's, long term care facilities may need to evaluate their ability to maintain a reasonably comfortable temperature inside of the facility. The State agency encourages all facilities to act now to avoid heat-related emergencies during the summer.
On 6/17/2023 at 1:120PM an observation was done for determining the hot areas in the building. The front area of the facility was cold, as you enter northeast and northwest hall, there is a significant change in room temperature. the hallways and resident's rooms are much warmer.
On 6/17/2023 at 1:25PM an observation of the water temperature in R3's room bathroom faucet after the water was run for 3 minutes, the water remained cold to the touch.
The facility water temperature log dated 6/1/2023 through 6/16/2023 documents, 6/1/2023 [NAME] shower 90 degrees, East shower 99 degrees, Rooms W6 Temp-99, East 25-Temp 99, NE18-Temp100, NW11Temp-99. 6/6/2023 [NAME] shower 99-degree, East shower 100, Room [NAME] 10-Temp 100 degree, East 26-Temp 100, NE 19-Temp-99, NW 10-Temp 99 degree. 6/12/2023 [NAME] Shower-Temp -99, East Shower-Temp-100, Rooms [NAME] 8-Temp 99, East 20-Temp100, NE25-Temp 99, MW5-Temp 99. Temperature Readings from 6/17/2023 Room [NAME] 6-89 degrees, NW1-Temp 90, NE19-Temp 89, E2P-Temp89, NW-Temp 84, and NW5-Temp 84.
On 6/17/2023 at 10:34AM V1/Administrator stated, There is one roof top air conditioner that isn't working. Our company is aware of this and is working on getting it fixed. I don't remember what residents were moved last week when it was very hot. I am assuming more residents were moved. I don't know how long the roof unit has not been working. Hot water heaters have been ordered. I don't know why the residents are not getting their showers. I am aware of (R3) going to V10's/ daughter's house to get a shower. I am ok with that.
On 6/17/2023 at 11:08AM V2/Maintenance Director stated, There is a roof top unit that is not working. That unit cools the hallways in the middle of the facility, the northeast and northwest hallways, and other offices. The residents have their own air conditioners in their rooms. I have worked on several air conditioners, but every room could use a new air conditioner. I will be cleaning out the unit on the roof that is not working to see if that doesn't help. The company is aware of the roof top unit that isn't working. They are getting quotes for a new unit. I do not know what the temperature of the rooms or hallways were. I did not take any temperatures. This issue with the roof unit has been going on since last summer. The front of the facility is the coolest area currently. (R2's) air conditioner is an old unit and needs to be replaced. I take water temperatures once a week. I take the shower rooms and residents rooms. The problem with no hot water has been going on about two weeks.
On 6/17/2023 at 12:45PM V4/Activity Director stated, I asked for screens for the windows in the activity room last week. It was so hot in there. I was told they didn't have screens, fans, or air conditioners. I thought if I could get the air flowing it would help. It was just too hot to sit in there. (R1) was drenched with sweat because of the heat. I moved the residents to a cooler area. I felt they would all be sick if I didn't. I have only been working here for a week. Every day I have been here they don't have hot water.
On 6/19/2023 at 8:55AM V12/R2's daughter stated, I was not told that (R2) had a spell and blacked out due to the heat. I was just told that he fell and injured his foot. It is always hot in his room. I don't think the air conditioner works.
On 6/19/2023 at 9AM V13/R2's Son in Law stated, The air conditioner in (R2's) room does not blow cool air. It is always hot in his room. They need to replace these old air conditioners. There is no hot water in the facility. I don't know when that will be fixed either.
On 6/19/2023 at 8:40AM V14/CNA stated, I came around the corner and noticed (R2) half on the floor and halfway on the bed. (R2) was bleeding from his foot. The room was very hot. I went to get the nurse. (R2) was just not acting right (R2) was disoriented. (R2) kept repeating I am really hot. The air conditioner wasn't working, it was blowing hot air.
On 6/17/2023 at 11AM R1 stated, My air conditioner in my room doesn't always work. Last week I was moved to another room because it was so hot. I asked them to move me back to my room. It was pretty hot in the facility last week I was sweating a lot.
On 6/17/2023 at 11:30AM R2 stated, My room has been warm. The air conditioner must be repaired by maintenance. It looks like an old system. I became sick last week. It was very hot in the hallways and in my room. I was taken to a cooler area after I started feeling better. I must have passed out from the heat. I was in the bathroom and then they found me halfway on my bed. I injured my great toe somehow.
R2's Progress Note, dated 6/15/2023, documents the following,16:10PM RN was called by V14/CNA because R2 was on their knees and laying across the bed. Upon entering room patient appeared very sweaty. R2 was assessed before moving and appeared to be able to be moved. Moved R2 to chair and full assessment performed. 2CM (Centimeter) laceration to the great toe on the right foot. Bandage applied. Bleeding was stopped prior to bandaging. Patient stating, 'I got really hot.' R2 was moved out of the room and into a cooler room. V1 was called into the room, and V1 called V2 to examine the air conditioner. Vital signs stable.
