BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER
For profit - Corporation
67 Beds
BRICKYARD HEALTHCARE
Data: November 2025
Trust Grade
35/100
#434 of 505 in IN
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brickyard Healthcare - Woodbridge Care Center has received a Trust Grade of F, indicating significant concerns regarding the quality of care, which places it in the poor category. With a state rank of #434 out of 505 facilities in Indiana, and #14 out of 17 in Vanderburgh County, it is in the bottom half of options available. The facility is currently improving, with a decrease in issues from 17 in 2024 down to just 1 in 2025. While staffing is rated as average with a turnover rate of 48%, the lack of fines is a positive aspect, as they have no fines on record. However, there have been serious incidents, including failures to treat urinary tract infections for residents, which led to hospitalizations and postponed surgeries, highlighting critical gaps in care and oversight. Overall, families should weigh these significant weaknesses against the few strengths when considering this facility for their loved ones.
- Trust Score
- F
- In Indiana
- #434/505
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Indiana facilities.
- Skilled Nurses ○ Average
- Each resident gets 38 minutes of Registered Nurse (RN) attention daily — about average for Indiana. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 42 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 15%
Needs review
17 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 17 issues
2025: 1 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 Indiana average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 48%
Near Indiana avg (46%)
Higher turnover may affect care consistency
Chain: BRICKYARD HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 42 deficiencies on record
1 actual harm
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure dialysis care was provided for 1 of 3 residents reviewed for dialysis. Routine assessments were not completed as ordered and the phy...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure dialysis care was provided for 1 of 3 residents reviewed for dialysis. Routine assessments were not completed as ordered and the physician was not notified when a resident refused or stopped dialysis treatments early. (Resident B)
Finding includes:
During record review on 3/6/25 at 10:30 A.M., Resident B's diagnoses included, but were not limited to, end stage renal disease and dependence on renal dialysis.
Resident B's most recent admission Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the resident was cognitively intact and received dialysis services.
Resident B's physician orders included, but were not limited to, dialysis treatment on Tuesdays, Thursdays, and Saturdays (started 2/1/25), monitor dialysis dressing for bleeding, every day and night shift for left dialysis permacath (started 2/1/25).
Resident B's care plan included, but was not limited to, resident needs dialysis due to renal failure (started 2/21/25). Interventions included, but were not limited to observe permacath for placement routinely.
Resident B's Treatment Administration Record (TAR) for February & March, 2025 indicated no monitoring of the resident's left dialysis permacath occurred on 2/14/25 night shift, 2/18/25 day shift, or 3/2/25 night shift.
Resident B's dialysis//observation communication forms contained the following:
2/6/25 - Resident only stayed 1.5 hours. Resident left against medical advice (AMA).
2/8/25 - Resident refused to stay. Resident left early AMA.
2/13/25 - Resident requested early termination from dialysis treatment.
2/15/25 - Resident refused dialysis treatment.
Resident B's progress notes contained no documentation that the physician was notified on 2/6/25, 2/8/25, 2/13/25, or 2/15/25 when the resident refused or left dialysis AMA.
During an interview on 3/7/25 at 11:15 A.M., LPN 4 indicated nursing staff assess a resident's dialysis access site daily and documented in the TAR or nurse's progress notes. If a resident refused dialysis or left dialysis before their treatment was completed, the resident's physician should be notified and the notification should be documented.
On 3/7/25 at 9:20 A.M., the facility administrator supplied a facility policy titled, Hemodialysis dated, 2024. The policy indicated, 8. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . 10. The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record . 16. Residents with external dialysis catheters will be assessed every shift to ensure that the catheter dressing is intact and not soiled .
This citation relates to complaint IN00454852.
3.1-37(a)
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
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 the misappropriation of resident's narcotic medication for ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of resident's narcotic medication for 1 of 3 residents reviewed for misappropriation of property. A resident's narcotic pain medication was missing. (Resident B)
Finding includes:
During record review on 12/17/24 at 10:39 a.m., Resident B's diagnoses included, but were not limited to, dysphagia following cerebral infarction, type 2 diabetes mellitus with hyperglycemia, aphasia following cerebral infarction. A MDS (Minimum Data Set) assessment dated [DATE], indicated cognition was severely impaired.
Care plans were reviewed and included, but were not limited to:
Pain : I am at risk for pain related to Hx (history) of Cva (cerebral infarction).
Interventions included, but were not limited to: Administer pain medications as ordered, date initiated, 6/26/24.
A progress note dated 12/5/24 at 4:48 p.m., indicated Facility nurse noticed when checking to see if resident needed refill on Norco during hospice visit that medication was not in the cart and count sheet was missing. ED, DNS, and Unit Manager. Resident was immediately assessed for pain and psychosocial distress. Not (sic) s/s noted. Hospice aware and initiated refill request. [name of pharmacy], resident's emergency contact, Medical Director, and [name], NP notified. Head to toe assessment completed. No injury or skin issues noted. Resident placed on psychosocial and pain monitoring x 72hrs(sic).
December 2024 physicians orders included, but were not limited to:
Norco (pain medication) oral tablet 5- 325 MG (milligram) (Hydrocodone- Acetaminophen * Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain, order date 11/20/24.
On 12/17/24 at 1:57 p.m., a state reportable with an incident date of 12/4/24, was reviewed and included, but was not limited to:
Description added- 12/5/24 During hospice visit, hospice nurse inquired if patient needed a refill on his Norco script. When facility nurse was checking quantity of Norco, the facility nurse noticed that the card of 57 Norco and associated count sheet was missing and could not be accounted for.
Follow up added- 12/12/2024 All follow up was completed with no further issues. [Resident B] did not display any signs of psychosocial distress while being monitored by social services. [Resident B] did not display any signs of increased pain or discomfort. Staff and resident interviews completed with no concerns of narcotics not being available or not given per MD orders. All nurses were drug tested with no concerns identified from the drug tests. Full reconciliation of all narcotics in the building completed with no discrepancies. [name of police department] notified and case number # [number] was provided. Staff education completed on narcotic administration and abuse reporting and prohibition.
On 12/18/24 at 10:15 a.m., the Administrator indicated the incident with Resident's B's missing narcotics was noticed on 12/5/24, she mistakenly put the date of 12/4/24 on the State Reportable as the incident date.
On 12/17/24 at 12:15 p.m., the Administrator provided the current policy on abuse, neglect, and exploitation with copyright date of 2024. The policy included, but was not limited to: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .
The deficient practice was corrected on 12/9/2024 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI meeting was held on 12/6/2024 an action plan included inservice review of policy for controlled substances with staff, staff drug testing on 12/5/24, the completion of IDT meeting for resident on 12/9/24 and the on-going monitoring of the controlled substances for all residents.
This citation relates to Complaint IN00448621
3.1-28(a)
Jul 2024
16 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 reasonable accommodations of needs by transpo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs by transporting a resident in an improperly fitted wheelchair for 1 of 1 residents reviewed for mobility. (Resident 8)
Findings include:
During an observation on 7/9/24 at 9:46 A.M., Resident 8 was observed sitting in a manual wheelchair in the hallway. Resident 8 indicated he was ready to get out of the wheelchair and go to bed.
During an interview on 7/10/24 at 9:47 A.M., RN (Registered Nurse) 3 indicated the manual wheelchair was not Resident 8's personal wheelchair and was the one staff used for transportation due to Resident 8's personal electric wheelchair not being able to fit in the facility's mobility van.
On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
Current orders included, but were not limited to:
OT (Occupational Therapy) screen attempted due to reports of poor positioning in wheelchair however pt (patient) LOA (leave of absence/out of building) at this time Order date 7/10/24
During an interview on 7/12/24 at 9:29 A.M. Occupational Therapist 10 indicated she was not aware until this week Resident 8's trunk was not being supported in the manual wheelchair nursing staff had been using to transport Resident 8 in the mobility van.
On 7/15/24 at 3:04 P.M., the Regional Support Consultant provided a document titled Functional Mobility and Wheelchair Assessment, dated 4/24/24, that indicated manual wheelchair use was contraindicated for Resident 8 by diagnoses, the only mobility device that met the needs for safety independent functional ambulation/mobility was a power wheelchair due to quadriplegia and impairment in arms, legs, and trunk, and stage 4 pressure wounds on the sacral region, and inability to achieve repositioning for pressure relief in a standard wheelchair.
On 7/15/24 at 12:10 P.M. the Administrator provided a policy titled Therapy Evaluation, dated 2023, that indicated The Licensed Therapist will perform an initial evaluation upon physician referral and any re-evaluation where indicated.
3.1-3(v)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify a resident's physician of treatments not provi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify a resident's physician of treatments not provided for 1 of 2 residents reviewed for pressure ulcers. (Resident 8)
Finding includes:
On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
Current physician orders included, but were not limited to:
Dakins external solution (sodium hypochlorite) Apply to coccyx topically every day and night shift for wounds, start date 7/3/24.
Cleanse with Dakins Solution, apply silver alginate to the wound bed and cover with superabsorbent dressing every day and night shift for Stage three pressure area to right dorsal foot.
Wound #1 left gluteal pressure treatment recommendations: Cleanse with 0.25% Dakins solution, apply silver alginate to base of the wound, secure with superabsorbent (dressing), change BID (twice a day) every day and night shift for stage three pressure area to left gluteal/buttock.
Wound #2 coccyx pressure treatment recommendations: Cleanse with 0.25% Dakins solution. apply silver alginate to base of the wound, secure with superabsorbent (dressing), change BID, every day and night shift for stage four pressure area to coccyx.
Wound #3 right gluteal pressure treatment recommendations: Cleanse with 0.25% Dakins solution, apply silver alginate to base of the wound, secure with superabsorbent (dressing), change daily, every day and night shift for stage four pressure area to right gluteal/buttock.
Current care plans included, but were not limited to:
(Resident) has personal preference to be changed on his time and not when staff come in to do it.
Honor personal preference as safely able.
Notify MD (doctor) of resident preference; Date initiated 1/18/24.
The following progress notes indicate times and dates during the past month when Resident 8 refused treatment, while sleeping, and further attempts to change dressings during wake hours were not documented.
7/11/24 4:37 A.M. (Resident) is currently asleep and does not want this nurse to change dressings on foot or buttocks and coccyx.
7/8/24 11:50 P.M. (Resident) states he just got comfortable and doesn't want to move.
7/6/24 5:34 A.M. Resident refused this nurse to do treatment stating he was trying to sleep and didn't feel like doing it.
6/30/24 12:35 A.M. Resident refused to have treatments done. Wanted to sleep.
6/29/24 4:21 A.M. Resident did not want this nurse to complete dressing changes while resident trying to sleep.
6/23/24 10:41 P.M. (Not administered) Resident sleeping
6/22/24 2:21 A.M. (Resident) refused to have treatments done. Resident was tired and just wanted to go to sleep.
During an interview on 7/12/24 at 9:23 A.M. Physician 12 indicated she had not been notified of wound treatment refusals or change in preference time of treatments for Resident 8.
During an interview on 7/12/24 at 11:09 A.M., the Regional Support Consultant read results, from the MRI performed on Resident 8 on 7/9/24, and indicated Resident 8 was positive for osteomylitis (bone infection) and the results had not yet been sent to Resident 8's physician, but she would send them at this time.
On 7/15/24 at 12:10 P.M., the Administrator provided a policy titled Promoting/Maintaining Resident Self-Determination, dated 2024, that indicated The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician.
A policy relating to physician notification was requested but was not provided.
3.1-5(a)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by sta...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 1 resident's reviewed for facility reported incidents of staff to resident physical contact. (Resident 8)
Finding includes:
On 7/9/24 at 8:45 A.M., a facility reported incident, dated 3/13/24 at 3:01 A.M., was reviewed. The incident form indicated Resident 8 reported that during PM (evening) care, Employee 13 made contact to Resident's head. Employee 13 was immediately suspended pending investigation. A follow up added 3/21/24 indicated Resident 8 showed no signs of distress and Employee 13 chose not to participate in the investigation and resigned from employment.
On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia and contracture of muscle/joint.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
During an interview on 7/9/24 at 8:55 A.M., the Administrator provided clarification that the verbiage made contact was intended to mean Resident 8's head bent forward and touched Employee 13's chest when Employee 13 was assisting Resident 8 with changing Resident 8's shirt. The investigation file was provided and the following was included:
A screenshot of a text message from QMA 15 reads I was passing meds (medications) with my back to (employee 13) and (Resident 8). (Resident 8) all of a sudden says why did you slap me? So I turned around and said what? (Employee 13) instantly started to apologize saying I thought you bit me.
An email from the Social Service Director dated 3/15/24 at 4:00 P.M. indicated on 3/12/24, while Resident 8 was being provided care, Employee 13 was attempting to remove Resident 8's shirt when Resident 8 involuntarily moved forward and his head touched Employee 13's nametag, and Employee 13 immediately took her hand and hit Resident 8's face.
A statement dated 3/13/24, signed by Employee 13, indicated she was helping Resident 8 change his shirt when Resident 8 acted like he was going to bite Employee 13 so she put her hand up to his face and pushed him back and he stated wow I just got slapped.
During an anonymous interview on 7/10/24 at 8:31 A.M., the anonymous person indicated an incident that happened on 3/12/24 between Employee 13 and Resident 8, where Employee 13 slapped Resident 8 in the face. The anonymous person indicated since Employee 13 was fired, she and her spouse had harassed Resident 8 about reporting the the incident while Resident 8 was out in the community with family.
During an interview on 7/15/24 at 8:59 A.M., the Administrator indicated she didn't recall the timeline of the incident that happened, that she was gone from the building for training at that time because administration was switching and there wasn't great communication between the old administrator about incidents going on in the building. The Regional Support Consultant states she is the one who made the report and even though employee 13 had given a written statement, she reported on the State Incident Form that Employee 13 had not given a statement because Employee 13 would not come to the building to talk to administration in person.
On 7/9/24 at 9:45 A.M., the Administrator provided a policy titled Abuse, Neglect, and Exploitation, dated 2022, that indicated The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of residents property, and exploitation. The facility will have written procedures that include reporting of alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement when applicable) Immediately, but not later that 2 (two) hours after the allegation is made, even if the events that cause the allegation involve abuse or result in serious bodily injury. Assuring that reporters are free from retaliation or reprisal.
3.1-27(a)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transport residents with proper documents, or transfers residents w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transport residents with proper documents, or transfers residents with legible documents for 2 of 3 residents reviewed for hospitalizations. (Resident 8 and Resident 54)
Findings include:
1. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
The clinical record indicated during the past year, Resident 8 was discharged from the facility and admitted to the hospital on [DATE] and 5/10/24.
A progress note dated 5/10/24 at 9:39 A.M., indicated Resident (was) sent to ER (emergency room). Transfer log, order summary, post form, and bed hold policy sent with resident.
During an interview on the Regional Support Consultant indicated there were no documents sent with Resident 8 during the hospital visit on 9/4/23. The transfer/discharge forms sent with Resident 8 on the 5/10/24 hospital visit were provided, however, the Administrator and Regional Support Consultant were unable to read the documents and indicated the paperwork sent with Resident 8 was not legible, and new forms would have to be printed to be able read them.
2. On 7/11/24 at 2:49 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease and essential (primary) hypertension,
The current admission MDS (Minimum Data Set) Assessment, dated 5/1/24, indicated Resident 54 was cognitively intact and needed supervision for eating, dressing, and mobility.
A Significant Change Nurse's Progress Note, dated 5/27/24 at 2:26 P.M., indicated the resident was having chest pain and shortness of breath. Vital signs indicated Blood Pressure 224/125, Pulse 86, Respirations 18, and Oxygen Saturation of 92%. Nurse Practitioner was called, and the new orders were received to transfer the resident to the Emergency Room.
The record lacked an order to transfer and paperwork for transfer, discharge, and bed hold.
During an interview on 7/15/24 at 8:53 A.M., the Regional Support Person indicated that the facility could not locate any transfer/discharge/ bed hold information requested for 5/27/24.
On 7/15/24 at 8:53 A.M. the Administrator provided a policy titled Transfer and Discharge, dated 2024, that indicated the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. For transfer to another provider, for any reason, the following information must be provided to the receiving provider: Contact information of the practitioner who is responsible for the care of the resident; Resident representative information, including contact information; all advanced directive information; all other information necessary to meet the residents needs . The original copies of the transfer form and Advance Directive accompany the resident. Provide a notice of transfer and the facility's bed hold policy to the resident and representative. The Social Services Director will provide copies of notices for emergency transfers to the Ombudsman.
3.1-12(a)(16)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and interview the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 2 residents reviewed for unnecessary medications and bladder.(Resident 4)
Findings include:
On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and flaccid neuropathic bladder, not elsewhere specified.
The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. The Bowel and Bladder section indicated Resident 4 had an indwelling, suprapubic and external catheters with a colostomy.
A Significant Change MDS dated [DATE] indicated that Resident 4 had an indwelling, suprapubic catheter and no external catheter or colostomy.
Physician orders included but were not limited to:
Change suprapubic catheter drainage bag weekly and PRN ( As Needed) dated 3/27/2024.
Change catheter as needed (occlusion, dislodgement, possible infection, etc.) as needed for catheter use dated 10/10/2023.
During an interview on 7/10/24 at 9:47 A.M., the MDS nurse indicated the MDS was wrong for Resident 4 and needed to be corrected.
During an interview on 7/15/24 at 11:40 A.M., the Regional Support Person indicated the facility would follow the RAI (Resident Assessment Instrument) and may have a policy for the accuracy of MDS.