On 6/17/2023 at 2PM R3 stated, It feels ok in here, today. I don't get hot too fast anymore. I know staff and the other residents are hot, say it is very hot in here.
On 6/17/2023 at 1:15PM R4 stated, It has been hot in here, especially in the hallways. I can take a shower but the water gets cold fast.
On 6/17/2023 at 3:15PM R5 stated, It has been hot in this facility. It makes it hard to sleep. The cold water feels good for a few minutes. Then you have to stop the water because it gets too cold.
On 6/17/2023 at 3:30PM R6 stated, Yes, it is hot in here. They say the air conditioning is broken. I hope they get it fixed soon. There hasn't been any hot water for a few weeks. I don't know what is going on here.
On 6/17/2023 at 11:15AM R7 stated, I am hot, but not as much as I have been. It has been hot in here. I can't take a shower because there is no hot water. I hope things get fixed soon.
The Resident Census and Conditions of Residents 672, dated 6/15/2023, has a census of 52.
May 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
Based on observation, interview, and record review the facility failed to ensure a call light was answered for one resident (R18) of five residents reviewed for call lights in a sample of 18.
Findings...
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Based on observation, interview, and record review the facility failed to ensure a call light was answered for one resident (R18) of five residents reviewed for call lights in a sample of 18.
Findings include:
Facility Residents' Rights Policy, revised 11/2018, documents the facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life and provide services to keep your physical and mental health at their highest practical levels.
The Facility Certified Nurse's Aide Job Summary, undated documents implementation of answers call lights.
On 5/30/23, during the hours of 11:38 am through 11:54 am, R18's call light was activated on the [NAME] Wing Hallway.
On 5/29/23, at 11:39 am, V3 (Registered Nurse), was looking down the [NAME] Wing Hallway while sitting at the nurses' station approximately two resident rooms away from R18's room and did not answer R18's activated call light.
On 5/20/23, at 11:40 am, V6 (Housekeeping) walked down the [NAME] Wing Hallway and walked past R18's room while the call light was activated and did not answer the call light.
On 5/30/23, at 11:47 am, V7 (LPN/Licensed Practical Nurse) walked down the [NAME] Wing Hallway and walked past R18's room while the call light was activated and did not answer the call light.
On 5/20/23, at 11:51 am, V10 (CNA) walked down the [NAME] Wing Hallway and walked past R18's room while the call light was activated and did not answer the call light.
On 5/20/23, at 11:52 am, V11 (CNA) walked down the [NAME] Wing Hallway and walked past R18's room while the call light was activated and did not answer the call light.
On 5/31/23 at 8:20 am, R15 stated, It takes them a long time to answer my call light, sometimes it takes them up to an hour to get to me.
On 5/30/23, at 11:32 am, R16 stated, Sometimes it takes them an hour to come in and get my call light.
On 5/30/23 at 1:15 pm, R17 stated, They are worse on third shift, that is when it takes them a long time to answer my call light and it takes them at least an hour to answer it.
On 5/30/23, at 12:26 pm, R18 stated, It takes them a long time to answer my call light, a lot of times it takes them an hour. They are disrespectful because I am incontinent and they take a long time to get to me.
On 5/31/23, at 11:00 am, V1 (Administrator) stated, We do not have a Call Light Policy, but all those staff should not be walking past a call light that is going off, they should be answering those, and an hour is too long of a time.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure oxygen saturation levels were checked and documented as per physician orders for three of three (R1, R2, and R3) revie...
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Based on observation, interview, and record review, the facility failed to ensure oxygen saturation levels were checked and documented as per physician orders for three of three (R1, R2, and R3) reviewed for oxygen in a sample of three.
Findings include:
The facility's Pulse Oximetry policy, undated, documents Pulse oximetry will be performed as ordered by the physician and PRN (as needed). All oximetries will be recorded on the TAR (Treatment Administration Record) and/or Nurses Notes. If a pulse oximetry is performed on room air, documentation needs to reflect this.
On 2-8-23, between 9:50am and 10:20am, R1-R3 were lying in their respective beds with oxygen flowing per oxygen concentrators via nasal cannulas.
R1 and R2's Physician Order Statements/ POSs, dated 2-1-23 to 2-28-23, document Treatment: Oxygen at 2 l/nc (liters per nasal cannula) prn (as needed) if saturation is less than 90%. Titrate to keep above 90%. Notify MD (Medical Doctor) of use. R1's and R2's POS documents diagnoses including COPD (Chronic Obstructive Pulmonary Disease).