A current, nondated policy Conducting an Accurate Resident Assessment. The policy indicated .an assurance that all residents receive and accurate assessment, reflective of the resident's status at the time of the assessment .qualified staff who knowledgeable about thee resident will conduct and accurate assessment addressing each resident's status, needs, strengths, and areas of decline .information provided by the initial comprehensive assessment establishes baseline data the ongoing assessment of resident progress.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, nonrheumati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, nonrheumatic aortic valve stenosis.
The most current Annual Minimum Data Set (MDS) Assessment, dated 6/3/24, indicated Resident 15 was cognitively intact, required supervision for eating, and received an antiplatelet medication during the 7-day look back period.
Current physician orders included, but were not limited to:
Aspirin (an antiplatelet medication) 81 mg (milligrams) Oral Tablet Delayed Release - Give 81 mg by mouth one time a day, dated 2/8/24
The clinical record lacked an order to monitor for side effects for an antiplatelet medication including bleeding.
The clinical record lacked a care plan for an antiplatelet medication or bleeding.
On 7/12/24 at 2:30 P.M., the Director of Nursing (DON) indicated monitoring for side effects of an antiplatelet medication would be in the orders.
On 7/15/24 at 8:44 A.M., the MDS Coordinator indicated care plans would include a care plan for antiplatelets or to monitor for bleeding if the resident received an antiplatelet.
On 7/15/24 at 10:50 A.M., the Administrator provided a Comprehensive Care Plans policy, dated 2023, that indicated The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
3.1-35(a)
3.1-35(b)(1)
Based on observation, record review, and interview, the facility failed to implement physician orders or develop care plans for 3 of 5 resident's reviewed for unnecessary medications. (Resident 4, Resident 9, Resident 15)
Findings include:
1. On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, major depressive disorder, anxiety state, unspecified, chronic pain, essential primary hypertension and osteoarthritis.
The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident 4 was cognitively intact and was dependent on transfer, eating, and mobility. During the 7 days look back period the resident was noted to be on the following types of medications: Antidepressant, Antianxiety, Antipsychotc, Opioid, and Diuretic.
Current physician orders included:
Norco Oral Tablet 7.5-325 MG (Milligrams) (Hydrocodone-Acetaminophen)(pain medication).Give 1 tablet by mouth every 6 hours as needed for Pain related to PRIMARY GENERALIZED (OSTEO)ARTHRITIS dated 4/8/24.
Pain monitoring q(every) shift, record any interventions (Pharmacological and Non-pharmacological every shift related to OTHER CHRONIC PAIN dated 1/1/24.
ClonazePAM Tablet 0.5 MG (Anti-Anxiety Medication).Give 1 tablet by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED dated 10/10/2023.
Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence every shift related to ANXIETY DISORDER, UNSPECIFIED dated 10/11/23
Dyazide Oral Capsule 37.5-25 MG (Triamterene and Hydrochlorothiazide)(Diuretic). Give 1 capsule by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION dated 5/27/24.
Monitor for S/S (Signs and Symptoms) of electrolyte imbalance related to diuretic use Q shift. Document and notify MD of Irregular Heartbeat, increased heart rate, fatigue, lethargy, convulsions/seizures, N/V/D( Nausea/Vomiting/Diarrhea), Constipation, muscle/abdominal cramping, confusion, headache
every shift for Dyazide medication therapy related to ESSENTIAL (PRIMARY) HYPERTENSION dated 1/2/2024.
Sertraline HCl Tablet 100 MG (Antidepressant).Give 200 mg by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23.
Trazodone HCL Oral Tablet 200 MG (Antidepressant). Give 1 tablet at bedtime related to MAJOR DEPRESSIVE , RECURRENT, MODERATE dated 10/10/23.
Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain
every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23.
Risperidone Tablet 1 MG (Antipsychotic).Give 2 tablets by mouth two times a day related to MAJOR DEPRESSIVE DISORDER; RECURRENT, MODERATE,UNSPECIFIED MOOD [AFFECTIVE] DISORDER dated 10/10/23.
Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (Extrapyramidal Symptoms), weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE dated 10/11/23.
The current care plan indicated that the resident has a potential for drug related complications associated with the use of antidepressant, antianxiety, and antipsychotic medications. Interventions included, but were not related to, Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS (Extrapyramidal Symptoms), weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention, Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain, Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss dated 10/12/23
The resident takes hypertension medication and will remain free of complications. Interventions include
Monitor for S/S (Signs and Symptoms) of electrolyte imbalance related to diuretic use Q shift. Document and notify MD of Irregular Heartbeat, increased heart rate, fatigue, lethargy, convulsions/seizures, N/V/D( Nausea/Vomiting/Diarrhea), Constipation, muscle/abdominal cramping, confusion, headache
dated 10/20/23.
The resident is at risk for pain related to osteoarthritis and adequate pain level will be maintained date 10/20/23. Interventions included but were not limited to administering pain medications as ordered and utilize pain monitoring tool to evaluate effectiveness of interventions dated 10/20/23.
On 7/11/24 at 2:10 P.M ., the June MAR (Medication Administration Record) and TAR (Treatment Administration Record) was reviewed, and the following dates and shifts lacked documentation:
MAR AND TAR reviewed for June 2024 indicated:
Lacked documentation for antianxiety interventions
evenings 6/8/34
Lacked documentation for electrolyte imbalance interventions
evenings-6/8/24
Lacked documentation for antipsychotic interventions
evenings-6/8/24
Lacked documentation for antidepressant interventions
evenings 6/8/24
Lacked documentation of pain monitoring interventions
evenings 6/8/24 and 6/9/24
TAR and MAR for April 2024
Lacked pain monitoring q shift interventions
days 4/5/24 and 4/19/24
evenings 4/6
4/10 days 4/8 4/18
Lacked monitoring for electrolyte monitoring interventions
even 4/6
night 4/5 4/19
days 4/8, 4/10 4/15
Lacked monitoring documentation for antianxiety interventions
evenings 4/6/24
nights 4/6/24 and 4/19/24
days 4/8/24, 4/10/24 and 4/15/24
Lacked monitoring documentation for antidepressant interventions
nights- 4/5/24 and 4/19/24
evening- 4/6/24
days- 4/8/24, 4/10/24, and 4/15 /24
Lacked monitoring documentation for antipsychotic interventions
nights- 4/5/24 and 4/19/24
evening -4/624
days- 4/8/24, 4/10/24, and 4/15/24
MAY MAR AND TAR
Lacked documentation of monitoring for electrolytes interventions
days 5/2/24
nights 5/1024
Lacked documentation of antianxiety interventions
days 5/2/24
nights 5/10/24
Lacked documentation of antidepressant interventions
days- 5/2/24
nights- 5/10/24
Lacked documentation of antipsychotic interventions
days 5/2
nights 5/10
Duplicate pain monitoring
days 5/2/10
nights 5/10/24
During an interview on 7/11/24 at 2:05 P.M., the DON (Director of Nursing) indicated if there is a refusal or reason the medication was not given should be documented in the progress notes.
2. On 7/11/24 at 9:27 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to non-specified dementia, unspecified severity, with other behavioral disturbance, generalized anxiety order, bipolar disorder, and major depressive disorder, recurrent.
The current Quarterly MDS assessment dated [DATE] indicated Resident 9 was cognitively impaired and needed supervision with eating, dressing, toileting, and transferring. During the 7 days look back period the resident was on the following types of medication antipsychotic, antianxiety, antidepressant, and opioid. No behaviors were exhibited during this time.
Current physician orders included but not limited to:
Diazepam Oral Tablet 5 MG (Milligrams) (Diazepam)
(antianxiety).Give 1 tablet by mouth three times a day related to GENERALIZED ANXIETY DISORDER,BIPOLAR DISORDER, UNSPECIFIED dated 4/22/2024.
Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence every shift for Diazepam related to GENERALIZED ANXIETY DISORDER dated 3/9/2024.
Risperdal Oral Tablet 3 MG (Risperidone)(Antipsychotic).Give 1 tablet by mouth in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE dated 4/15/2024
Risperdal Oral Tablet 2 MG (Risperidone)(Antipsychotic). Give 1 tablet by mouth in the evening related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE dated 4/15/2024.
Monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention every shift for side effect monitoring for antipsychotic dated 7/31/23.
Zoloft Oral Tablet 100 MG (Sertraline HCl)(Antidepressant).Give 200 mg by mouth one time a day related to BIPOLAR DISORDER, UNSPECIFIED.MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD dated 2/4/2024.
Monitor for side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain every shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, MILD dated 3/9/24.
Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen)(Pain medication).Give 1 tablet by mouth two times a day for Pain dated 7/27/2023.
Rivastigmine Transdermal Patch 24 Hour 13.3 MG/24HR (Rivastigmine).Apply 1 patch transdermal in the morning related to UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE and remove per schedule dated 7/3/24.
Namenda Oral Tablet 10 MG (Memantine HCl)(Dementia).Give 1 tablet by mouth two times a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY dated 2/8/2024.
Behavior monitoring for: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE Interventions: 1-1 on 1, 2-Activity, 3-Adjust room temperature, 4-Backrub, 5-Change position, 6-Give fluids, 7-Give food, 8-Redirect, 9-Refer to nurse's notes, 10-Remove resident from environment, 11-Return to room, 12-Toilet, 13-Other: Outcomes: I(Improved), S(Same), W(Worsened) every day and night shift dated 7/6/24.
The current care plan indicated the resident take any psychotropic, antianxiety, and antidepressant medications and is at risk for side effects. Interventions included, but not limited to, observe for side effects and report to physician: Anti-anxiety/Hypnotic medications drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, tachycardia, weakness, sedation, lethargy, confusion, memory loss and dependence dated 12/13/2022. Observe for side effects and report to physician: Antidepressant-Sedation,
drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain dated 12/13/22. Observe for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention dated 12/13/22.
There is a current care plan indicated the resident has impaired cognitive function, dementia or
impaired thought process related to dementia. Interventions include but not limited to administer medications as ordered dated 12/13/22.
On 7/11/24 at 2:00 P.M., the MAR (Medication Administration Record) and TAR (Treatment Administration Record) was reviewed Rivastigmine Transdermal Patch used for Dementia was not administered on 6/3/24, 6/4/24, 6/5/24, 6/9/24, and 6/22/23 for administration and removal
was administered on 6/28/24 but not removed at 6:30 P.M. on 6/29/24 there was no reason for not administration noted in progress notes.
Diazepam 5 mg not given on 6/7/24 at 2:30 P.M ,6/22/24 at 6:00 A.M. and 6/29/24 at 2:30 P.M. there was no reason for not giving in the progress notes.
Lack documentation to monitor for side effects 6/8/24 evening shift- antianxiety, antidepressant, antipsychotic and mood stabilizer.
Lacked documentation to monitor for side effects of mood stabilizer for 6/9/24 evening shift.
During an interview on 7/11/24 a 11:27 P.M., RN (Registered Nurse) indicated there has to be some indication why the medication was not given.
During an interview on 7/15/24 at 12:10 P.M., the Regional Support Person indicated the facility did not have policy for following physician order but would follow the physician written orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure medication was being properly administered for 1 of 1 random observations of insulin administration. (Resident 25)
Fi...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure medication was being properly administered for 1 of 1 random observations of insulin administration. (Resident 25)
Finding includes:
On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed preparing a Humalog Insulin Kwikpen for insulin administration for Resident 25. An AccuCheck (blood glucose test) indicated the resident had a blood sugar of 200. RN 3 indicated the resident received sliding scale insulin and was to receive 4 units of insulin lispro (a fast acting insulin) for a blood glucose reading of 200. RN 3 set the insulin pen to 6 units and indicated the resident got 4 units of insulin plus 2 units of insulin to prime the pen. She cleaned the tip of the pen, attached the needle, and administered 6 units of insulin to Resident 25 in her left arm.
On 7/12/24 at 11:51 A.M., Licensed Practical Nurse (LPN) 6 indicated insulin pens do not have to be primed and she had never primed an insulin pen before.
On 7/12/24 at 1:46 P.M., the Humalog Kwikpen user manual was reviewed. It indicated Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 8 times. If you still do not see insulin, change the needle and repeat priming steps 6 to 8.
On 7/12/24 at 2:30 P.M. the Director of Nursing (DON) indicated that an insulin pen should be primed with 2 units before administration of the required insulin dose.
On 7/12/24 at 12:46 P.M., the Administrator provided an Insulin Pen policy, dated 2024, that indicated Prime the insulin pen: Dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears.
3.1-35(g)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents who required restorative services received servic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents who required restorative services received services in their plan of care for 3 of 4 residents reviewed for restorative nursing. (Resident 2, Resident 7, Resident 13)
Findings include:
1. On 7/12/24 at 8:52 A.M., Resident 2's clinical record was reviewed. Resident 2's diagnoses included, but were not limited to, dementia, weakness, and intellectual disabilities.
The most recent Quarterly MDS (Minimum Data Set Assessment), dated 6/3/24, indicated resident 2 was severely cognitively impaired, required substantial assistance of staff with toileting and transfers, and was dependent on staff for bathing.
Care plans included, but were not limited to:
Nursing rehab/restorative AROM (active range of motion) program: AROM to BLE (bilateral lower extremities), hips, knees, and ankles, 20 reps 1-2 sets daily; date initiated 9/13/22.
On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 2. The following dates were documented with no restorative active range of motion provided in 2024:
January 3, 5, 26
February 4
March 10, 17, 23
April 3, 5, 7, 26, 29
May 4, 6, 9, 10, 14, 16, 18, 19, 21, 25, 26
June 1, 8, 11, 13, 14, 20, 25, 28, 29
July 5, 6, 7, 8, 9, 11
2. On 07/11/24 at 9:08 A.M., Resident 7's clinical record was reviewed. Resident 7 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease and dementia.
The most recent Annual MDS (Minimum Data Set) Assessment, dated 5/31/24, indicated Resident 7 was cognitively intact, required moderate assistance from staff for bathing, and required supervision of staff for eating, toileting, and transfers.
Care plans included, but were not limited to:
I will perform (1) set of (20) reps of AROM (active range of motion) to (BLE) extremities daily; date Initiated: 5/1/23.
On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 7. The following dates were documented with no restorative active range of motion provided in 2024:
January 5, 7, 10, 12, 14, 16, 18, 29, 30
February 1, 5, 8, 13, 15, 16, 24, 25
March 2, 5, 9, 14, 23
April 3, 6, 7, 26, 30
May 5, 6, 15, 25, 26, 28, 31
June 8, 28, 29, 30
July 1, 3, 6, 8, 11
3. On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Resident 13 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact, required moderate assistance from staff for toileting and bathing, and was receiving hemodialysis.
Current care plans included, but were not limited to:
Nursing rehab/restorative AROM (active range of motion) program: AROM seated AROM of BUE/BLE (bilateral upper and lower extremities) 20 reps 6 days a week; date initiated 3/13/24.
On 7/12/24 at 12:14 p.m., the Administrator provided restorative nursing minutes documented in the clinical record for Resident 13. The following dates were documented with no restorative active range of motion provided in 2024:
April 1, 2, 3, 4, 5, 6, 7, 8, 26, 27, 28, 29
May 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 19, 28, 29, 30
June 20, 21, 24, 25, 26, 29, 30
July 5, 6, 7, 8, 9, 11
During an interview on 7/10/24 at 2:45 P.M., Occupational Therapist 10 indicated it is a nursing staff task to perform restorative therapy and provided active range of motion exercises.
On 7/15/24 at 8:53 A.M. the Administrator provided a policy titled Restorative Nursing Program, dated 2023, that indicated The restorative nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented.
3.1-42(a)(2)
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 interview and record review, the facility failed to reduce the risk of falling for 1 of 3 residents reviewed for falls. Falls were not accurately documented, and the care plan was not updated...
Read full inspector narrative →
Based on interview and record review, the facility failed to reduce the risk of falling for 1 of 3 residents reviewed for falls. Falls were not accurately documented, and the care plan was not updated with new interventions for a resident with multiple falls. (Resident 6)
Finding includes:
On 7/9/24 at 9:49 A.M., Resident 6 indicated she had recently fallen and broken her nose because she could not reach her call light.
On 7/9/24 at 2:58 P.M., Resident 6's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and history of falling.
The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 6 was cognitively intact, was dependent on staff for transfers, and had 1 fall with major injury since the previous assessment.
A Fall Risk Assessment, dated 6/11/24, indicated the resident was at risk for falls.
A falls care plan, dated 12/20/22, indicated the resident was at risk for falls due to deconditioning, gait/balance problems, incontinence, poor safety awareness, psychotropic drug use, hearing problems, and clutter in room, and included an intervention for the call light to be within reach.
A Post Fall Evaluation, dated 7/20/23 at 5:57 A.M., indicated Resident 6 had an unwitnessed fall while reaching for an item in her room. An Interdisciplinary Team (IDT) Note, dated 7/20/23 at 12:51 P.M., indicated staff were to lay clothes out for the resident the night before to prevent reaching. The care plan was not updated with a new intervention.
A nurse's progress note, dated 8/14/23 at 11:54 P.M., indicated Resident 6 was complaining of persistent stiffness and soreness following recent incident where resident was lowered to the floor by staff. The doctor was notified, and new orders were received for ibuprofen (a pain reliever) 800 mg (Milligrams), 1 tablet by mouth two times a day for inflammation. The clinical record lacked a post fall evaluation, IDT note, progress note, follow up, or updated care plan related to this fall.
A Post Fall Evaluation, dated 9/3/23 at 7:43 P.M., indicated Resident 6 had an unwitnessed fall while reaching for an item in her room. Room ergonomics was added to the care plan on 9/5/23.
A Post Fall Evaluation, dated 9/5/23 at 2:52 A.M., contained a physical assessment with vitals, but had no other details regarding the fall. The clinical record lacked an IDT note, progress note, follow up, or updated care plan related to this fall.
A nurse's progress note, dated 1/12/24 at 7:36 A.M., indicated that a 2nd shift CNA (Certified Nurse Aide) dropped the resident while putting her to bed the previous evening. An IDT Note, dated 1/15/24 at 5:14 P.M., indicated the fall happened on 1/12/24 at 9:00 A.M. The IDT Note indicated staff were educated on safe and proper transferring of the resident. The care plan was not updated with a new intervention.
A Change of Condition note, dated 6/11/24 at 10:10 P.M., indicated Resident 6 had an unwitnessed fall while waiting for staff to assist her into bed. The resident sustained a laceration to the bridge of her nose and it was evident resident had suffered head trauma and required immediate assistance. The on-call Nurse Practitioner (NP) was notified, and the resident was sent to the emergency room (ER) for evaluation and treatment. An IDT note, dated 6/12/24 at 10:18 A.M., indicated the resident returned to the facility with Dermabond (a liquid skin adhesive) for closure of laceration to the bridge of the resident's nose and a fracture to the tip of the nose. Resident indicated to the Administrator during an interview that she fell because she was not able to reach her call light. Staff educated to keep call light within reach was added to the care plan on 6/12/24. A nurse's progress note, dated 6/13/24 at 12:38 P.M., indicated an inservice was provided to staff members for proper call light placement.
On 7/12/24 at 12:13 P.M., a handwritten post it note from the Administrator indicated [Resident 6] 1-12-24 was staff assisted to the floor. A Post Fall Evaluation for the fall on 1/12/24 was not provided.
On 7/12/24 at 2:30 P.M., the Administrator indicated that an intervention got added to the care plan every time a resident fell.
On 7/15/24 at 8:44 A.M., the MDS Coordinator indicated every time a resident fell, an intervention was added to the care plan after the IDT met. The IDT met every morning where new falls were discussed. If education was provided to the staff or resident, that got added to the care plan, too.
On 7/15/24 at 8:53 A.M., the Regional Support indicated she could not find any documentation about the resident's fall on 8/14/23 and was not sure about the circumstances surrounding that progress note. At that time, she indicated that the resident did not fall on 9/5/23 and that the nurse must have opened a new event and forgotten that the Post Fall Evaluation was triggered automatically after a resident fell.
On 7/15/24 at 8:53 A.M., the Administrator provided a Care Plan Revisions Upon Status Change policy, dated 2023, that indicated The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with the new or modified interventions.
On 7/15/24 at 8:53 A.M., the Administrator provided an Accidents and Supervision policy, dated 2023, that indicated Fall refers to unintentionally coming to rest on the ground, floor, or other lower level . Both the facility-centered and resident-directed approaches include evaluation hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk . implementation of interventions - using specific interventions to try and reduce a resident's risk from hazards in the environment. The process includes . documenting interventions . ensuring that the interventions are put into action.
3.1-45(a)(2)
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 record review and interview, the facility failed to follow physician orders and implement plan of care relating to dial...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders and implement plan of care relating to dialysis services for 1 of 1 resident's reviewed for hemodialysis. (Resident 13)
Finding includes:
On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Resident 13 was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact, required moderate assistance from staff for toileting and bathing, and was receiving hemodialysis.
Current physician orders included, but were not limited to:
Obtain weight after dialysis treatments one time a day every Monday, Wednesday, Friday; start date 6/21/24.
Monitor left upper extremity for (signs and symptoms) of infection. Every day and night shift for fistula; start date 6/5/24.
Dialysis diet, Regular texture; start date 5/27/24.
Current care plans included, but were not limited to:
Alterations in kidney function due to end stage rental disease; date initiated 8/22/22.
Do not take blood pressure, blood samples, or insert IV in arm with access site; date initiated 8/22/22.
Resident is on a dialysis diet; date initiated 7/15/22.
Monitor weight per MD order; date initiated 7/15/22.
During an interview on 7/12/24 at 11:04 A.M. LPN 14 indicated Resident 13 had a new fistula placed in the left upper extremity on 6/4/24.
On 7/12/24 at 12:14 P.M., the Regional Support Consultant provided Resident 13's documented blood pressure readings. The following dates/times indicated staff obtained a blood pressure reading in Resident 13's restricted limb (left upper arm) since her fistula placement in June 2024:
6/5/24 10:07 A.M.
6/8/24 9:15 A.M.
6/13/24 9:09 A.M.
6/14/24 4:32 P.M.
6/14/24 5:30 P.M.
6/15/24 9:02 P.M.
6/20/24 3:20 P.M.
6/27/24 3:23 P.M.
6/29/24 5:59 P.M.
7/3/24 1:57 P.M.
7/4/24 10:44 P.M.
7/5/24 2:59 P.M.
7/6/24 1:44 A.M.
7/6/24 9:11 P.M.
On 7/12/24 at 12:14 P.M., the Regional Support Consultant provided Resident 13's recorded weights. The following dates/times indicated staff failed to record a weight when Resident 13 returned from dialysis in the past month:
6/21/24
6/24/24
6/28/24
7/1/24
7/3/24
7/5/24
7/10/24
7/12/24
On 7/15/24 at 10:50 A.M., the Administrator provided a policy titled Comprehensive Care Plans, dated 2023, that indicated The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
During an interview on 7/15/24 at 12:10 P.M., the Regional Support Consultant indicated the facility did not have policy for following physician order but indicated physician orders should be followed as written.
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 meal tray tested for food temperature.
Findings include:
On ...
Read full inspector narrative →
Based on observation, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 meal tray tested for food temperature.
Findings include:
On 7/10/24 at 12:09 P.M., a meal test tray was obtained on the 200 Unit Hall the following temperatures were obtained:
chicken thigh- 126.5 degrees F (Fahrenheit)
potato -125.5 degrees F
cottage cheese 48.2 degrees F
desert chocolate eclair pudding- 67.5 degrees F
salad 53.6-degrees F
During an interview on 7/8/24 at 11:21 A.M., Resident 15 indicated the food is cold.
During an interview on 7/9/24 9:43 A.M., Resident 6 indicated the food is not always hot. The CNA's (Certified Nurse Aide) won't serve food right away.
During an interview on 7/9/24 at 11:35 A.M., the Dietary Manager indicated the temperature for meats and vegetables should be greater than 165 degrees Fahrenheit and cold items should be less than 41 degrees Fahrenheit.
On 7/15/24 at 8:55 A.M., the Administrator provided a current, nondated policy Record of Food Temperatures. The policy indicated .hot foods will be held at 135 degrees Fahrenheit or greater and . cold food temperatures will be kept at or below 41 degrees Fahrenheit.
3.1-21(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
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 safe storage of foods brought in externally fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe storage of foods brought in externally for 1 of 1 residents reviewed for resident refrigerators. (Resident 8)
Findings include:
During an observation on 7/9/24 at 9:39 A.M., Resident 8's refridgerator had two blank temperature logs, dated June 2024 and July 2024, taped to the outside door of the refrigerator; no temperatures were recorded.
On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia and contracture of muscle/joint. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
During an interview on 7/12/24 at 11:04 A.M., LPN 14 indicated each morning when staff do rounds to check on resident's, they record the temperature of resident room refrigerators on the paper on the outside of the refrigerator.
On 7/12/24 at 12:45 P.M., the Regional Support Consultant provided a policy titled Resident Refrigerators, dated 2024, that indicated It is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. Dormitory-sized refrigerators are allowed in a resident's room under the following conditions: The refrigerator is inspected and deemed safe prior to use and upon routine inspections. The refrigerator maintains proper temperature.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that documentation was completed entirely or a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that documentation was completed entirely or accurately for 2 of 3 residents reviewed for wounds and 1 of 5 residents reviewed for unnecessary medications. Duplicate medication order was entered, therapeutic leaves were not tracked, and documented skin assessments were not completed accurately. (Resident 15, Resident 8, and Resident 26)
Findings include:
1. On 7/11/24 at 10:13 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but was not limited to, major depressive disorder.
The most current Annual Minimum Data Set (MDS) Assessment, dated 6/3/24, indicated Resident 15 was cognitively intact, required supervision for eating, and received an antidepressant medication during the 7-day look back period.
Current physician orders included, but were not limited to:
Sertraline (an antidepressant medication) Oral Capsule 150 mg (milligrams) - Give 1 capsule by mouth at bedtime related major depressive disorder, dated 1/28/24.
Sertraline 100 mg Tablet - Give 1 tablet by mouth at bedtime related to major depressive disorder. Give with 50mg to equal 150mg, dated 7/4/24.
A medication administration note, dated 7/9/24 at 7:45 P.M., indicated the order dated 7/4/24 was a duplicate order, and the resident received one tablet of 100 mg sertraline and one tablet of 50 mg sertraline.
A Medication Administration note, dated 7/10/24 at 7:51 P.M., indicated the order dated 7/4/24 was a duplicate order.
The July MAR (Medication Administration Record) indicated the resident received medication from both orders on 7/7/24.
On 7/12/24 at 9:25 A.M., the Regional Nurse provided a medication packet with Resident 15's name on it from the pharmacy that contained one 100 mg tablet of sertraline and one 50 mg tablet of sertraline. She indicated that the order was a transcription error and not a medication error. The orders were supposed to reflect that the resident was receiving a 100 mg tablet and a 50 mg tablet because that was how the pharmacy dispensed it. She indicated a nurse tried to fix the order by creating two orders, but made the order more confusing. She indicated she would correct the orders immediately.
2. On 7/10/24 at 10:39 A.M., Resident 8's clinical record was reviewed. Resident 8 was admitted on [DATE]. Current diagnoses included, but were not limited to, quadriplegia, post traumatic seizures, COPD (chronic obstructive pulmonary disease), stage four (4) pressure ulcers, and contracture of muscle/joint.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/22/24, indicated Resident 8 was cognitively intact, and was fully dependent on staff for eating, toileting, bathing, and transfers.
During an observation on 7/10/24 at 12:25 P.M., LPN 8 entered the exit door code and assisted Resident 8 outside. LPN 8 assisted Resident 8 with lunch on the outside patio, then went back into the building while resident 8 remained outside.
During an interview on 7/12/24 at 11:04 A.M., LPN 14 indicated Resident 8 takes LOA (leave of absence) with family/friends almost daily and staff have to enter a code to let Resident 8 outside and back into the building but do not sign the LOA book for Resident 8 because Resident 8 usually verbally lets the nurse know when he is leaving.
The clinical record lacked documentation each time Resident 8 left or returned from the building during therapeutic leaves.
During an interview on 7/15/24 at 3:04 P.M., the Regional Support Consultant indicated Resident 8 did not have an evaluation for therapeutic LOA (leave of absence) and did not have a physician's order to go LOA.
On 7/15/24 at 8:53 A.M., the Administrator provided a policy titled Therapeutic Leave, dated 2024, that indicated The nurse will obtain an order from the practitioner specifying approval for therapeutic leave. The facility will document in the medical records the resident's leave of absence, any medications sent with the resident, and any education given to the resident and/or representative prior to the leave. If a resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record.
3. On 7/11/24 at 12:39 P.M., Resident 26's clinical record was reviewed. Resident 26 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia and type 2 diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 26 was cognitively impaired and required moderate assistance from staff for toileting, bathing, and transfers.
A weekly skin review (assessment) completed on 6/10/24 by RN 9 indicated Resident 26's skin was intact and no alterations.
A weekly skin review (assessment) completed on 6/17/24 by RN 9 indicated the only skin alteration Resident 26 currently had was a laceration to the chin.
A physician's order for Mupirocin external ointment 2 % (antibacterial ointment) Apply to top of right foot topically three times a day for Abrasion for seven (7) Days, dated 6/10/24 through 6/17/24, was marked administered by RN 9 on 6/10/24, 6/12/24, 6/13/24, and 6/14/24.
During an interview on 7/11/24 at 2:15 P.M., RN 9 indicated she was unsure where wound on resident foot was, was unsure of what the treatment was, and would need to look at orders on computer.
On 7/15/24 at 11:09 A.M., the Administrator provided a Documentation in Medical Record policy, dated 2024, that indicated Documentation shall be accurate, relevant, and complete .
3.1-50(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure multi-resident use glucometers were cleaned according to manufacture instructions for 1 of 1 random observations. (100...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure multi-resident use glucometers were cleaned according to manufacture instructions for 1 of 1 random observations. (100 unit)
Finding includes:
On 7/10/24 at 12:06 P.M., Registered Nurse (RN) 3 was observed cleaning a glucometer after acquiring a blood sugar from a resident. She wiped the machine with a Micro-kill Bleach wipe for 2 seconds and placed it in the medicine cart.
On 7/11/24 at 12:58 P.M., Qualified Medication Aide (QMA) 4 indicated that to clean a glucometer you wipe the machine for 30 seconds using a bleach wipe and then let it air dry.
On 7/15/24 at 9:53 A.M., the Infection Preventionist indicated that to clean a glucometer you wrap it in a bleach wipe for 3 minutes and place it in a water cup or on a paper towel so it became clean.
On 7/11/24 at 10:15 A.M., the Administrator provided an EvenCare blood glucose monitoring system user's guide, dated 2022, that indicated Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe meter dry or allow to air dry.
On 7/11/24 at 12:58 P.M., a Micro-kill Bleach Wipes user instructions were reviewed. It indicated A 30 second contact time is required to kill the bacteria and viruses on the label . Allow surface to air dry .
On 7/15/24 at 8:53 A.M., the Administrator provided a Glucometer Disinfection policy, dated 2024, that indicated The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use.
3.1-18(b)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 7/9/24 at 9:44 A.M., Resident 6 indicated she was supposed to get her showers on Wednesdays and Saturdays but hadn't recei...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 7/9/24 at 9:44 A.M., Resident 6 indicated she was supposed to get her showers on Wednesdays and Saturdays but hadn't received a shower for the past 2 weeks.
On 7/9/24 at 2:58 P.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.
The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/21/24, indicated Resident 6 was cognitively intact, was dependent on staff for bathing, and had no rejection of care during the 7-day look back period.
A Preference Evaluation, dated 6/25/24, indicated Resident 6 preferred showers at any time of the day.
An Activities of Daily Living (ADL) care plan, dated 12/20/22, indicated Resident 6 had a self-care deficit and was dependent on one staff for bathing assistance.
The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Wednesdays and Saturdays. Resident 6 did not receive or refuse a shower on the following days in 2024:
January 3, 6, 10, 20, 27
February 10, 14, 17, 24
May 4, 25
June 1, 5, 22, 26
On 7/10/24 at 9:51 A.M., the Administrator indicated the facility did not use shower sheets. If a resident refused a shower, it was documented in POC Tasks.
On 7/15/24 at 8:53 A.M., the Administrator provided a Resident Rights policy, dated 2024, that indicated The resident has .the right to receive the services and/or items included in the plan of care.
3.1-38(a)(3)(B)
2. On 7/11/24 at 10:13 A.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, end stage renal disease, hypertension, and dementia.
The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/3/24, indicated Resident 13 was cognitively intact and required moderate assistance from staff for toileting and bathing.
A physical functioning deficit care plan, dated 7/1/22, indicated Resident 13 had self-care impairment and required substantial assistance of one staff for bathing.
The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Tuesdays and Fridays. Resident 13 did not receive or refuse a shower on the following days in 2024:
January 2, 12, 26
May 24, 31
June 14, 18, 24
3. On 7/12/24 at 8:52 A.M., Resident 2's clinical record was reviewed. Resident 2's diagnoses included, but were not limited to, dementia, weakness, and intellectual disabilities.
The most recent Quarterly MDS (Minimum Data Set Assessment, dated 6/3/24, indicated Resident 2 was severely cognitively impaired, required substantial assistance of staff with toileting and transfers, and was dependent on staff for bathing.
A physical functioning deficit care plan, dated 4/27/17, indicated Resident 2 had self-care impairment and required total assistance of one staff for bathing.
The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering indicated the Resident received showers on Wednesdays and Saturdays. Resident 2 did not receive or refuse a shower on the following days in 2024:
January 31
February 3, 7, 17, 28
March 2, 6, 20
May 4, 25
June 1, 8
July 6
Based on observation, record review, and interview, the facility failed to provide timely showers for 4 of 4 dependent residents reviewed for ADL (Activities of Daily Living (Resident 4, Resident 2, Resident 13, and Resident 7)
Findings include:
1. On 7/10/24 at 8:31 A.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy and flaccid neuropathic bladder, not elsewhere specified.
The current Quarterly MDS (Minimum Data Set) assessment dated [DATE]. The MDS indicated Resident 4 was cognitively intact and was dependent on transfer, mobility, eating, and hygiene.
Physician orders included but not limited
Weekly skin review on Saturdays on Day Shift dated 10/11/23
Showers are scheduled for Wednesday and Saturday and the day shift is 7-3 P.M.
The current care plan indicated that Resident 4 has a self-care deficit related to primary diagnosis of cerebral palsy. Interventions included bathing assistance of dependent dated 10/20/23. The current care plan also indicated Resident 4 has incidents of being uncooperative/refusal of showers dated 5/6/24. Interventions included but are not limited to explaining all risks of not cooperating with care in simple terms and offer bed bath when showers refused dated 5/6/24.