R3's POS, dated 2-1-23 to 2-28-23, documents Treatment: Oxygen saturations check every shift and as needed. Oxygen at 2 l/nc (liters per nasal cannula) prn (as needed) if saturation is less than 90%. Titrate to keep above 90%. Notify MD (Medical Doctor) of use. R3's POS documents diagnoses including COPD.
R1's Treatment Administrative Records/TARs, dated 1-13-23 to 1-31-23 and 2-1-23 to 2-7-23, do not have any recordings of R1's oxygen saturation levels being checked.
R2's TARs, dated 1-1-23 to 1-31-23 and 2-1-23 to 2-7-23, do not have any recordings of R2's oxygen saturation levels being checked.
R3's TAR, dated 12-1-23 to 12-31-23, documents R3's oxygen saturation level was checked four times. R3's TAR, dated 1-1-23 to 1-31-23, documents R3's oxygen saturation level was checked 24 times. R3's TAR, dated 2-1-23 to 2-7-23, documents R3's oxygen saturation level was checked four times.
On 2-8-23, between 2:10pm and 2:20pm, V2 Director of Nursing/DON stated the following: Residents' oxygen saturation levels are to be checked every shift and we are on 12 hour shifts. They should document this on the TAR (Treatment Administration Record) when they do vital signs. Nurses have oximeters on their carts and should be doing them.
On 2-8-23, at 2:36pm, V1 Administrator stated that oxygen saturation levels should be obtained per physician order.
Aug 2022
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
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 a resident had enough clothing for daily livin...
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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 a resident had enough clothing for daily living for one (R38) of 26 residents reviewed for dignity in a sample of 26.
Findings include:
Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels.
Facility Social Service Director, no date, documents The Social Service Director responsibilities: general duties a. Provide consultation to members of our staff, community agencies, etc. in the efforts to solve the needs and problems of the resident.
R38's medical record documents R38 was admitted to the facility on [DATE], cognitively intact, and walks independently.
R38's medical record Inventory of Personal Effects, dated 5/24/22, documents the following; house slippers, one top coat, one pair of socks, one undershirt, one shirt, and two ladies suits.
On 8/09/22 at 12:22 pm, R38 stated I only have one set of clothes which is what I have on, and I have no other clothes. R38 would not answer when asked what he wore when he took a shower and if his clothes were ever laundered. R38 was in a private room (no roommate) and was sitting on the edge of the bed wearing yellow gripper socks, slippers, long pants, and a t-shirt with a flannel shirt over top. R38's dresser, closet and room only had one pair of socks in the dresser, one coat and one flannel hanging in the closet, one belt, and no other clothes were found/observed in R38's room.
On 8/10/22 at 11:35 am and 8/11/22 at 10:30 am R38 was in bed with the same clothes on as on 8/9/22.
On 8/11/22 at 9:28 am, V4 SSD/Social Services Director stated Me or housekeeping should be told if they (resident) needs clothes. He (R38) came from a shelter, and he had very little stuff he came with. I help them (residents) get what they need. We have clothes in housekeeping that residents can have. I did not know he (R38) needed clothes because I was never told. The CNA/Certified Nurse Aides take inventory and I would expect them to tell me or housekeeping if a resident needs something. At that same time V4 verified R38 had on a t-shirt, flannel, pants, slippers, and yellow gripper socks. In his dresser he had no underwear, one pair of socks, and no other clothing in the dressers or bedside dresser. A belt was on R38's countertop, and in his closet there was a coat and a flannel. No other clothing was found in R38's room. R38 is in a room with no roommate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to develop and comprehensive care plan for two (R31 and R37) of 12 residents reviewed for care planning in the sample of 26.
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Based on observation, interview, and record review the facility failed to develop and comprehensive care plan for two (R31 and R37) of 12 residents reviewed for care planning in the sample of 26.
Findings include:
The facility's Comprehensive Care Planning policy and procedure, revised 11/1/17, documents It is the policy of (the facility) to comprehensively assess and periodically reassess each Resident admitted to this facility. The results of this Resident assessment shall serve as the basis for determining each Resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each Resident that will describe the services that are to be furnished to attain or maintaining the Resident's highest practicable physical, mental, and psychosocial well-being.
1. On 8/10/22 at 1:30 pm, V18 Hospice CNA (Certified Nursing Assistant) stated she comes to the facility to provide cares for R31 weekly.
On 8/11/22 at 9:46 am, V9 and V10 CNA's provided incontinence care to R31 and blood was visible on the washcloth V10 CNA was cleansing with. V9 CNA stated this is not unusual for R31 to have some bleeding from her vagina, it has been happening off and on for a couple of months and the doctor is trying to figure out what is going on with her.
The current Care Plan for R31 does not include R31 receiving hospice (end of life) services and does not include R31's episodes of vaginal bleeding.