During an interview on 7/9/24 at 10:22 A.M., Resident 4 indicated that showers were not given on shower days of Wednesday and Saturday.
On 7/12/24 at 9:00 A.M., the Administrator provided showers recorded from the Task Charting in the facility charting program that the CNA(Certified Nurse Aide) do when care is provided from January 2024 until July 2024
Showers dates missed:
2/7/24- Wednesday no shower
3/6/24 Wednesday no shower
3/27/24 Wednesday no shower
4/24/24 Wednesday no shower
6/12/24 Wednesday no shower
6/22/24 Saturday no shower
During an interview on 7/11/24 at 9:19 A.M., CNA 7 indicated Resident 7 will refuse a lot but should be encouraged to take and will offer alternative.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 17 random observations on 5 of 6 days. Urine smells in unit ...
Read full inspector narrative →
Based on observation and interview, the facility failed to provide a safe and sanitary environment for residents, staff, and the public for 17 random observations on 5 of 6 days. Urine smells in unit hallways, conference rooms, common areas, stairwells.(100 Unit Hallway, 200 Unit Hallway, Basement Hallway, Conference Room, Stairwell off 100 Unit, Stairwell off 200 Unit)
Findings include:
1. On 7/8/24 at 8:14 A.M., the smell of urine was observed in the 100 Unit Hallway.
On 7/8/24 AT 8:15 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway.
On 7/8/24 at 8:16 A.M., the smell of urine was observed in Basement Hallway.
On 7/8/24 at 10:30 A.M., the smell of urine was observed in the 200 Unit Hallway and into the Common Area of the unit.
2. On 7/9/24 at 8:05 A.M., the smell of urine was observed in the 100 Unit Hallway.
On 7/9/24 at 8:06 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway.
On 7/9/24 at 8:17 A.M., the smell of urine was observed in Basement Hallway.
On 7/9/24 at 10:30 A.M., the smell of urine was observed in the Basement Hallway.
3. On 7/11/24 at 8:10 A.M., the smell of urine was observed in the 100 Unit Hallway.
On 7/11/24 at 8:11 A.M., the smell of urine was observed in the Stairwell off the 100 Unit Hallway.
On 7/11/24 at 8:12 A.M., the smell of urine was observed in Basement Hallway.
On 7/11/24 at 10:30 A.M., the smell of urine was observed in the 200 Unit Common Area.
On 7/11/24 at 1:00 P.M., the smell of urine was observed in the 200 Unit Hallway.
4. On 7/12/24 at 10:04., the smell of urine was observed in the elevator going to the 200 Unit Hall.
On 7/12/24 at 10:05 A.M., the smell of urine was observed in 200 Unit Hallway.
On 7/12/24 at 10:23 A.M., the smell of urine was observed in 200 Unit Common Area.
During an interview on 7/15/24 at 11:14 A.M., LPN (Licensed Practical Nurse) 8 indicated the facility should be free of smells.
On 7/15/24 at 8:54 A.M., the Administrator produced a current, nondated policy Safe and Homelike Environment. The policy indicated .the facility will provide a safe, clean . environment .housekeeping and maintenance services will be provided as necessary to maintain a sanitary,orderly, and comfortable environment .minimize odors by disposing of soiled linens promptly and reporting lingering odors . needing cleaning to Housekeeping Department.
3.1-19(f)
Oct 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a urinary tract infection (UTI) for 2 of 3 resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a urinary tract infection (UTI) for 2 of 3 residents reviewed for infections. Resident F resident's lab results weren't reviewed, follow up appointments with specialists weren't scheduled, and treatment related to the UTI found were not done in a timely manner which resulted in a hospitalization from 9/22/23 to 9/30/23. Resident C had a Urinary Tract Infection (UTI) that was not diagnosed, the resident was then hospitalized that resulted in a necessary surgery being postponed. (Resident F and Resident C)
Findings include:
1. During an observation on 10/11/23 at 11:24 A.M., Resident F was observed sleeping in bed.
On 10/10/23 at 12:39 P.M., Resident F's clinical record was reviewed. Diagnoses included, but were not limited to, renal insufficiency and neurogenic bladder.
Resident F's most recent Quarterly Minimal Data Set (MDS) Assessment, dated 9/19/23 indicated the resident was cognitively intact and required an extensive assist of 1 person for toileting.
Resident F's care plans included, but were not limited to, I have a history of chronic/ recurring urinary tract infections r/t [related to] esbl [Extended Spectrum Beta-Lactamase. Beta-lactamases are enzymes produced by bacteria that could make them resistant to some antibiotics] infection, dated 9/20/23.
Resident F's Physician Orders included, but were not limited to:
- UA [urine analysis] WITH C&S [culture and sensitivity] IF INDICATED one time only for DYSURIA related to PERSONAL HISTORY OF URINARY (TRACT) INFECTIONS, dated 9/11/23.
- Contact Deaconess Clinic Urology in AM to inquire which atb [antibiotic] resident is to be placed on for atb resistant UTI et [and] clarify if Urologist wants staff to resume straight cath [catheter] BID [two times a day] order, dated 9/19/23.
A urinalysis report, dated 9/12/23, indicated the urine sample was collected at the facility on 9/12/23 at 12:00 A.M., received by the lab at 9/12/23 at 3:52 P.M., results were reported from the lab to the facility on 9/12/23 at 6:28 P.M., and results were reviewed by the facility on 9/18/23 at 12:47 P.M.
The results included the following:
Protein: reference range- less than 30, result- 70
Blood: reference range- negative, result- small
Leukocyte Esterase: reference range- negative, result- large
Appearance: reference range- clear, result- turbid
urine red blood cells: reference range- less than 3, result- 27
urine white blood cells: reference range- less than 5, result- greater than 100
bacteria: reference range- none, result- few
squamous epithelial: reference range- less than 5, result- 8
A urine culture report, dated 9/12/23, indicated the urine speciman for culture was collected on 9/12/23 at 12:00 A.M., received by the lab at 9/12/23 at 3:52 P.M., the result was reported from the lab to the facility on 9/14/23 at 7:04 A.M., and was reviewed by the facility on 9/18/23 at 1:01 P.M.
The results included the following:
Greater than 100,000 Escherichia Coli, ESBL producing organism detected.
Resident F's progress notes from September 2023 included, but were not limited to:
9/11/23 at 7:45 P.M. - daughter here this afternoon asking about in and out cath [catheter] resident [sic]. will pass on to following shift to see if we are able to get order for this. daughter states we were doing this prior to residents [sic] latest hospital admission.
9/12/23 at 1:08 A.M. - Urine specimen obtained via in and out cath. Prior to cath, resident states she toileted herself. Once laying in bed her abdomen was distended but not tender to touch. Once cath inserted, urine specimen obtained and bladder emptied. 1,000cc [mililiters] of malodorous,cloudy yellow urine obtained. At the end of the stream urine became thick and white. Res [resident] tolerated procedure well. Denies burning with urination. Fluids encouraged.
9/13/23 at 1:42 P.M. - Received call from residents [sic] daughter [name of person] stating that she had gotten notification on my chart that residents [sic] US [sic] had came back positive for a UTI. Call placed to DR [name of doctor] office, md [doctor of medicine] aware and stated that they were waiting for the culture to culture out due to her allergies and that they would then start her on something.
Notified res daughter and she stated okay
9/19/23 at 6:18 P.M. - . Staff to follow up with urologist in AM to determine which atb [antibiotic] is appropriate to treat atb resistant UTI et [and] to clarify if staff to resume [sic] straight catheterization BID [twice daily]. Fluids ecouraged [sic] et within easy reach. Meticulous peri-care provided, contact precautions being observed. Will continue to monitor.
9/19/23 at 9:07 P.M. - ESBL producing organism detected in urine, resident to be placed on contact isolation. Bedside commode obtained et placed in room for resident's use only. Staff observing all necessary measures.
9/20/23 at 12:40 A.M. - Referral sent to [name of hospital] Infectious disease at this time.
9/22/23 at 12:00 A.M. - Admin [administrator] states that patient has been having increased behaviors. She recently returned from a stay at an inpatient psych [psychology] hospital. Last week she was able to have a conversation; however, this week she is chanting, crying and yelling. Staff states she has not slept for 3 days. Staff states she has a UTI. Results were sent to infectious disease and facility has been waiting numerous days for orders as to which antibiotic she is to take. DON [Director of Nursing] was notified that no orders had been received for antibiotics for treatment of UTI.
9/22/23 at 7:34 P.M. - daughter called unit at 1715 [5:15 P.M.] and stated she wanted her mother sent to ER [emergency room] to be checked since she has a UTI and has not been placed on antibiotic yet.
Resident F was hospitalized from [DATE] through 9/30/23. Hospital notes included, but were not limited to:
- . Patient is hysterically crying during exam and is focused on that she has been sitting in feces and urine. Patient was sent from nursing home for altered mental status but unable to obtain further clarification from their facility as they are not picking up their phone . patient was admitted to Internal Medicine service for further management of acute kidney injury, metabolic encephalopathy . recent urine culture, with ESBL. Started on ertapenem [name of antibiotic] .
A confidential correspondence indicated that Resident F had a positive urine culture and the results were known for 8 days and nothing was done about it.
During an interview on 10/11/23 at 1:01 P.M., Registered Nurse (RN) 5 indicated the facility failed to receive an order from the doctor and infectious disease to treat Resident F and the resident's daughter requested to send her to the ER.
During an interview on 10/12/23 at 8:31 A.M., Licensed Practical Nurse (LPN) 7 indicated she thought Resident F received antibiotics prior to being admitted to the hospital and that she was colonized.
During an interview on 10/12/23 at 9:32 A.M., the DON indicated they try to do what they can to keep the resident in the facility.
During an interview on 10/12/23 at 9:39 A.M., Licensed Practical Nurse 9 indicated Resident F did not have a UTI care plan at the time of her UTI, but he would have expected her to have one prior to her hospital stay. 2. On 10/10/23 at 9:26 A.M., Licensed Practical Nurse (LPN) 3 indicated Resident C had a catheter and a current UTI.
On 10/10/23 at 10:44 A.M., Resident C's clinical record was reviewed. Diagnosis included, but were not limited to, sepsis, neuromuscular dysfunction of bladder, disorder of kidney and ureter, and infrarenal abdominal aortic aneurysm.
The most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated no cognitive impairment. Resident C required extensive assistance with bed mobility, transfers, and toileting, and had an indwelling urinary catheter.
Current physician orders included, but were not limited to, the following:
Ertapenem Sodium (an antibiotic) Solution Reconstituted 1 GM (gram) intravenously every 24 hours for infection for 30 Days from 9/22/23 through 10/22/23.
A current risk for infection related to catheter use care plan was dated 11/22/22.
A current history of chronic/recurring urinary tract infections related to suprapubic catheter care plan, dated 8/14/23, included, but were not limited to, the following interventions: Observe and report signs and symptoms of UTI: changes in color, odor or consistency of urine, dysuria, frequency, fever, pain (dated 8/14/23).
Progress notes included, but were not limited to, the following:
9/3/23 at 7:43 P.M. Resident C was reaching for an item and fell.
9/5/23 at 11:00 P.M. [MD] reviewed and addressed labs prior to 9/4/23 visit Diagnostic result review of the following labs: antibody screen, CBC (complete blood count) auto differential, basic metabolic profile, urine culture, urine 24 hour creatinine, lipid profile, liver profile, hemoglobin a1c, urinalysis with microscopic, culture if indicated, EKG with interpretation, ALT, AST, creatinine/GFR, free T4, TSH. The progress notes lacked information as to when the labs had been done.
9/6/23 at 10:59 A.M. This writer phoned [family member], listed contact, to insure he was aware that [Resident C] slid out of her wheelchair and was not injured
9/7/23 at 11:01 P.M. eMAR - Medication Administration Note Change foley catheter drainage bag weekly and PRN [as needed] changed due to bag leaking
9/11/23 at 4:30 P.M. covid tested and negative results
9/11/23 at 7:59 P.M. resident came in approx [4PM] from smoke break and had large emesis [vomit] in room .
9/11/23 at 11:00 P.M. written by the Nurse Practitioner (NP) Notified by nursing vomiting x2 nights unable to keep down prn phenergan [an antiemetic medication] or any meds i.e. bp [blood pressure], cool and clammy covid neg, 176/107, 90-99, 80% RA [room air] 88% on 2L [liters] 97.8, states not feeling well has not been eating well isdiabetic [sic] 483 did eat dinner, lethargic but easy to wake lungs diminished orders for IM [intramuscular] phenergan 25mg [milligrams]/ml [milliliter] . IM . PRN QID [four times a day] . supplemental O2, CXR [chest xray] and labs . IM phenergan effective 88-90% on 2L 98/52, 105 hx [history] COPD
9/12/23 at 2:06 P.M. COVID 19 Test Result: Negative
9/12/23 at 7:55 P.M. CNA notified this nurse of resident having emesis in her bedroom while sitting up in w/c watching tv. Upon entering, resident noted to be diaphoretic and lethargic. Does wake up when name called. Mumbling words. Blood glucose 483 VS: 176/107 p94 T97.8 forehead infrared, resp 18 SaO2 80% on room air. Per nursing measure, supplemental oxygen started via concentrator however was not effective. Once liquid oxygen per portable tank administered SaO2 increased to 90% on 2L/NC [liters per nasal canula]. Staff instructed to lay resident down in bed after cleaning her up and elevate HOB [head of bed] to prevent aspiration . No cough or SOB [shortness of breath] noted at rest. Res [resident] weak. On call NP phoned and notified of assessment findings. New orders rec'd [received]. Will call back to update on status once IM Phenergan administered. If effective will administer routine PO [by mouth] Clonidine [blood pressure medication] for HTN [hypertension]
9/12/23 at 11:39 P.M. Res tested again for covid and test results were negative. No further emesis. Tolerated IM injection well. Sleeping. NP phoned and updated on resident's current vitals and assessment findings. No new orders at this time
9/13/23 at 5:25 A.M. Res currently laying in bed with HOB elevated. SaO2 91% on 2L/NC from portable liquid oxygen tank. Resp 18. Skin warm and dry. BP 163/91 pulse 107 T98.2. Did have a cough during assessment. No sputum produced. Denies feeling SOB. Will continue to monitor
9/13/23 at 1:41 P.M. Staff called this nurse to residents room stating that res was not acting like her self. When I entered the room res was noted to be leaning over in her chair to the left and hard to arouse. When asked what was wrong res stated that she just didn't [sic] feel well and that she thought that she needed to go to the hospital. Res BP was noted to be low, 60s/30s with her pulse low and thready. Res foley cath is patent and draining yellow urine, small amount of sediment noted in the bag. MD updated of res change in condition and stating that she needed to go to the hospital, new order was obtained to send her to [hospital] ER [emergency room] for eval and treatment. [Transportation service] called for transport and report called to [hospital] ER .
9/13/23 at 7:50 P.M. Resident admitted to the hospital with acute kidney injury, sepsis, hypotension, and complicated urinary tract infection.
9/14/23 at 12:17 P.M. Resident returned from the hospital. Transferred to personal W/C [wheelchair]with extensive assistance x2 staff members. VSS [vital signs stable] . BP 124/67; HR [heart rate] 81; T [temperature] 97.5; RR [respiratory rate] 18; O2 SAT [oxygen saturation] 93% RA. midline intact to LUE [left upper extremity] and flushes well with no resistance. Resident will continue IV ATB [antibiotic] r/t [related to] urinary sepsis w/e-coli bacteria.
9/22/23 at 7:30 P.M. spoke with [representative] at [surgery center] today and she states surgery for September 28 is cancelled [sic] until she is finished with antibiotic for UTI. when antibiotic is finished on October 22 we are to get medical clearance from [medical director] and then surgery will be [sic] rescheduled .
9/26/23 at 11:00 P.M. Patient is on IV antibiotics for complicated UTI. She was recently hospitalized for hypotension, AKI [acute kidney injury], and sepsis. She was seen by infectious disease and has IV Invanz [an antibiotic] daily until 9/26/23 . through a PICC [peripherally inserted central catheter] line. She is to follow up with infectious disease NP 1-2 weeks from now. Shealso [sic] has appointment with urology, [urologist name] on 10/26/23. She has a 5.6cm [centimeter] infrarenal AAA [abdominal aortic aneurysm], but will not receive intervention for that until her urinary infection is cleared. Patient reports being tired all the time for about the last 3 months .
10/6/23 at 9:43 A.M. eMAR - Medication Administration Note Resident refused, stating I don't feel well.
10/6/23 at 8:31 P.M. resident has felt better today. yesterday was in bed all day due to feeling sick to stomach and having some diarrhea
10/9/23 at 12:00 A.M. During session resident presented as neutral with flat affect. Resident described she was not feeling well and nursing stated that her blood pressure was up. Resident described feeling weak her speech was slightly slurred and she had trouble staying awake . We will follow-up
10/10/23 at 12:00 P.M. resident has had increasing lethargy today. does not want to lay down for nap
10/10/23 at 4:01 P.M. has continued to be lethargic and is now slurring her words. desires to go out to hospital to be checked out. vitals stable. o2 97% on room air bp 102/83 hr 61
10/10/23 at 7:33 P.M. res sent to ER
Blood pressure readings for Resident C included, but were not limited to, the following:
9/12/23 7:53 P.M. 176 / 107
9/12/23 9:15 P.M. 118 / 66
9/12/23 10:48 P.M. 99 / 53
9/12/23 11:38 P.M. 98 / 52
9/13/23 5:29 A.M. 163 / 91
9/13/23 9:26 A.M. 114 / 65
The Medication Administration Record (MAR) for 9/2023 indicated Resident C did not receive her blood pressure medication on the evening of 9/12/23 due to vomiting.