On 8/11/22 at 9:06 am, V3 MDS (Minimum Data Set) Assessment Coordinator stated he does not develop or revise all of the resident care plans because he only comes to the facility to do the MDS's but will help with care plans when he comes to the facility.
2. The Quarterly MDS (minimum data set) assessment for R37, dated 6/8/22, documents R37 with a significant weight gain and was on physician -prescribed weight gain regimen, smokes cigarettes and is cognitively intact.
On 8/11/22 at 11:45 am, R37 was sitting outside in the facility patio area smoking cigarette with another resident. R37 stated she does smoke but not as much as she used to.
The current Care Plan for R37 does not include any documentation regarding R37 smoking cigarettes.
On 8/10/22 at 10:09 am, 11:20 am, 2:00 pm, and 3:10 pm, R37 was not seen in the facility.
On 8/10/22 at 1:00 pm, V15 Receptionist stated R37 did not tell her she was leaving the facility.
On 8/10/22 at 3:10 pm, V14 RN (Registered Nurse) stated (R37) is not here and she doesn't know where (R37) is.
On 8/10/22 at 3:12 pm, V2 DON (Director of Nursing stated he does not know where R37 is but probably went out with friends. V2 stated R37 is supposed to let the Nurse or front desk know when she goes out.
On 8/11/22 at 10:22 am, V1 Administrator stated R37 has done this before, has been talked to about it multiple times, and R37 knows she is supposed to sign out prior to leaving the facility. V2 confirmed R37's care plan did not include R37's non-compliance with signing out.
On 8/11/22 at 11:45 am, R37 stated she has not been signing out when she leaves the facility for some time and can't remember the last time she signed out. R37 stated she usually just tells someone I'm leaving. R37 stated no one has said anything to her about for a while.
The current Care Plan for R37 does not include any documentation of R37's non-compliance with signing out when leaving the facility for outings.
On 8/9/22 at 12:35 pm, R37 stated she has been at the facility for about a year and her doctor wanted her to gain some weight and she started gaining weight and it just keeps coming. R37 stated her doctor put her on a water pill to help because her bilateral amputee stumps have been swelling.
The RD (Registered Dietician) documents follow up documentation due to R37's weight gain with last recommendation on 4/28/22 as Recommend staff to educate on weight gain and encourage resident to moderate intake.
The current Care Plan for R37 does not include any documentation regarding R37's weight gain.
On 8/12/22 at 11:00 am, V1 Administrator confirmed R31 needed care plans developed for hospice and vaginal bleeding and R37 needs a smoking, weight gain and non-compliance care plan. (V1 Administrator stated she put a care plan in for R37 not signing out before leaving the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to shave and provide nailcare for one (R15) of 12 reviewed for grooming in a sample of 26.
Findings include:
Facility Residents...
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Based on observation, interview, and record review, the facility failed to shave and provide nailcare for one (R15) of 12 reviewed for grooming in a sample of 26.
Findings include:
Facility Residents' Rights for People in Long-Term Care Facilities, revised 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must provide services to keep your physical and mental health at their highest practical levels.
On 8/10/22 at 3:45 pm, R15 was in the activity room in a manual wheelchair, and alert and oriented. R15 had a long gray and black beard and moustache, and yellow long thick fingernails. R15 stated I want my nails clipped to at least half of what they are now, and I asked to be shaved a week ago and it was never done.
On 8/11/22 at 9:00 am, R15 still had long fingernails, moustache and beard.
On 8/11/22 at 9:10 am, V11 Certified Nurse Aid/CNA stated I am taking care of (R15) and I plan on shaving him today. As part of our job, we do shave and clip nails, and his fingernails need done.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to treat reddened and excoriated abdominal skin folds for one (R32) of 12 residents reviewed for skin care in a sample of 26.
Find...
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Based on observation, interview and record review the facility failed to treat reddened and excoriated abdominal skin folds for one (R32) of 12 residents reviewed for skin care in a sample of 26.
Findings include:
Facility Preventative Skin Care Policy, revised 1/2018, documents: that the Facility is to provide preventative skin to keep the resident clean, comfortable, well groomed and free from pressure ulcers; that staff on every shift and as necessary will provide skin care; and a thin layer of body lotion/skin protestant may be applied as a protective barrier to areas exposed to incontinence.
Facility Pressure Sore Prevention Guidelines, revised 11/2012, documents: to provide adequate interventions for prevention of pressure ulcers for residents who are identified as High or Moderate risk for skin breakdown; weekly skin checks for Moderate to High Risk for skin breakdown; and any resident at risk for skin breakdown will be noted on the Treatment Sheet and signed off by the Nurse and a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet.
R32's current Care Plan documents that R32 has diagnoses including Obesity, Diabetes, Incontinence, poor/fair nutrition intake, mobility is poor and requires assistance. The Care Plan also documents that R32 has risk factors for pressure ulcers related to pressure ulcers and skin conditions. The Care Plan also documents that a house stock barrier cream will be applied after every incontinence care and to report to the charge nurse for any skin concerns.
R32's Physician Order Sheet, dated 8/1/22 through 8/31/22, documents an order, dated 6/11/22, for a topical treatment (Nystatin Powder) to R32's skin folds (Abdominal).
R32's Treatment Administration Record/TAR, 6/1/22 through 8/10/22, does not document weekly skin checks on 6/13/22, 6/27/22, 7/4/22, 7/11/22, 7/18/22 and 7/29/22. R32's TAR documents an order, twice a day, for a topical treatment (Nystatin Powder) to R32's abdominal skin folds. The TAR does not document completion of the topical treatment on 6/15/22 (6:00 am to 6:00 pm shift); 7/1/22 through 7/31/22 (6:00 am to 2:00 pm shift; 8/6/22 (6:00 to 2:00 pm shift); or 8/1/22 through 8/10/22 (2:00 pm to 10:00 pm shift).
On 8/10/22, at 9:52 am, V8 (Certified Nursing Assistant) was providing incontinence care to R32. R32's abdominal folds were red and excoriated. V8 stated, Because we see how red her abdominal folds are and that we know that (R32) is a High Risk for skin breakdown, we tell the nurses all the time, that (R32) needs the powder for her abdominal folds, and they never come down. That is why it is so red. I also even ask them for barrier cream, and they never bring that down either.
On 8/10/22, at 9:53 am, R32 stated, Look how red I am down there. The nurses rarely ever put the medicine on it, that is why it is so red and irritated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to supervise and ensure a resident signed out prior to leaving facility for outing for one (R37) of 12 residents reviewed for sup...
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Based on observation, interview, and record review the facility failed to supervise and ensure a resident signed out prior to leaving facility for outing for one (R37) of 12 residents reviewed for supervision in the sample of 26.
Findings include:
The undated, Facility Sign Out Policy, documents If a resident leaves the facility grounds either with family or on their own to go for a walk, shopping, etc., it is the policy of the facility that either the Responsible Party or the Resident MUST sign out at the nurse's station and sign in when they return to the facility.
The Sign Out/Acceptance of Responsibility for Leave of Absence for R37 documents last time R37 signed out of the facility was on 7/7/22.
On 8/10/22 at 10:09 am, 11:20 am, 2:00 pm, and 3:10 pm, R37 was not seen in the facility.
On 8/10/22 at 1:00 pm, V15 Receptionist stated R37 did not tell her she was leaving for the day and (V14) does not know where R37 is.
On 8/10/22 at 3:10 pm, V14 RN (Registered Nurse) stated (R37) is not here and (V14 RN) doesn't know where (R37) is.
On 8/10/22 at 3:12 pm, V2 DON (Director of Nursing) stated he does not know where R37 is but is probably went out with friends. V2 stated R37 is supposed to let the Nurse or front desk know when she goes out.
On 8/11/22 at 10:22 am, V1 Administrator stated R37 has done this before, has been talked to about it multiple times, and R37 knows she is supposed to sign out prior to leaving the facility. V2 confirmed R37's care plan did not include R37's noncompliance with signing out.
On 8/11/22 at 11:45 am, R37 stated she goes out with friends frequently and has not been signing out when she leaves the facility and can't remember the last time she signed out. R37 stated she usually just tells someone I'm leaving. R37 stated no one has said anything to her about for a while.
The current Care Plan for R37 does not include any documentation of R37's non-compliance with signing out when leaving the facility for outings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to monitor and document the assessment of the dialysis graft site for 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 monitor and document the assessment of the dialysis graft site for two (R19 and R99) of two residents reviewed for dialysis in a sample of 26.
Findings include:
Facility Dialysis Policy, revised 1/2002, documents: the normal thrill and bruit of the graft will be absent and the thrill is to be checked every shift and recorded on the treatment sheet.
R19's current Care Plan documents: that R19 has Chronic Kidney Disease and receives dialysis on Tuesday, Thursday and Saturday. The Care Plan also documents to monitor the bruit and thrill daily and notify the Medical Director of changes to auditory assessment of the site.
R19's Treatment Administration Record/TAR, dated 7/1/22 through 8/11/22, documents that R19 admitted to the facility on [DATE]. The TAR does not document assessment of the dialysis graft for bruit and thrill.
On 8/11/22 at 2:50 pm, V7 (Assistant Director of Nursing/Restorative Nurse) stated We used to check (R19) for bruit and thrill but somehow the pharmacy dropped it off of the treatment sheets back in February. Nothing has been checked with the dialysis graft since then for (R19). I also am not sure how we missed (R99's) dialysis graft assessment either. I think something happened during change over and these got missed.