Behavior monitoring from 7/31/23 through 10/12/23 indicated no behaviors were observed any day on any shift.
Resident C's clinical record lacked a urinalysis or urine culture since 3/2023.
Current hospital records as follows:
New diagnosis of Hepatitis C, possible liver cirrhosis, kidney stone.
The resident received emergency kidney dialysis, was identified as having a decompressed bladder around Foley catheter on admission and one kidney was atrophied.
Labs obtained in the hospital on 9/13/23 included, but were not limited to, the following:
A urine culture, dated 9/13/23, indicated escherichia coli (a bacteria) ESBL (extended spectrum beta-lactamase) producing organism detected.
A blood culture, dated 9/13/23, indicated enterobacterales (a bacteria), escherichia coli, and ESBL were detected.
A progress note from an infectious disease physician, dated 9/16/23 (during Resident C's hospitalization), indicated a recommendation for Ertapenem for a total of 14 days, to end on 9/26/23.fd
On 10/10/23 at 12:19 P.M., the Director of Nursing (DON) indicated Resident C had not had a urine culture done prior to the hospitalization on 9/13/23 possibly because she was colonized. At that time, the DON indicated she was unaware what bacteria Resident C was colonized with, and to find out could take a lot of digging.
On 10/11/23 at 10:29 A.M., DON indicated Resident C's March 2023 labs were reviewed on 9/6/23 because something was not right with the resident, but could not find an exact reason for the review in the resident's chart. She indicated Resident C began to have some odd behaviors on 8/24/23. She indicated on that date, she had come back from LOA (leave of absence) with behaviors that were different for her that had continued until the hospitalization on 9/13/23. The DON also indicated she was still unsure what the resident was colonized with, as she may have gotten her mixed up with another resident, and Resident C may not have been the one that was colonized. She indicated when a resident was colonized, the doctor would have the staff go off of symptoms to check for a UTI, then do a urinalysis and culture if indicated. She further indicated Resident C was supposed to have AAA surgery on 8/28/23, but it was postponed due to a yeast infection she had at that time, then postponed again due to being on IV antibiotics for 30 days. She indicated Resident C's AAA was originally scanned on 3/10/23, then again on 3/17/23 and 7/22/23 that showed an increase in size. She then indicated when a resident came back from the hospital, all labs and orders were reviewed by either herself or LPN 3. She indicated she was unaware of the discrepancy between the infectious disease physician order and the admitting order for the IV antibiotic, and if she had been aware, she would have questioned it to verify what the order should have been.
On 10/11/23 at 1:18 P.M., the DON indicated she had called the Medical Director and he told her he had changed the original order for the 14 day antibiotic to a 30 day because he knows her better than infectious disease and wanted her to be on it for a longer period of time.
On 10/12/23 at 9:01 A.M., LPN 7 indicated when Resident C had been sent to the hospital on 9/13/23, she was working that day. She indicated the night shift nurse for the previous night had notified her that morning that Resident C's blood pressure had been high and her cognition was off. She indicated she had been aware that Resident C had a history of frequent UTIs and that a symptom she had displayed in the past was weakness. She indicated she had noticed a recent shift with Resident C that she had previously been energetic and happy, and recently she had been weak and not as happy.
On 10/12/23 at 8:45 A.M., Certified Nurse Aide (CNA) 21 indicated Resident C would have symptoms of deliriousness and weakness with UTIs, and had been sick for about a month prior to her hospitalization on 9/13/23. CNA 21 indicated she was unaware of any precautions for Resident C's aneurysm, other than to be mindful of the area when assisting to transfer and positioning in the bed.
On 10/12/23 at 10:40 A.M., a current Behavioral Health Services policy, dated 1/1/23, was provided and indicated Assess and develop a person-centered care plan for concerns identified in the resident's assessment . Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record .
On 10/12/23 at 10:40 P.M., a current Comprehensive Care Plans policy, dated 1/1/23, was provided and indicated The comprehensive care plan will describe, at a minimum, the following . The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
On 10/12/23 at 10:40 A.M., the Regional Consultant provided a current Notification of Changes policy, revised 1/1/23, that indicated .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification .significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-Threatening conditions, or b. clinical complications .circumstances that require a need to alter treatment. This may include: .ii. acute condition. iii. exacerbation of a chronic condition .
A nursing assessment policy was requested and not provided.
This Federal tag relates to Complaint IN00417333 and Complaint IN00418540.
3.1-41(a)(2)
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop a baseline care plan for 1 of 2 residents reviewed for base...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan for 1 of 2 residents reviewed for baseline care plans. (Resident B)
Finding includes:
On 8/23/23 at 8:52 a.m., Resident B's clinical record was reviewed.
A progress note titled Clinical admission Evaluation dated 5/20/23 at 1:53 p.m. Late Entry: indicated that Resident B was admitted to the facility on [DATE].
Resident B had diagnoses that included, but were not limited to: Chronic obstructive pulmonary disease, Alzheimer's disease, psychotic disturbance, paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, chronic pain syndrome, essential hypertension, peripheral vascular disease, unspecified asthma, systemic Lupus erytheematosus, emphysema.
Care plans were reviewed and included, but were not limited to:
Resident is on a regular diet, date initiated 5/22/24. (48 hours after admission)
Other care plans reviewed started with a date of 5/24/23 or later. (96 hours after admission)
On 8/23/23 at 1:10 p.m., the MDS (Minimum Date Set) Coordinator indicated he did not see in the clinical record that a baseline care plan was done for Resident B, CMS guidelines were followed for care plans,a baseline care plan should be developed within 48 hours after admission.
On 8/24/23 at 12:37 p.m., the Regional Nurse Consultant provided the current baseline care plan policy with a copyright date of 2022. The policy included, but was not limited to: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of care. 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders.
ii. Physician orders.
iii. Dietary orders.
iv. Therapy orders.
v. Social services.
vi. PASSAR recommendation, if applicable.
.A supervising nurse shall verify within 48 hours that a baseline care plan has been developed .
This Federal tag relates to Complaints IN00415301.
3.1-35(d)(1)
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0659
(Tag F0659)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the plan of care was followed for 2 of 3 residents reviewed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the plan of care was followed for 2 of 3 residents reviewed for urinary elimination and 1 of 1 residents reviewed for medications. ( Resident B, Resident C, Resident D)
Findings include:
1. On 7/12/23 at 12:54 p.m., the clinical record of Resident D was reviewed. Diagnoses included, but were not limited to, acquired absence of of other parts of urinary tract, other artificial openings of urinary tract status. A quarterly MDS (Minimum Data Set) assessment, dated 6/30/23, indicated Resident D's cognition was severely impaired.
Care plans were reviewed and included, but were not limited to:
Resident has a urostomy related to: personal history of malignant neoplasm of [NAME] (prostate), date initiated 11/30/22.
June 2023 physician orders were reviewed and included, but were not limited to: Document output, every shift document urinary output, start date 1/5/23.
The June 2023 EMAR (Electronic Medical Administration Record), was reviewed and the following dates did not have urine output recorded:
6/1- night shift
6/4-evening shift
6/12-day shift
6/19-day shift
6/20-day shift, night shift
6/23-night shift
6/24-day shift
6/25-day shift, evening shift
6/26-night shift
6/27- night shift
6/29-night shift
July 2023 physicians orders were reviewed and included, but not limited to: Document output, every shift document urinary output, start date 1/5/23.
The July 2023 EMAR (Electronic Medical Administration Record), was reviewed and the following dates did not have urine output recorded:
7/2-day shift
7/5-night shift
7/7-day shift
7/9-day shift
7/10-night shift
There were no refusals documented on the EMAR, or in the clinical record.
2. On 7/12/23 at 10:05 a.m., Resident C indicated nursing staff did not always provide care to his supra pubic catheter.
On 7/12/23 at 12:02 p.m., the clinical record for Resident C was reviewed. Diagnoses included, but were not limited to, flaccid neuropathic bladder, retention of urine, lower urinary tract symptoms, spastic quadriplegic Cerebral Palsy. A quarterly MDS (Minimum Data Set), assessment dated [DATE], indicated Resident C's cognition was intact.
Care plans were reviewed and included, but were not limited to: Alteration in elimination of bowel and bladder functional incontinence, indwelling urinary catheter, dx, flaccid neuropathic bladder, history of UTI's, benign prostatic hypertrophy, constipation, bladder spasms, diuretic use I choose to keep my stock of briefs on top of cabinet or dresser in my room for easy access vs closet or drawer- 8/24/17 .I
June 2023 physician orders were reviewed and included, but were not limited to: Record urinary output every shift, start date 1/25/23.
The June 2023 EMAR (Electronic Medical Administration Record), was reviewed and the following dates did not have urine output recorded:
6/1- night shift
6/5- day shift
6/12- day shift
6/15- night shift
6/20- day shift, night shift
6/21-night shift
6/23-night shift
6/24- day shift
6/25-day shift, evening shift
6/26-night shift
6/27-night shift
6/29-night shift
July 2023 physician orders were reviewed and included, but were not limited to: Record urinary output every shift, start date 1/25/23.
The July 2023 EMAR (Electronic Medical Administration Record), was reviewed and the following dates did not have urine output recorded:
7/2- day shift
7/5- night shift
7/7- day shift
7/9-day shift
7/10-night shift
There were no refusals documented on the EMAR, or in the clinical record.
3. On 7/12/23 at 10:56 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, Alzheimer's disease with early onset, psychotic disturbance. A quarterly MDS (Minimum Data Set) assessment, dated 5/16/23, indicated resident B's cognition was intact. Resident B was discharged from the facility to the hospital on 7/9/23.
Care plans were reviewed and included, but were not limited to:
alteration in blood glucose due to: insulin dependent diabetes mellitus. Interventions included, but were not limited to: administer medications as ordered, accuchecks as ordered.
June 2023 physician orders were reviewed and included, but were not limited to: Faxiga (diabetic medicine) oral tablet 10 mg give 1 tablet by mouth in the morning, order date 3/29/23. Insulin Aspart flexpen 100 unit/ml solution pen-injector (diabetic medication) inject 35 unit subcutaneously before meals.
Basaglar Kwickpen solution pen-injector (diabetic medication) 100 unit/ml inject 35 unit subcutaneously two times a day.
The June 2023 EMAR (Electronic Medical Administration Record) was reviewed. The following dates were not documented as medication given:
Faxiga - 6/15, 6/28, 6/29
Insulin Aspart -6/1 11:00 a.m., 4:30 p.m.
6/12-4:30 p.m.
6/17-4:30 p.m.
Basaglar Kwickpen- 6/1- 5:00 p.m.
6/6-5:00 p.m.
6/12-5:00 p.m.
July 2023 physician orders were reviewed and included, but were not limited to: Baclofen (skeletal muscle relaxant), tablet give 10 mg (milligram) by mouth three times a day, start date 12/11/23. Faxiga (diabetic medication) oral tablet 10 mg give 1 tablet by mouth in the morning, order date 3/29/23. Insulin Aspart flexpen 100 unit/ml solution pen-injector (diabetic medication) inject 35 unit subcutaneously before meals.
The July 2023 EMAR (Electronic Medical Administration Record) was reviewed. The following dates were not documented as medication given:
Baclofen - 7/5- 2:00 p.m.
Faxiga- 7/8.
Insulin Aspart-7/5 11:00 a.m.
The clinical record did not have refusals of medications on the above dates.
On 7/13/23 at 2:00 p.m., the DON indicated if a resident refuses there is a code to document the refusal on the EMAR.
On 7/13/23 at 2:20 p.m., RN 1 indicated if a resident refuses medication it should be documented on the EMAR, progress notes, education provided to the resident on negative effects, the doctor and responsible party notified. If a resident refuses insulin or to have a blood sugar taken, she notifies the Medical Director, endocrinologist if the resident has one, if blood sugar is high notify the doctor.
On 7/13/23 at 4:13 p.m., the DON provided the current policy on comprehensive care plans with a copyright date of 2022. The policy included, but was not limited to, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident comprehensive assessment.
This Federal tag relates to Complaints IN00412710 and IN00412889.
3.1-35(g)(2)
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notification of change for 1 of 3 residents reviewed for no...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notification of change for 1 of 3 residents reviewed for notification. A resident's representative was not notified of an incident with another resident. (Resident P)
Finding includes:
On 6/28/23 at 11:00 A.M., Resident P's clinical record was reviewed. Resident P was admitted on [DATE]. Diagnosis included, but were not limited to, dementia. The most recent quarterly MDS (minimum data set) Assessment, dated 6/9/23, indicated no cognitive impairment. Resident P required extensive assistance of one staff with bed mobility, transfers, and toileting, had behaviors of rejection of care, but no other behaviors.
Progress notes included, but were not limited to, the following:
6/18/23 Resident in the Dining Room with a female resident, he had her shirt pulled up and was having inappropriate conduct with (her). Female resident was allowing this to occur. One on one given to resident and educated on inappropriateness of sexual behavior in common areas and behavior improved. MD (Medical Director) aware. Will continue to monitor. Documented by LPN (Licensed Practical Nurse) 9.
6/22/23 IDT (Interdisciplinary Team) Note: Behavior, inappropriate touching. Seen by (psych services). Will be seen next week, 6/26/23. MD and family notified. Has brother in (city) that is active in his care. No visitation noted. Friends visit. Phone conversations frequently. Documented by RN (Registered Nurse) 5.
On 6/28/23 at 11:34 A.M., Resident P's brother indicated via phone call that he was listed as the resident's only contact, and the only person that should have been notified of any change of condition or incidents that may have happened with the resident. He indicated he had not received any phone calls from the facility since admission related to any behaviors or otherwise. He indicated that, to his knowledge, there had not been any incidents that have happened since his admission, and indicated Resident P had not had any behaviors of sexual inappropriateness prior to admission, or since admission.
On 6/29/23 at 6:30 A.M., LPN 9 indicated she was the nurse on the unit at the time of the incident involving Resident P on 6/18/23, but did not witness it directly. She indicated she reported the incident to the Administrator, the MD, and the family. She indicated the family was concerned about the incident because this type of behavior had happened before.
On 6/29/23 at 9:45 A.M., RN 5 indicated the nurse that was on the unit during the incident with Resident P on 6/18/23 did not notify the resident's family. She indicated that she did not notify the family either, but would take a look at the progress notes and see if she remembered anything. RN 5 did not indicate remembering anything after that time.
On 6/29/23 at 11:42 A.M., a current non-dated Notification of Changes policy was provided, and indicated The purpose of this policy is to ensure the facility promptly informs the resident consults with resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Circumstances requiring notification include: . Accidents . Potential to require physician intervention.
This Federal tag relates to Complaint IN00411219.
3.1-5(a)
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 F0742
(Tag F0742)
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 behavioral health services were provided to a ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure behavioral health services were provided to a resident with a history of trauma to obtain the highest practicable well-being for 1 of 4 residents reviewed for behaviors. (Resident D)
Finding includes:
On 6/28/23 at 9:50 A.M., Resident D indicated he was having trouble sleeping at night due to nightmares related to childhood trauma. He indicated during the day, he could not stop thinking about the trauma he had endured in his past. He indicated he had notified the Social Services Director (SSD) that there was some trauma in his past, but had not shared details. He indicated he wished to share the concern in detail with a doctor, but had not had the opportunity to do so yet. At that time, Resident D was visibly upset, and pausing several times during the interview when remembering details of the trauma that was being relayed.
On 6/28/23 at 10:00 A.M., the SSD indicated she was aware that Resident D had some sort of childhood trauma, but did not know the details. She indicated any time a resident shared with her that they had a history of trauma, she would sign them up for psychiatric services, and had done so with Resident D. She indicated she had spoken with Resident D about any possible triggers he had related to his past trauma, and none were identified, so a care plan was not developed.
On 6/28/23 at 10:05 A.M., QMA (Qualified Medication Aide) 17 indicated she was unaware of Resident D's inability to sleep at night, but would pass that information along to a nurse so the doctor could be notified.
On 6/28/23 at 1:27 P.M., Resident D's clinical record was reviewed. Resident D was admitted on [DATE] from the hospital. Diagnosis included, but were not limited to, dementia, epilepsy, anxiety depression, and psychotic disorder. The most recent admission MDS (minimum data set) Assessment, dated 5/13/23, indicated no cognitive impairment. Resident D required supervision of one staff with bed mobility, transferring, and eating, and limited assistance of one staff with toileting. The MDS indicated no behaviors. Resident D had indicated little interest or pleasure in doing things, feeling down, depressed, or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, and feeling bad about self.
Current physician orders included, but were not limited to:
Psych services may evaluate and treat, dated 5/6/23.
A current psychotropic medication use care plan, initiated 5/15/23, indicated an intervention that included, but was not limited to, refer to mental health services for medication and behavior intervention recommendations, dated 5/15/23.
A current at risk for sleep pattern disturbance care plan indicated resident had a diagnosis of sleep disturbance.
A current mental health needs care plan, initiated 5/17/23, included interventions to provide the resident with opportunity to express mental health needs to staff, dated 5/17/23, and skilled nursing staff will provide routine opportunities to identify mental health needs of resident, dated 5/17/23.
Hospital notes, dated 4/24/23, indicated Resident D had been admitted to the hospital on [DATE] after living in a homeless shelter. The notes indicated on 4/23/23, the resident indicated he was not sleeping well at night, and during an interview he was appropriate but depressed and flat mood and affect.