2. R99's Treatment Administration Record (TAR) dated 8/5/22-8/10/22 documents R99 was admitted on [DATE] and does not document staff are to monitor R99's dialysis site for bleeding, or his fistula for bruit or thrill each shift.
On 8/10/22 at 12:13pm V2, Director of Nursing, confirmed that R99's TAR does not document that his dialysis site should be monitored for bleeding, or his fistula monitored for bruit and thrill each shift, and stated that they should be documented on the TAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to schedule a dental appointment, for dentures, for one resident (R47) of 12 reviewed for dental services in a sample of 26.
Findi...
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Based on observation, interview and record review the facility failed to schedule a dental appointment, for dentures, for one resident (R47) of 12 reviewed for dental services in a sample of 26.
Findings include:
Facility Resident Rights, revised 11/2018, documents the facility must: treat you with dignity and respect and must care for you in a manner that promotes your quality of life; provide equal access to quality care regardless of diagnoses, condition or payment source; and provide services to keep your physical and mental health at their highest practical levels.
R47's Social Service Progress Notes, dated 12/23/21, documents that a message was left with V12 (R47's Sister) for a dental assessment. No further documentation was noted.
On 8/10/22, at 9:42 am, R47's teeth were missing. No dentures were present.
On 08/09/22, at 10:46 am, V12 (R47's Sister) stated, I asked about getting my brother dentures over a year ago and I still do not think that he has ever gotten them, and I have never heard anything about them since.
On 8/11/22, at 10:22 am, V4 (Social Service Director) stated, We tried to set up a dental appointment last December for (R47) to get dentures and contacted (V12/R47's Sister). I think what happened is (V13/former Bus Driver) dropped the ball and did not set up the appointment for (R47) to get the dentures. I remember it was a few days before Christmas and (V13) quit working for us about a month later. Once an appointment is set up, (V13) should have followed up for the transportation to the appointment and I do not think that was ever done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to have a working cold faucet, fix a leaking hot water faucet, and fix a leaking toilet for three (R38, R40, and R46) of 12 resi...
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Based on observation, interview, and record review, the facility failed to have a working cold faucet, fix a leaking hot water faucet, and fix a leaking toilet for three (R38, R40, and R46) of 12 residents reviewed for environmental concerns in a sample of 26.
Findings include:
Facility Maintenance Person, no date, documents The Maintenance Person maintains all building, equipment, systems and grounds in good, safe, and presentable condition. Regularly inspects and maintains plumbing systems. Maintains the building in good, safe repair.
On 8/11/22 the facility was unable to provide any maintenance repair/request logs.
1. At the end of the Northwest hallway R38 and R46's bathroom were connected/shared. R38 and R46's toilet appeared to be leaking onto the floor, and the floor was wet in front of the toilet into the main entrance of the bathroom. The toilet was elevated off the ground and secured to the back wall where water appeared to be running down the back of the wall and the floor every time the residents flushed the toilet. The back wall was pulling away from the floor trim, water basins were by the toilet but were empty and not wet, and the tile floor was wet and slick.
On 8/9/22 at 10:45 am, V16 (R46 family member) stated (R46) and (R38) share the bathroom and it has been leaking since (R46) was admitted to the nursing home. (R46) has been here since July 2022, I told staff and the maintenance man (V17) about the leaking toilet. Pans were put in the room to collect the water. I come three to four days a week to visit (R46) and the toilet has been like that since he came here in July. (R46) uses the bathroom and I am worried he is going to fall. At that same time R46 stated I use the toilet, I can toilet myself, and I am in control of my bowel and bladder.
On 8/09/22 at 11:54 am, V17 Maintenance Director stated, I know (R38 and R46's) toilet is leaking. At that same time, V17 went into R38 and R46's bathroom and verified the toilet appeared to be leaking clear water out from the back of the toilet, there was water on the floor, and the back wall was soft and pulling away from the floor trim.
On 8/09/22 at 12:08 pm, R38 walked in to his bathroom and was sitting on the toilet and had to step over water on the floor. R38's medical record documents R38 is independent with toilet use.
On 8/09/22 at 12:31 pm, R46 walked in to his bathroom and sat on the toilet with the water on the floor. R46's medical record documents R46 is independent with toilet use.
2. On 8/11/22 at 10:15 am, R40 was using a wheeled walker down the hallway and stated, My hot water faucet is leaking and the cold water does not work.
On 8/11/22 at 1:32 pm, V17 went into R40's bathroom and verified R40's cold water did not work, and the hot water faucet was leaking. V17 stated I knew (R40's) faucet needed repaired. There are a few faucets where the cold water does not work, and I am working on getting approval for the repairs that are needed here.
On 8/11/22 at 2:30 pm, V1 Administrator stated Our maintenance man has only been here a few months, and we do not have any maintenance repair requests logs because we tell (V17) what needs fixed and he tells me when it has been fixed. We need to start keeping a log and have staff fill out the maintenance request forms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R4's medical record documents R4 was admitted on [DATE] and has no record a care plan meeting has been done in 2022.