On 6/29/23 at 9:23 A.M., all behaviors listed in Resident D's progress notes were provided, and indicated the following:
4/30/23 Resident became anxious this morning, stating that he is too young to be in a nursing facility and that this is not where he is supposed to be. This nurse spoke 1 on 1 with resident, resident is upset r/t (related to) not having clothes at the facility. CNA (Certified Nurse Aide) found some clean [sic] clothes for resident and assisted him to shower, this was effective in improving behaviors at this time.
6/22/23 On 6/21 @ approx 12:00 Pt (patient) and another pt had verbal altercation regarding remote control and the channel being turned. A Pt had gone out to garden on patio and when he returned the show he had been watching was changed by gentlemen playing cards. Verbal obscenities were yelled between two pts (patients).
6/22/23 IDT Note: 6/21 was in 300 dr (dining room) and when verbal altercation with two other male residents happened [sic]. Administration was involved. Pt's separated. SS (Social Services) talked with all parties. All followed by (psych services) and will be seen on next visit, 6/26 and/or 6/30. Family and MD notified.
All behavior monitoring since admission was requested and provided on 6/29/23 at 12:48 P.M. Resident D's behaviors included the following:
6/5/23 (repeats movements, resident has had the behavior before)
Behaviors listed in the progress notes on 4/30/23 and 6/21/23 were not listed on the behavior monitoring documentation provided.
On 6/28/23 at 2:15 P.M., the SSD indicated she had been mistaken thinking that Resident D had been seen by psych services, as he was not on the list for them to see this month. She indicated she had to put him on the list to be seen at the next visit.
On 6/29/23 at 9:00 A.M., the SSD indicated psych services came to see residents 2 times a week (Monday and Friday) every other week. She indicated they had their own list of residents to see, and that she could add to the list as needed for new admissions, behaviors, or medication change requirements. She indicated if the resident's MDS mood assessment triggered depression, she would ask them if they wanted psych services. She then indicated Resident D's mood assessment did trigger depression upon admission, and he did not decline services.
On 6/29/23 at 11:42 A.M., a current non-dated Behavioral Health Services policy was provided, and indicated It is the policy of this facility to ensure all residents's receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning . The facility will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma and/or post-traumatic stress disorder (PTSD), as reflected in the facility assessment.
3.1-43(a)(1)
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 F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received the appropriate dosage of a medication f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident received the appropriate dosage of a medication for 1 of 4 residents reviewed for medications. A resident received 4 times the ordered dose of cimetidine for more than 6 weeks. (Resident S)
Finding includes:
On 6/28/23 at 11:15 A.M., Resident S's clinical record was reviewed. Resident S was admitted on [DATE]. His diagnoses included, but were not limited to, vascular dementia with agitation and schizoaffective disorder. The most current annual MDS (Minimum Data Set) assessment, dated 5/6/23, indicated Resident S was moderately cognitively impaired and had physical behaviors directed towards others for 1 to 3 days and verbal behaviors directed towards others for 4 to 6 days during the look back period.
Current physician orders included, but were not limited to, the following:
Cimetidine (antihistamine medication), 200 MG (milligrams) by mouth at bedtime for sexual inappropriate behaviors, dated 3/20/23.
Discontinued physician orders included, but were not limited to, the following:
Cimetidine, 200 MG by mouth four times a day for sexual inappropriate behaviors, dated 2/2/23, and was discontinued on 3/20/23.
A GDR (gradual dose reduction), dated 1/31/23, recommended please consider a trial dose reduction to 200mg QD (every day). The physician approved and signed the GDR on 2/1/23.
A progress note, dated 2/2/23, indicated MRR (medication regimen review) received from pharmacy. Recommended to GDR cimetidine from 300mg q (every) daily from [sic] 200mg q daily. eMAR (electronic medication administration record) updated to reflect change. [Name] notified. Signed MRR faxed to pharmacy.
A progress note, dated 2/26/23, indicated Resident seen by MD (medical doctor) for routine visit. Medications reviewed, order summary signed. No changes made.
A pharmacy note, dated 2/28/23, indicated an MRR was completed with no irregularities found.
A progress note, dated 3/20/23, indicated Medications reviewed related to loose stools. It was noted that he is on cimetidine QID (4 times a day). Cimetidine can cause diarrhea. Noted that order was changed on 2/2. Pharmacist had requested a GDR from 300 mg to 200 mg daily. Order was inadvertently written as 200 mg QID. [Name of Doctor] notified. New order received to dc (discontinue) cimetidine 200 mg QID and change to cimetidine 200 mg daily. [POA] notified.
The progress notes indicated that Resident S had loose stools on 3/6, 3/12, 3/13, 3/18, 3/19, 3/20, and 3/26.
The MAR (medication administration record) indicated that Resident S had received 200 mg of cimetidine four times daily from 2/2/23 to 3/20/23.
On 6/29/23 at 9:23 A.M., RN (Registered Nurse) 5 indicated medications are reviewed for each resident daily and contraindications or irregularities should be caught by staff at that time. She further indicated that Resident S's medication error should have been identified by staff earlier than it was.
A policy on the MRR process was requested and not provided.
On 6/29/23 at 11:49 A.M., the Regional Consultant indicated there was no policy related to the MRR process.
3.1-48(a)(6)
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of resident's narcotic pain medication for 1 of 3 residents reviewed for missing drugs. Na...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of resident's narcotic pain medication for 1 of 3 residents reviewed for missing drugs. Narcotics were unaccounted for once delivered to the facility for Resident B. (Resident B)
Finding includes:
On 3/10/23 at 8:00 A.M., facility reported incident reports were reviewed. An incident report dated 3/7/23 indicated On 3/6/23 at 14:00, [Resident B's] father provided the facility with a progress note from a doctor's visit on 3/1/23 indicating a new order for Butrans Transdermal Patch 10 mcg/hr [micrograms per hour] (a narcotic pain medication). Upon writing the new order and secure faxing to the pharmacy, the facility was notified that the medication had been sent to the facility on 3/2/23 as it was filled from an electronic script sent to [name of ] pharmacy. The facility was unable to locate the Butrans Transdermal patches
On 3/10/23 at 9:47 A.M., Resident B's clinical record was reviewed. Diagnosis included, but were not limited to, chronic pain syndrome. The most recent admission MDS (minimum data set) Assessment, dated 1/24/23, indicated Resident B was cognitively intact, and received scheduled and PRN (as needed) pain medication. Resident B experienced pain almost constantly over the previous 5 (five) days prior to the assessment, which made it hard to sleep and limited day to day activities.
Current physician orders included, but were not limited to, the following:
Butrans Transdermal Patch weekly 10 mcg/hr apply 1 (one) patch transdermally one time a day every Thursday, dated 3/9/23.
Discontinued physician orders included, but were not limited to, the following:
Butrans Transdermal Patch weekly 10 mcg/hr apply 1 (one) patch every Monday, dated 3/6/23 and discontinued 3/9/23.
A current risk for pain care plan, dated 1/26/23, included, but was not limited to, an intervention to administer pain medication as ordered, dated 1/26/23.
A doctor's progress note, dated 3/1/23, indicated Continue physical therapy. Decrease Percocet to [every 6 hours] PRN pain. Start Butrans 10 mcg patch weekly, signed by the practitioner at the pain clinic.
Progress notes included, but were not limited to, the following:
3/1/2023 7:15 P.M. resident has returned from appointments with residents' step farther [sic]. no [sic] paperwork was handed in and per resident my dad forgot to bring the paperwork in. resident [sic] states there are new orders from the pain clinic. nurse [sic] will follow up with this. no [sic] complaints voiced. resident [sic] ready to take medication and head to bed. will [sic] continue to monitor
3/6/2023 10:57 A.M. Paperwork received from resident recent appointment at [name of pain clinic]. New orders received to decrease Percocet from q4hrs [every 4 hours] to q6hrs [every 6 hours] PRN. New order for Butrans 10 mcg patch q [every] weekly [sic]. eMAR [electronic medication administration record] updated to reflect new orders
The clinical record lacked documentation of any follow up from 3/1/23 through 3/6/23 with the pain clinic related to any new orders.
During an interview on 3/10/23 at 9:15 A.M., LPN 9 indicated when pharmacy brought medications, the pharmacy delivery person that delivered the medications would usually sign off on them as well as the nurse that received them.
During an interview on 3/10/23 at 10:23 A.M., Pharmacy Representative 3 indicated on 3/1/23, the pharmacy received an escript (electronic prescription) for Butrans Transdermal Patch (4 patches at 10 mcg/hr) from the pain clinic practitioner at 11:16 A.M. for Resident B. The pharmacy filled the order and put it into their system at 10:30 P.M. on 3/1/23. Pharmacy Representative 3 indicated the pharmacy brought the medications to the facility on 3/2/23, and it was signed for by LPN (Licensed Practical Nurse) 5 at 8:17 A.M. He then indicated the pharmacy protocol was to have facility staff, preferably nursing staff, sign for any medications that were delivered.
During an interview on 3/10/23 at 11:30 A.M., the Regional Support Nurse indicated Resident B went to the pain clinic on 3/1/23 (Wednesday), and sent his dad with the paperwork, who brought it in the following Monday. Because of the new order, the facility MD wrote out an order and sent it to the pharmacy, having not known about the original prescription because it was sent to the pharmacy as an escript from the pain clinic. When the facility was made aware of this, they asked the pharmacy for a delivery manifest, which showed that a nurse from the facility had signed for it. Upon investigation, the Regional Support Nurse indicated the nurse that signed off on it handed it to RN 9, who then gave it to QMA 17, who was on the Unit where Resident B resided. QMA 17 indicated she had received it, and put it in the medication cart. The Regional Support Nurse indicated that QMA 17 was unaware that the medication was a controlled substance, thought they were nicotine patches, and just placed them in the medication cart with the other medications. They were not placed with the other controlled substances under double lock. She indicated at that time that only nurses and QMAs had access to the medication carts. She further indicated QMA 32 had worked on Saturday, 3/4/23, and indicated there were no Butrans transdermal patches in the medication cart during that shift. She indicated a drug disposition sheet could not be located, and no one had indicated they had destroyed the medication.
On 3/10/23 at 11:55 A.M., a current Medication Ordering and Receiving From Pharmacy policy, dated 12/17, was provided and indicated An individual resident's controlled substance record is provided by the pharmacy or the facility for each controlled substance prescribed for a resident. The following information is completed upon dispensing or upon receipt of the controlled substance: 1) Name of resident. 2) Prescription number. 3) Drug name, strength (if designated), and dosage form of medication. 4) Directions for use (Controlled Substance Accountability Sheet) 5) Date received. 6) Quantity received. 7) Name of person receiving the medication supply . Procedures for receiving controlled substances include: 1) A nurse signs for the medications, including the controlled substances, on the pharmacy delivery ticket and inspects the medications. 2) A nurse reconciles controlled substance orders and refill requests against what has been received from the pharmacy. 3) A nurse notifies the pharmacist if controlled substance orders or doses are missing or incorrect. 4) The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication). 5) Controlled substance inventory sheets are completed, if necessary, and filed appropriately per state regulation
On 3/10/23 at 11:55 A.M., a current Controlled Substance Storage policy, dated 3/17, was provided and indicated [Controlled substances] and other medications subject to abuse or diversion are stored in a permanently affixed, [double-locked] compartment separate from all other medications or per state regulation . All pharmacy supplied medication carts have a specified Controlled Substance Box designated for the storage of Controlled Substances under both the lock of the medication cart itself, and the lock located on the Controlled Substance Box
3.1-28(a)
Sept 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Skilled Nursing Facility Advanced Beneficiary Notice...
Read full inspector narrative →
Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) before the proposed end of services for 1 of 3 beneficiary notices reviewed. (Resident 15)
Finding includes:
On 8/30/22 at 1:45 P.M., during review of three randomly chosen resident Medicare Part A discharge notices, Resident 15's notice stated, The facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted, and a SNF ABN notification form was not provided, and a written note was provided from the facility that stated employee turnover new employee inserviced on process.
On 9/1/22 at 1:16 P.M., the Business Office Manager (BOM) indicated an ABN should have been completed.
On 9/2/22 at 12:48 P.M., a current, undated Advance Beneficiary Notices policy was provided and indicated .The current CMS-approved [Centers for Medicare and Medicaid Services] version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055.
3.1-4(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizati...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a notice of transfer or discharge was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a notice of transfer or discharge at the time of hospitalization. (Resident K, Resident C)
Findings include:
1. On 8/30/22 at 10:23 A.M., Resident K's clinical record was reviewed. Resident K had been sent to the hospital on the following dates:
From 5/6/22 through 5/12/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative.
On 9/1/22 at 10:52 A.M., a notice of transfer or discharge form was provided for Resident K's hospital visit on 5/6/22, but the form was not filled out or dated.
From 6/11/22 through 6/13/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative.
During an interview on 9/1/22 at 10:52 A.M., the Regional Consultant indicated the transfer or discharge form was not found for that hospitalization, and should have been provided.
2. On 9/1/22 at 1:26 P.M., Resident C's clinical record was reviewed. Resident C had been sent to the hospital on 7/16/22.
On 9/1/22 at 2:00 P.M., a notice of transfer or discharge form was provided that indicated it was issued on 7/16/22. The form lacked the name and address of the facility being transferred to, or the transfer or discharge effective date.
During an interview on 9/2/22 at 9:14 A.M., RN (Registered Nurse) 3 indicated the nurse on duty at the time of a resident transfer was responsible for filling out the appropriate paperwork, including the notice of transfer or discharge to include the name, date, and name and address of where they are going.
On 9/2/22 at 1:17 P.M., a current non-dated Transfer and Discharge policy indicated The facility's transfer/discharge notice will be provided to the resident and the resident's representative . The notice will include all of the following at the time it is provided . The effective date of transfer or discharge . the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged
This Federal tag relates to Complaint IN00377528.
3.1-12(a)(6)(A)(i)
3.1-12(a)(6)(A)(ii)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. There was n...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a bed hold policy was given to residents or resident representatives for 2 of 5 residents reviewed for hospitalizations. There was no documentation of a resident or representative receiving a bed hold policy at the time of hospitalization. (Resident K, Resident C)
Findings include:
1. On 8/30/22 at 10:23 A.M., Resident K's clinical record was reviewed. Resident K had been sent to the hospital on the following dates:
From 5/6/22 through 5/12/22 - Resident K's clinical record lacked documentation of a bed hold policy being given to the resident or resident's representative.
From 6/11/22 through 6/13/22 - Resident K's clinical record lacked documentation of a transfer or discharge form being given to the resident or resident's representative.
During an interview on 9/1/22 at 10:52 A.M., the Regional Consultant indicated the transfer forms, including the bed hold policy, was not found for that hospitalization, and should have been provided.
2. On 9/1/22 at 1:26 P.M., Resident C's clinical record was reviewed. Resident C had been sent to the hospital on 7/16/22.
On 9/1/22 at 2:00 P.M., a notice of transfer or discharge form was provided that indicated it was issued on 7/16/22. On the back page, there was a blank bed hold policy with a space reserved for the resident's name. At that time, the Regional Consultant indicated the name of the resident should have been filled in.
During an interview on 9/2/22 at 9:14 A.M., RN (Registered Nurse) 3 indicated the nurse on duty at the time of a resident transfer was responsible for filling out the appropriate paperwork, including a bed hold policy, to include the name of the resident.
On 9/2/22 at 12:48 P.M., a current nondated Bed Hold policy was provided, and indicated It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital .
This Federal tag relates to Complaint IN00377528.
3.1-12(a)(6)(A)(i)
3.1-12(a)(6)(A)(ii)
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 implement interventions to prevent accidents for 1 of 2 residents reviewed for falls. Resident 62 had 16 falls April through ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to implement interventions to prevent accidents for 1 of 2 residents reviewed for falls. Resident 62 had 16 falls April through August, care plan interventions were not followed. (Resident 62)
Finding includes:
During record review on 08/31/22 10:27 A.M., Resident 62's most recent quarterly MDS (Minimal Data Set) Assessment, dated 8/20/22, indicated the Resident was an extensive assist with 2 (two) staff members for transfers.
Resident 62's diagnoses include, but were not limited to, Parkinson's disease, repeated falls, traumatic subdural hemorrhage with loss of consciousness of unspecified duration, fracture of unspecified part of right clavicle, with routine healing, unspecified displaced fracture of seventh cervical vertebra, with routine healing, multiple fractures of ribs, right side, with routine healing, unspecified fracture of the first thoracic vertebra, with routine healing, orthostatic hypotension, cerebral infarct, and syncope and collapse.
Resident 62's care plan included, but was not limited to, at risk for injury from falls. The fall risk care plan included the interventions, bed in lowest position (initiated 4/18/22), footwear or gripper socks to prevent slipping (initiated 4/5/22), mat beside bed (initiated 4/5/22), use activity box to stimulate and occupy resident while in wheelchair (initiated 4/18/22), use weighted blanket for comfort while in bed (initiated 4/18/22).
A review of Resident 62's falls included the following:
04/04/2022 7:15 P.M.-Fall was not witnessed. Resident was found on floor of their room sitting on floor next to bathroom with head under chair sitting next to door. No injury noted. Neurological checks initiated. New intervention: Resident's bed placed in low position.
4/5/2022 8:30 A.M.-Fall was not witnessed. Resident attempted to get dressed independently and missed the chair when he tried to sit down. Resident found lying on the floor of their room. He was not wearing any non-skid socks or shoes at the time of fall. Floor mat was not on floor. No injury noted. New interventions: Neurological checks initiated, fall mat at bedside and resident to be moved to room closer to nurse's station with increased supervision.