On 8/11/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R4's medical record documents R4 was admitted on [DATE] and has no record a care plan meeting has been done in 2022.
On 8/11/22 at 11:34 am, V4 Social Services Director/SSD stated no care plan meeting has been done this year for R4.
4. R15's medical record documents R15 was admitted on [DATE] and has no record a care plan meeting has been done in 2022.
On 8/11/22 at 11:34 am, V4 Social Services Director/SSD stated no care plan meeting has been done this year for R15.
5. R30's medical record documents R30 was admitted on [DATE] and has no record a care plan meeting has been done in 2022.
On 8/11/22 at 11:34 am, V4 Social Services Director/SSD stated no care plan meeting has been done this year for R30.
Based on interview and record review the facility failed to ensure Care Planning Meetings were held with residents and their representatives for nine (R4, R11, R15, R23, R30, R31, R32, R37 and R47) of 12 residents reviewed for care planning meetings in a sample of 26.
Findings include:
The Facility Comprehensive Care Planning Policy, revised 11/1/17, documents: the Care Plan Conference shall be held as necessary to communicate major revisions to the Comprehensive Care Plan and minimally with every Comprehensive Minimum Data Set/MDS completed; the Facility shall make an effort that the conference be attended by a representative from each discipline involved in resident care; be attended by the Resident unless the Resident is
incapable of understanding the proceedings or chooses not to attend; be attended by a representative of the Resident's choice; serve as a means of communication among disciplines and resident/representative; provide a setting to discuss the Resident's condition, medications, progress, lack of progress and changes in or continuance of care plans; care information be communicated to the Resident and/or representative of Resident's choice if unable to attend and document such relay information in the Resident's record; and record such event by creating attendance record that states the dates and persons in attendance, via the Care Plan Summary/Participation Record.
Facility Resident Rights, revised 11/2018, documents: right to participate in your own care; participate in developing a person-centered care plan; attend the care plan conference at a time and location convenient to you; and may choose to have family, friends or a representative join the care plan conference.
1. R32's Nursing Notes and Social Service Notes, dated 6/9/22 do not document a Care Planning meeting. The Facility could not provide a Care Plan/Participation Record for R32.
2. R47's Nursing Notes and Social Service Notes, dated 3/1/22 through 8/10/22, do not document a Care Planning meeting. The Facility could not provide a Care Plan/Participation Record for R47.
On 08/09/22, at 10:46 am, V12 (R47's Sister) stated, I have not attended, let alone been invited, to a Care Plan meeting for my brother since last year, I think it is because of COVID, but I am not sure why they are not having those meetings anymore.
On 8/11/22, at 11:20 am, V4 (Social Service Director) stated, We have not had a Care Plan Nurse since last year, that is why we do not have any participation records or care planning sign in sheets. We have occasionally got with family and talked with them but nothing formal.
On 8/11/22, at 10:16 am, V1 (Administrator) stated, I have been employed here since October of 2021 and we have not had a Care Plan nurse since then. All the department heads help make sure that the Care Plans are up to date, but we have not sent out any Care Plan meeting letters or held any care plans since I have been here.
6. R31's medical record does not include any Social Service Notes or Interdisciplinary Team notes of R31 or R31's representative being invited or attending a care planning meeting for R31.
7. R37's medical record does not include any Social Service Notes or Interdisciplinary Team notes of R37 or R37's representative being invited or attending a care planning meeting for R37.
On 8/11/22 at 11:51 am, R37 stated she has never been invited or attended any care planning meeting since admitting to the facility.
8. R11's Medical Record, Social Service Notes, and Care Plan dated 12/1/21-8/11/22 do not document any care planning conferences offered or held with R11 and her resident representative/family members.
9. R23's Medical Record, Social Service Notes, and Care Plan dated 12/1/21- 8/11/22 do not document any care planning conferences offered or held with R23 and his resident representative/family members.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
3. R19's current Care Plan documents that R19 is to continue Restorative Nursing Programs already in place. R19's chart did not document any Restorative Programs.
4. R47's current Care Plan documents...
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3. R19's current Care Plan documents that R19 is to continue Restorative Nursing Programs already in place. R19's chart did not document any Restorative Programs.
4. R47's current Care Plan documents that R47 is on a Restorative Nursing Program for Range of Motion and Bed Mobility. R47's chart did not document any Restorative Programs.
On 8/9/22, at 11:14 am, R19 stated, I do not get any therapy, no I do not.
On 8/10/22, at 1:14 pm, V7 (Assistant Director of Nursing/Restorative Nurse) stated, I cannot find you any documentation of any of the the Resident's Restorative Programs because we do not have a Restorative Aide or Restorative Program.
Based on observation, interview, and record review the facility failed to provide Restorative Rehabilitation program for four (R19, R31, R37 and R47) of four residents reviewed for restorative services in the sample of 26.
Findings include:
The facility's undated Restorative Care/Nursing Rehabilitation policy and procedure documents, Restorative nursing focuses on what the resident is able to do. Interventions are focused on promoting the resident's ability to attain his/her maximum functional potential. The goals are to create independence, reduce the level of assistance required, and increase level of dignity. The Program Qualifiers include Quarterly note written by a Licensed Nurse including progress, participation and response/tolerance to each program . Nurse aides are trained in the techniques that promote resident involvement in the task . Interventions are carried out or supervised by the nursing staff . Provided for at least 15 min (minutes) per day.
1. Quarterly MDS (minimum data set) assessment for R31, dated 6/8/22, documents R37 is receiving restorative nursing programs for transfers and/or grooming. This same MDS documents R37 is cognitively intact.
The current Care Plan for R37 documents R37 is on two Restorative Nursing Programs. Restorative Nursing Program - Transfers documents problem as inability to transfer safely without staff assistance with goal to participate in every transfer with set up and verbal cues. Restorative Nursing Program - Bathing/Hygiene documents problem as potential for decline in ability to complete hygiene task independently with goal to perform hygiene task of washing face/hand/peri area during AM/PM (morning and evening) cares with set up of equipment and verbal cues daily.
On 8/11/22 at 11:51 am, R37 stated No one has been doing any restorative programs with me. I try to do all my stuff the best I can.
2. The Significant Change MDS (minimum data set) assessment for R31, dated 6/6/22, documents R31 is receiving Restorative Nursing Programs for active range of motion exercises and for eating.
The current Care Plan for R31 documents R31 is on two Restorative Nursing Programs. Restorative Nursing Program - Range of Motion documents problem as impaired ability to perform ROM (range of motion) exercises with goal to actively participate in moving/exercising of BUE (bilateral upper extremities) and BLE (bilateral lower extremities) joints with verbal cues twice daily. Restorative Nursing Program - Eating documents problem as potential in ability to feed self independently. The goal is for R31 to feed self 25% (percent) of meal three times daily with set up and verbal cues.
On 8/11/22 at 9:46 am, V9 and V10 CNA's (Certified Nursing Assistants) transferred R31 to bed and during cares R31's knees remained bent and V9 and V10 CNA's were unable to get R31 to straighten her legs out. R31's knees were stiff and when R31 was turned to the side R31 brought her legs up towards her waist.
On 8/11/22 at 10:43 am, V9 CNA stated we do not have any restorative CNA's and we have not been doing the restorative programs. V9 stated she thinks V7 Restorative Nurse does the programs.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 3 life-threatening violation(s), 2 harm violation(s), $181,422 in fines, Payment denial on record. Review inspection reports carefully.
- • 84 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $181,422 in fines. Extremely high, among the most fined facilities in Illinois. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.
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About This Facility
What is Goldwater Care Peoria Heights's CMS Rating?
CMS assigns GOLDWATER CARE PEORIA HEIGHTS an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Illinois, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Goldwater Care Peoria Heights Staffed?
CMS rates GOLDWATER CARE PEORIA HEIGHTS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 71%, which is 25 percentage points above the Illinois average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 100%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Goldwater Care Peoria Heights?
State health inspectors documented 84 deficiencies at GOLDWATER CARE PEORIA HEIGHTS during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 78 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Goldwater Care Peoria Heights?
GOLDWATER CARE PEORIA HEIGHTS is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GOLDWATER CARE, a chain that manages multiple nursing homes. With 94 certified beds and approximately 46 residents (about 49% occupancy), it is a smaller facility located in PEORIA HEIGHTS, Illinois.
How Does Goldwater Care Peoria Heights Compare to Other Illinois Nursing Homes?
Compared to the 100 nursing homes in Illinois, GOLDWATER CARE PEORIA HEIGHTS's overall rating (1 stars) is below the state average of 2.5, staff turnover (71%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Goldwater Care Peoria Heights?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Goldwater Care Peoria Heights Safe?
Based on CMS inspection data, GOLDWATER CARE PEORIA HEIGHTS has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Illinois. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Goldwater Care Peoria Heights Stick Around?
Staff turnover at GOLDWATER CARE PEORIA HEIGHTS is high. At 71%, the facility is 25 percentage points above the Illinois average of 46%. Registered Nurse turnover is particularly concerning at 100%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Goldwater Care Peoria Heights Ever Fined?
GOLDWATER CARE PEORIA HEIGHTS has been fined $181,422 across 1 penalty action. This is 5.2x the Illinois average of $34,893. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Goldwater Care Peoria Heights on Any Federal Watch List?
GOLDWATER CARE PEORIA HEIGHTS 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.