04/09/2022 8:40 A.M.-Fall was witnessed. Fall occurred in the hallway as Resident was trying to ambulate and fell out of wheelchair. The wheelchair was unlocked. No injury noted. New intervention: added anti-roll back brakes to his wheelchair.
04/12/2022 6:40 P.M.- Fall was witnessed. Fall occurred in dining room as Resident was sitting in a straight back chair in the dining room and attempted to stand up but slid out of the chair onto the floor onto his buttock. No injury noted. The care plan was not updated with a new intervention.
4/13/2022 12:20 A.M.-Fall was unwitnessed. Resident found in their room off their bed on the mat. Resident denied hitting head. No injury noted. Resident assisted in broda chair and put by nursing station. Neurological checks initiated. The care plan was not updated with a new intervention.
04/13/2022 12:10 P.M.-Fall was unwitnessed. Resident was sitting up in bed and staff brought in his lunch tray. While staff returned to hallway to continue passing out trays, they turned around and noted that resident was on floor, partly on mat near bed . No injury noted. Resident continued neurological checks from previous fall. New intervention: do not leave him in his wheelchair in his room.
04/14/2022 6:42 P.M.-Fall was unwitnessed. Fall occurred in the Resident's room and it was clear that resident hit head. Found with knot and bleeding on left side of temple. Left eyebrow also had a small cut and was bleeding as well. Once resident was in chair, resident began to vomit. Resident sent to ER. No acute findings with CT of head and spine. New intervention: use weighted blanket to reduce anxiety/promote calmness and more restful sleep. A record of neurological checks was asked for but not provided and was not recorded in clinical record.
4/16/2022 12:45 A.M.-Fall was witnessed. Resident stood up from gerichair in front of nurses station without assistance and fell to his knees onto the floor striking left elbow on the chair. Resident had abrasions to left knee and left elbow. New intervention: provide activity box when up in Broda chair at nurses station.
4/17/22 11:58 A.M.-Fall was unwitnessed. Resident found on floor of room with 4 cm laceration to above left eyebrow. Resident sent to ER and returned to facility with 7 (seven) sutures. Bed was at normal height and a mattress was on the floor instead of a beveled fall mat. New intervention: put bed in low position and remove mattress. A record of neurological checks was asked for but not provided and was not recorded in clinical record.
04/20/2022 6:30 A.M.-Fall was witnessed. Resident was food on floor lying between the bedroom and bathroom. Resident was wearing regular socks. Resident had laceration on their left eyebrow measuring 2.5 cm and an egg size knot above previous stitches. Resident transferred to ER. No acute findings on CT of head. 5 (five) sutures were placed to laceration of left temple. A record of neurological checks was asked for but not provided. New intervention: resident be placed on toileting program.
4/25/2022 4:40 P.M.-Fall was witnessed. Resident was in dining room after activity resident attempted to stand from wheelchair and slid to floor. No injury noted. New intervention: staff to keep eyes on Resident if awake and in chair and also keep Resident near nurse's station if not in activity.
4/26/2022 6:07 P.M.-Fall was witnessed. Resident was in activity room after participating in activity in their reclining chair. Resident attempted to stand up and ambulate without assist of staff. Resident slid from chair onto his bottom. No injury noted. The care plan was not updated with a new intervention.
5/29/22 5:56 P.M.-Fall was witnessed. Staff was assisting resident to restroom from broda chair with use of gait belt. While transferring resident into the hallway restroom, Resident lost balance. Staff was unable to maintain balance due to Resident's height. Staff assisted to the floor and Resident landed on top of staff in a sitting position. No injury noted. New intervention: Resident on hospice services.
07/09/2022 1:05 P.M.-Fall was witnessed. Fall occurred in dining room while Resident was attempting to transfer from gerichair alone while foot rests were lowered. Resident had a laceration measuring 0.4 cm across bridge of nose. Resident sent to ER. No acute findings and wound care completed. Neurological checks were initiated. New intervention: will offer and encourage rest period after lunch, place with staff member to keep resident within line of sight at all times while out of bed, and up with assist only using appropriate assistive equipment.
07/20/2022 3:50 P.M.-Fall was unwitnessed. Fall occurred in the hallway while Resident was ambulating without assistance. Staff found Resident lying on the floor in the hallway on his right side.
Resident had a skin tear to left elbow measuring 1.5 x 0.5 cm and one to right elbow measuring 0.5 x 0.2 cm. A record of neurological checks was asked for but not provided and not recorded in clinical record.
7/29/2022 4:09 P.M.-Fall was unwitnessed. Resident attempted to transfer self from bed and fell in the process. No injury noted. Post fall evaluation was provided but was blank. A record of neurological checks was asked for but not provided.
8/31/2022 6:20 P.M.-Fall was unwitnessed. Staff found Resident on the floor by their bed with blood everywhere. Before the fall, the resident had been saying repeatedly they wanted their shoes on. Resident sent to the ER. No acute findings found. Wound care to abrasion on head. Neurological checks initiated and placed on 15 (fifteen) minute checks for 24 (twenty-four) hours. New intervention: staff to place shoes in closet when not in use so that the resident doesn't worry about his shoes.
During an observation on 8/31/22 at 11:15 A.M., Resident 62 was in the dining room eating in Broda chair not interacting with staff. The resident did not have shoes on, there was not an activity box present.
During an interview on 9/2/22 at 10:50 A.M. CNA (Certified Nursing Assistant) 14 indicated that she was unaware of an activity box or weighted blanket use for the Resident.
During an interview on 9/2/22 at 10:40 LPN (Licensed Practical Nurse) 8, indicated that staff could not provide constant supervision to him. She further indicated that she was unaware of an activity box or weighted blanket to use for the Resident.
On 9/2/22 at 12:48 P.M., the DON (Director of Nursing) provided an undated facility policy titled, Fall Prevention Policy. The policy stated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk . implement interventions .If a fall should occur .review the resident's care plan and update as indicated.
3.1-45(a)(2)
CONCERN
(D)
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 ensure it was free from a medication error rate greater than 5% for 2 of 26 opportunities observed to administer medications ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 2 of 26 opportunities observed to administer medications correctly, resulting in an error rate of 7.69%. This affected 2 of 5 residents observed during medication administration. (Resident K, Resident 40)
Findings include:
1. On 8/30/22 at 9:55 A.M., Licensed Practical Nurse (LPN 8) was observed to administer 2 (two) 110 mg (milligram) tablets of Zinc sulfate (A total of 220 mg) to Resident 40.
The physician's orders included, but were not limited to, Zinc Tablet 50 MG Give 2 tablet by mouth one time a day for supplement.
2. On 8/31/22 at 7:35 A.M., Registered Nurse (RN) 15 removed an oatmeal from the meal cart and RN 15 pushed a liquid substance into Resident K's oatmeal and returned the oatmeal to the meal cart. During an interview at that time, RN 15 indicated the medication pushed into the oatmeal was Haldol.
On 8/31/22 at 8:52 A.M., Resident K's clinical record was reviewed. Current physician orders included, but were not limited to: .Haloperidol [Haldol] Lactate Concentrate 2MG/ML [milligram/ milliliter] Give 0.25 ml by mouth two times a day for mix with drink of choice at meals related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, . started 7/28/22.
During an interview on 9/1/22 at 1:14 P.M., Director of Nursing (DON) indicated Haldol should be given mixed with a drink of choice two times a day.
On 9/2/22 at 1:06 P.M., a current, undated Medication Administration policy was provided and indicated .Administer medications as ordered .observe resident consumption of medication .
3.1-48(c)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to test symptomatic residents for COVID-19 for 1 of 1 residents with signs and symptoms. A resident was not tested for COVID-19 until 7 days a...
Read full inspector narrative →
Based on interview and record review, the facility failed to test symptomatic residents for COVID-19 for 1 of 1 residents with signs and symptoms. A resident was not tested for COVID-19 until 7 days after symptoms started. (Resident 46)
Finding includes:
On 8/31/22 at 1:04 P.M., Resident 46's clinical record was reviewed. On 8/26/22 Resident 46 was tested for COVID-19 and had a positive result.
During an interview on, 8/31/22 at 1:16 P.M., the Director of Nursing (DON) indicated Resident 46 had COVID-19 symptoms starting on 8/19/22. The DON was unable to find a COVID-19 test result from 8/19/22 through 8/25/22. At that time, the DON indicated residents should currently be tested every Tuesday and Thursday of when symptoms start.
On 9/2/22 at 12:48 P.M., a current Clinical Guidance for COVID-19 testing, dated 2/8/22, was provided and indicated when a symptomatic resident was identified, they should be tested for COVID-19 regardless of vaccination status.
3.1-18(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to follow their contingency plan for staff that are not fully vaccinated for 1 of 1 staff not fully vaccinated. (Staff 19)
Finding includes:
...
Read full inspector narrative →
Based on interview and record review, the facility failed to follow their contingency plan for staff that are not fully vaccinated for 1 of 1 staff not fully vaccinated. (Staff 19)
Finding includes:
On 8/30/22 at 11:50 P.M., the COVID-19 staff vaccination status was reviewed. Staff 19 was documented as partially vaccinated.
On 8/31/22 at 6:33 A.M., Staff 19 was observed wearing a surgical mask entering a room with 3 residents and was within an arms length of one of those residents.
During an interview on 8/31/22 at 6:35 A.M., Staff 19 indicated administrative staff had said something about wearing an n95 while in the facility due to being partially vaccinated.
During an interview on 9/2/22 at 9:30 A.M., the Director of Nursing (DON) indicated she was unsure why Staff 19 was working due to facility policy that employees without exemption or approved delay are required to have unpaid leave until fully vaccinated.
On 8/29/22 at 10:00 A.M., a current COVID-19 Vaccination and Testing policy, revised 4/18/22, indicated .Any employee that has not provided .an approved delay in vaccination .will have their status changed to unpaid leave after February 14, 2022.
3.1-18(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environmen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment in resident spaces in 2 of 3 halls observed. Holes in door, broken footboard, SHARPS container full at bedside, personal care items uncovered and unlabeled.(100 Hall, 200 Hall)
Findings include:
1. On 8/30/22 at 8:54 A.M., in the shared bathroom of room [ROOM NUMBER], there was a quarter size hole in the bathroom door, an unlabeled, used urinal on the sink, an uncovered plunger on the floor, uncovered wash basin with used rags on the floor, bucket on floor open with paper towels and an empty, unlabeled urinal in it. In the bedroom, there were 4 (four) used gloves and an empty medication cup on the floor.
On 9/2/22 at 9:10 A.M., there was still a quarter size hole in the bathroom door and an uncovered plunger on the floor.
2. On 8/29/22 at 9:03 A.M., in room [ROOM NUMBER], the footboard of bed closest to the bathroom was broken and hanging off the bed and there were multiple black footprints on the floor in the middle of the room. In the shared bathroom, the sharps container was very full, an uncovered and unlabeled urine hat was on the floor.
On 9/2/22 at 9:10 A.M., the footboard was still broken.
3. On 8/29/22 at 8:04 A.M., in the shared bathroom of room [ROOM NUMBER], there was an uncovered plunger on the floor, no liner in the trash can, unlabeled toothpaste on sink shelf, and no gloves in the box.
On 9/2/22 at 9:10 A.M., the plunger was still uncovered on the floor.
During an interview on 9/2/22 at 10:54 A.M., QMA 16 indicated all items should be labeled with the resident's name. She further indicated that plungers should be stored with a plastic bag covering them.
During an interview on 9/02/22 at 11:02 P.M., the Maintenance Supervisor indicated he was unaware of the broken footboard in room [ROOM NUMBER] and the hole in the bathroom door of room [ROOM NUMBER]. He further indicated that the facility utilizes a computer program that the staff are supposed to use to notify maintenance of issues.
During an interview on 09/01/22 at 8:00 A.M., housekeeping indicated that in the resident rooms they are supposed to wipe all surfaces, pull trash and put in new bags daily. In the resident bathrooms, they are supposed to wipe the sink, toilet, and paper towel holders daily along with sweep and mop floors daily. She further indicated sometimes they have to clean the bathrooms more than once and they are still cleaning high touch surfaces (bed side tables, bed rails, remote controls) due to COVID with EPA approved cleaner.
During an interview on 9/02/22 at 11:48 P.M.,the DON (Director of Nursing) indicated there is not a specific policy for labeling resident items, but she would assume that the facility policy would be to label items.
On 9/2/22 at 11:48 P.M., the DON provided an undated Safe and Homelike Environment policy that indicates .the facility will provide a safe, clean, comfortable, and homelike environment .
This Federal tag relates to Complaint IN00385834.
3.1-19(f)(5)
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** 4. On 8/31/22 8:30 A.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to paranoid schizop...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/31/22 8:30 A.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to paranoid schizophrenia,schizoaffective disorder, and dementia. The most recent quarterly MDS (Minimum Data Set), dated 8/18/22, indicated Resident L had a significant cognitive impairment and required extensive assistance of 2 (two) staff with dressing, transfers, eating, bed mobility, and toileting. The MDS also indicated Resident L received antipsychotics on a daily basis for the 7 (seven) day look-back period.
Current physician orders included, but were not limited to:
Monitor for side effects and report to physician: Antipsychotic medication, initiated 5/13/22
Iloperidone: Tablet 1 MG (milligram),Give 1 mg by mouth three times a day, initiated 5/12/22
Haloperidol Lactate Concentrate: Give 0.25 ml (milliliters) by mouth three times a day, initiated 7/7/22.
A current psychotropic medication use care plan, initiated 1/25/22, included, but were not limited to, the following interventions:
Monitored for side effects and reported to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS [extrapyramidal symptoms], weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention , initiated 1/25/22.
Resident L's MAR (medication administration record) for June through August 2022 included the following dates that Haldol failed to be administered:
6/20/22 at 5:30 P.M.
7/10/22 at 8:30 A.M. and 12:30 P.M.
7/13/22 at 5:30 P.M.
8/13/22 at 12:30 P.M.
Resident L's MAR indicated from June through August 2022, side effects from Haldol were not monitored on the following dates:
7/10/22 day shift
7/27/22 night shift
7/30/22 evening and night shift
8/1/22 evening shift
8/9/22 night shift
8/10/22 night shift
Resident L's MAR indicated from June through August 2022, Illoperidone was not administered on the following dates:
6/20/22 at 5:00 P.M.
7/10/22 at 8:30 A.M. and 12:30 P.M.
7/13/22 at 5:00 PM
7/20/22 at 8:30 AM, 12:30 PM, and 5:30 PM
7/30/22 at 5:00 PM
8/13/22 at 12:30 PM
Resident L's MAR indicated from June through August 2022, side effects from Illoperidone were not monitored on the following dates:
7/10/22 day shift
7/27/22 night shift
7/30/22 evening and night shift
8/1/22 evening shift
8/9/22 night shift
8/10/22 night shift
During an interview on 9/2/22 at 9:29 A.M., the DON (Director of Nursing), indicated nurses were supposed to document on Resident L's MAR the administration of medication and side effects of Haldol and Illoperidone and was unsure why Resident L's MAR lacked documentation in June, July, and August for these areas.
5. On 8/29/22 at 12:24 A.M., Resident O was observed lying in bed. The resident's feet were observed uncovered and the right foot third toe was black. On the left foot, all toes were black except the second toe. All toes were stained orange. The resident indicated that he does not wear his oxygen continuously, he was observed to not have oxygen on .
On 8/30/22 at 9:24 A.M., Resident O was observed laying in his bed without oxygen on.
On 8/31/22 at 12:58 P.M., Resident O was observed laying in his bed without oxygen on.
On 9/1/22 at 10:10 A.M., the resident was observed lying in his bed awake with oxygen tubing on the floor beside his bed.
On 09/01/22 at 8:20 A.M., Resident O's clinical record was reviewed. Diagnoses included, but were not limited to, atherosclerosis of native arteries of right leg with ulceration of other part of foot, atherosclerosis of native arteries of extremities of left leg with ulceration of other part of foot, atherosclerosis of native arteries of extremities with gangrene, bilateral legs, and COPD (chronic obstructive pulmonary disease). The most recent significant change MDS (minimum data set) Assessment, dated 7/11/22 indicated Resident O required extensive assistance of 1 (one) staff with bed mobility, and had a moderate cognitive impairment.
A current care plan titled Impaired Gas Exchange . initiated 6/3/22, indicated but not limited to the following interventions: Administer oxygen as prescribed or per standing order.
A current physician's order, dated 6/29/22, was reviewed and included Betadine solution 10% (Povidone-Iodine) apply to feet toes topically every day shift.
Resident O's TAR (treatment administration record) was reviewed for 8/1/22 through 8/31/22. The following dates of Betadine solution treatments were not completed:
8/5/22, 8/12/22, 8/13/22, 8/14/22, 8/15/22, 8/18/22, 8/22/22, 8/26/22.
A current physician's order, dated 7/20/22, was reviewed and included continuous oxygen @ 2 lpm (liters per minute) via NC (nasal cannula). Call MD if O2 sats are below 90% every shift.
Vital signs were reviewed for 8/1/22 through 8/31/22. The Residents oxygen was not monitored as ordered on the following shifts:
8/1/22 evening shift
8/2/22 evening and night shift
8/3/22 evening shift
8/4/22 evening shift
8/5/22 day shift
8/6/22 night shift
8/7/22 evening shift
8/9/22 evening and night shift
8/10/22 evening and night shift
8/11/22 evening shift
8/12/22 evening shift
8/13/22 day and evening shift
8/14/22 day and evening shift
8/15/22 day and evening shift
8/19/22 day, evening, night shift
8/20/22 evening and night shift
8/21/22 night shift
8/22/22 day and evening shift
8/23/22 evening shift
8/24/22 evening shift
8/25/22 evening and night shift
8/26/22 day and evening shift
8/27/22 evening and night shift
8/28/22 evening and night shift
8/29/22 evening shift
8/30/22 evening shift
8/31/22 evening shift
During an interview on 09/01/22 10:20 A.M., CNA 12 indicated that resident did not wear oxygen continuously.
6. On 08/29/22 at 9:27 A.M., Resident P was observed laying in his bed.
On 08/31/22 07:56 A.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, Type II Diabetes Mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolarity coma, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus, and hypokalemia. The most recent quarterly MDS Assessment, dated 7/22/22, indicated Resident P required total dependence of 2(two) staff with bed mobility, and had severe cognitive impairment.
A current care plan titled Nutrition initiated on 6/30/10 included not limited to the following interventions: Monitor lab values as ordered, initiated 2/10/20.
A list of physician orders included but was not limited to the following:
Levetiracetam solution 100MG/ML give 10 ml via PEG-tube four times a day related to localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus active 3/16/22.
Potassium Chloride Solution 20 MEQ/15ML (10%) give 10 mEq via PEG-Tube three times a day related to hypokalemia active 1/12/21.
CBC, Lipid, BMP, and Keppra level every 4 months every night shift .active 3/5/22.
During an interview on 8/31/22 at 1:08 P.M., RN (Registered Nurse) 15 indicated the labs drawn on 3/10/22 were the last labs the resident completed.
During an interview on 9/2/22 at 12:48 P.M., the DON (Director of Nursing) indicated there was not a specific policy related to care plan interventions, but the facility policy was to implement care plan interventions.
On 9/2/22 at 9/2/22 at 1:06 p.m., the DON provided the current undated policy on Medication Administration. The policy included, not limited to: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician, administer medication as ordered in accordance with manufacturer specifications, sign MAR after administered, report and document any adverse side effects or refusals.
This Federal tag relates to Complaint IN00385834.
3.1-35(a)
3.1-35(g)(2)
3. On 8/31/22 at 8:52 A.M., Resident K's clinical record was reviewed. Diagnosis included, but were not limited to, schizoaffective disorder, bipolar, and anxiety disorder. The most recent quarterly MDS (minimum data set) Assessment, dated 7/7/22 indicated Resident K was cognitively intact.
Resident K's care plans were reviewed and included, not limited to:
Mood/Behavior: I have a diagnoses of Schizoaffective DO (disorder) and Bipolar. I do not always understand my my situation/circumstances and will make statements that I feel like I am being neglected/abused because I think I should have been able to leave the facility after I finished therapy. I sometimes have behaviors which include loud disruptive yelling/screaming. false beliefs/delusions, such as my dad has taken over my body. I sometimes am non-compliant w/ my medication regime. I tend to pick and choose the medications I want to take and when I want to take them, refusing them at other times. I will attempt to to hide medications I do not want to take. I experience delusions with medications. I will state things like the devil told me not to take this I am allergic or thinking the medication will harm me in some way. I make false accusations towards staff. Interventions included, not limited to: Give my medications as my doctor has ordered, initiated 1/6/22.
Current physician orders included, but were not limited to: .Haloperidol [Haldol] Lactate Concentrate 2MG/ML [milligram/ milliliter] Give 0.25 ml by mouth two times a day for mix with drink of choice at meals related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, . started 7/28/22.
On 8/31/22 at 7:35 A.M., Registered Nurse (RN) 15 removed an oatmeal from the meal cart and RN 15 pushed a liquid substance into Resident K's oatmeal and returned the oatmeal to the meal cart. During an interview at that time, RN 15 indicated the medication pushed into the oatmeal was Haldol.
On 8/31/22 at 8:26 A.M., Resident K was observed lying in bed with a backpack on the bed and the meal tray sat on the bedside table next to the resident.
On 8/31/22 at 8:37 A.M. Certified Nurse Aide (CNA) 17 removed Resident K's tray. At that time, the oatmeal was observed to have one-third of the oatmeal left in the bowl.
During an interview on 9/1/22 at 1:14 P.M., Director of Nursing (DON) indicated Haldol should be given mixed with a drink of choice two times a day.
Based on observation, interview, and record review, the facility failed to ensure physician orders were followed and care plans were implemented for 6 of 6 residents reviewed for medications and treatments. Residents did not receive medications, side effects were not monitored, skin treatments not performed, labs not obtained, oxygen not applied/worn, care plan interventions not implemented. (Resident B, Resident M, Resident L, Resident K, Resident O, Resident P)
Findings include:
1. On 8/29/22 at 8:22 a.m., Resident B indicated they did not always receive their insulin shot.
On 8/31/22 at 1:58 p.m., Resident B's clinical record was reviewed. Diagnoses included, not limited to, Diabetes Mellitus with stable proliferative diabetic retinopathy, hyphema, left eye, atelectasis unspecified. A quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was moderately impaired.
Care plans were reviewed and included, not limited to:
Alteration in blood glucose due to: hyperglycemic episodes, hypoglycemic episodes, insulin dependent Diabetes Mellitus. Interventions included, not limited to: Administer medications as ordered, initiated 5/10/22.
August 2022 physician orders were reviewed and included, not limited to:
Basaglar KwikPen 100 unit/ml (milliliters) solution pen-injector - inject 24 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications, order date 7/15/22.
Insulin Lispro (1 unit dial) solution pen injector 100 unit/ml inject as per sliding scale:
150-189 =1
190-229 = 2
230-269 = 3
270-299 = 4
300+ = 5
If blood glucose > 300 give 5 units and recheck BS at next ordered time. If remains > 300 contact MD, subcutaneously before meals for hyperglycemia related to Type 2 Diabetes Mellitus without complications, order date 5/11/22.
The August 2022 EMAR (Electronic Medication Administration Record) was reviewed and included, not limited to: Basaglar KwikPen 100 unit/ml solution pen-injector inject 24 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications. The following dates on the EMAR were blank:
8/5/22
8/16/22
8/18/22
8/20/22
8/28/22
Progress notes for August 2022 were reviewed and did not contain refusals for the above dates.
Insulin Lispro (1 unit dial) solution pen injector 100 unit/ml inject as per sliding scale:
150-189 =1 units
190-229 = 2 units
230-269 = 3 units
270-299 = 4 units
300+ = 5 units
If blood glucose > 300 give 5 units and recheck BS at next ordered time. If remains > 300 contact MD, subcutaneously before meals for hyperglycemia related to Type 2 Diabetes Mellitus without complications. The following date and times were blank on the EMAR:
8/5/22 11:00 a.m.
8/17/22 7:30 a.m., 11:00 a.m.
8/20/22 11:00 a.m.
8/21/22 11:00 a.m.
8/29/22 4:30 p.m.
Progress notes were reviewed and contained the following:
A progress note dated 8/21/22 at 10:15 a.m., indicated that Resident B's blood sugar was 109, the nurse did not feel comfortable giving the insulin dose.
8/22/22 9:20 a.m., .Insulin held. BS 148 at present. No concerns at this time .
No documentation was seen in the progress notes of refusals, or the physician was notified of the insulin being held.
On 9/1/22 at 12:44 p.m., RN 3 indicated if a resident refuses insulin, the physician should be notified, document refusal on the EMAR and progress notes, a code of 3 should be documented for insulin held.
2. On 9/2/22 at 8:11 a.m., Resident M indicated they sometimes do not receive their insulin.
On 8/31/22 at 2:53 p.m., Resident M's clinical record was reviewed. Diagnoses included, not limited to, Type 2 Diabetes Mellitus with unspecified complications, Bipolar disorder, Type 1 Diabetes Mellitus with diabetic neuropathy, Type 1 Diabetes Mellitus with unspecified diabetic retinopathy with macular edema. A quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident M's cognition was intact.
Care plans were reviewed and included, not limited to:
Alteration in blood glucose due to: hyperglycemic episodes, hypoglycemic episodes, insulin dependent diabetes, initiated 5/17/22. Interventions included, not limited to, Administer medications as ordered.
August 2022 physician orders were reviewed and included, not limited to:
Insulin Glargine Solution inject 36 unit subcutaneously at bedtime related to Diabetes Mellitus due to hyperglycemia, order date 5/16/22.
Insulin Lispro solution 100 unit/ml inject 8 unit subcutaneously before meals related to Diabetes Mellitus due to underlying condition with hyperglycemia, order date 5/17/22.
Insulin Lispro solution 100 unit/ml inject as per sliding scale:
151-200 = 4 units
201-250 = 6 units
251-300 = 8 units
301-350 = 10 units
400 = 20 units
4-1-450 = 24 units over 450 call MD, subcutaneously before meals related to Diabetes Mellitus due to underlying condition with hyperglycemia, order date 5/17/22.
The August 2022 EMAR (Electronic Medication Administration Record) was reviewed and included, not limited to:
Insulin Glargine solution inject 36 unit subcutaneously at bedtime related to Diabetes Mellitus due to underlying condition with hyperglycemia. The following dates were blank on the EMAR:
8/5/22
8/16/22
8/18/22
8/20/22
8/28/22
Progress notes were reviewed and not observed to contain any refusal of the bedtime dose of insulin.
Insulin Lispro solution 100 unit/ml inject 8 unit subcutaneously before meals related to Diabetes Mellitus due to underlying condition with hyperglycemia. The following date and times were blank on the EMAR:
8/2/22 at 11:00 a.m.
8/5/22 at 11:00 a.m.
8/7/22 at 4:30 p.m.
8/21/22 at 11:00 a.m.
8/29/22 at 4:30 p.m.
8/31/22 at 7:30 a.m.
Progress notes were reviewed and not observed to contain a refusal for the above date and times.
On 9/2/22 at 9:05 a.m., the DON indicated if a resident refuses insulin it should be documented and the physician notified.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the temperature of food items were taken before food was served to residents for 1 of 1 meal observations.
Findings i...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure the temperature of food items were taken before food was served to residents for 1 of 1 meal observations.
Findings include:
On 8/31/22 at 7:16 A.M., [NAME] 49 was observed placing food items on trays to be delivered to residents.
On 8/31/22 at 7:27 A.M., [NAME] 49 pushed the meal cart out of the kitchen to be delivered to the 200 hall residents. At that time, [NAME] 49 indicated temperatures were not taken for any of the following food items: oatmeal, waffles, sausage links, puree sausage, puree waffles, scrambled eggs, and gravy.
During an interview on 9/1/22 at 10:17 A.M., the Dietician indicated all food items should have the temperature taken when the food items are on the steam table and right before being put on the plate from the steam table.
On 9/2/22 at 12:48 P.M., a current undated Food Safety Requirements policy was provided and indicated .Cooking--foods shall be prepared as directed until recommended temperatures for the specific foods are reached .
3.1-21(a)(2)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The dietary manager la...
Read full inspector narrative →
Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies to carry out the functions of food and nutrition services. The dietary manager lacked appropriate certification for 1 of 1 kitchen.
Finding includes:
On 8/31/22 at 10:00 A.M., employee records were reviewed. The current dietary manager lacked a state approved dietary certification.
During an interview on 9/2/22 at 9:08 A.M., the Director of Nursing (DON) indicated the current dietary manager obtained that position on 2/2/18, and was currently working on becoming certified.
On 9/2/22 at 10:21 A.M., a current manager of dining services job description, dated 9/27/15, was provided and indicated qualifications must include State approved dietary manager certificate or become certified within one year from hire date.
3.1-20(h)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety in 1 of 2 obser...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety in 1 of 2 observations of the kitchen. The dishwasher was not tested with chemical strips, and the rinse solution container was empty. (Kitchen)
Finding includes:
During an initial kitchen observation on 8/29/22 at 7:27 A.M., a strip was placed in the dishwasher after a load was ran, and did not change color. At that time, the Kitchen Manager indicated she was unaware until recently that chemical strips were needed to test the dishwasher, and have had that dishwasher for about a year. At that time, the sanitizer container under the dishwasher was observed to be empty.
On 8/29/22 at 7:56 A.M., the Kitchen Manager indicated the sanitizer, rinse, and detergent containers for the dishwasher were supposed to be changed when the solutions get to the bottom of the containers, and could be done by whoever was doing the dishes at that time. She indicated all staff were aware of when and how to change the containers. At that time, [NAME] 41 indicated staff did not test the dishwasher with strips, and only checked that it was 120 degrees while running.
During an interview on 8/29/22 at 9:15 A.M., [NAME] 47 indicated staff was supposed to use a strip with the dishwasher, but had not done so the previous night when she had worked. She further indicated the only thing staff logged for the dishwasher was the temperature, and not the results of the strips. She also indicated she was unaware who was responsible for changing the solution containers for the dishwasher, and did not look at them during her shift.
On 8/29/22 at 10:00 A.M., a dish machine temperature log was provided for August 2022. The log was filled out daily with the wash and final rinse for breakfast, noon meal, and evening meal. The form included a space to log PPM (parts per million), but all days were left blank.
On 8/29/22 at 12:15 P.M., a current installation and operation manual for the dishwasher, dated December 5, 2007, indicated . titration should be between 50 and 100 ppm .
3.1-21(i)(2)
3.1-21(i)(3)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to designate a qualified individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a c...
Read full inspector narrative →
Based on interview and record review, the facility failed to designate a qualified individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a current certified Infection Preventionist for 1 of 1 employee file reviewed.
Finding includes:
During an interview on 8/29/22 at 10:21 A.M., the Director of Nursing (DON) indicated she was the Infection Preventionist, but was not yet certified. At that time, the DON indicated no other staff was acting as Infection Preventionist . The DON's hire date was 5/3/22.
On 9/2/22 at 12:48 P.M., a current, undated Infection Preventionist policy was provided and indicated The facility will ensure the Infection Preventionist is qualified by education, training, experience or certification
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to provide staffing information on 2 of 3 units (100 unit, 200 unit) and failed to ensure the correct date was posted for staffi...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide staffing information on 2 of 3 units (100 unit, 200 unit) and failed to ensure the correct date was posted for staffing forms for 5 of 5 days during the survey. Posted nurse staffing was only able to be viewed in the front lobby. Resident units 100, 200, and 300 all failed to have staffing information posted in resident areas.
Findings include:
On 8/29/22 at 6:53 A.M., a staffing form, dated 8/25/22 was observed to be posted in the front lobby.
On 8/30/22 at 2:33 P.M., a staffing form, dated 8/29/22 was observed in the front lobby.
On 8/31/22 at 11:10 A.M., a staffing form, dated 8/30/22 was observed in the front lobby.
On 9/1/22 at 8:06 A.M., a staffing form, dated 8/31/22 was observed in the front lobby.
On 9/2/22 at 7:55 A.M., a staffing form, dated 9/1/22 was observed in the front lobby.
During an interview on 9/2/22 at 8:33 A.M., the Director of Nursing (DON) indicated the staffing forms were posted by the time clock and front door and was unsure if the staffing forms should be posted on the other units. At that time, the DON indicated the staffing forms should be posted for the previous day.
On 9/2/22 at 12:48 P.M., a current, undated Nurse Staffing Posting Information policy was provided and indicated .The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: .The current date .
Jun 2021
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to provide residents information regarding what services were not covered ny Medicare and what services they would be financially responsible...
Read full inspector narrative →
Based on interview, and record review, the facility failed to provide residents information regarding what services were not covered ny Medicare and what services they would be financially responsible for 2 of 3 resident's reviewed. Resident's were not provided NOMNC (Notice of Medicare Non-Coverage) or ABN (Advanced Beneficiary Notice) when skilled services ended. ( Resident 44, Resident 201).
Finding includes:
On 6/16/21 the SNF Beneficiary Notification Review's were reviewed. Resident 44's Medicare Part A Skilled services had a start date of 12/14/21, last covered day was 2/12/21. The document was marked for the facility/provider initiated discharge when days were not exhausted. There was not documentation provided for Resident 44 receiving a NOMNC, or ABN. Resident 44 remained in the facility. Resident 201's Medicare Part A Skilled services had a start date of 1/26/21, last day covered 2/23/21. The documentation was marked the resident was not provided a NOMNC due to it was not completed.
On 6/16/21 at 1:58 p.m., the Administrator indicated he could not find documentation of the resident's being notified before their skilled services ended.
On 6/17/21 at 9: 15 a.m., the Administrator indicated Social Services does the Beneficiary notification reviews, she was out on maternity leave, and another Social Services designee was filling in for her, but was out sick for the week.
On 6/17/21 at 9:50 a.m., the Director of Staff Development provided the current policy Advanced Beneficiary Notices, the policy was undated. The policy included, but was not limited to: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .The current CMS-approved version forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form.
a. For part A items and services, the facility shall use the Skilled Nursing g Facility Advance Beneficiary Notice SNFABN), form CMS-10055.
b. For Part B items and services, the facility shall use the Advance Beneficiary Notice of Non-Coverage(ABN), Form CMS-R-131.
c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination form their Quality Improvement Organization (QIO).
i. this notice is used when all covered services end for coverage reasons.
ii. An exhaustion of benefits is not considered a termination of coverage reasons.
To ensure that the resident, or representative has enough tie to make a decision whether or not to receive the services in question and assume financial responsibility, the notice shall be provided within two days of the last anticipated covered day.
3.1-4(f)(3).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents were free of abuse for 1 of 1 residents reviewed for abuse. A resident was verbally abused. (Resident B)
Findings include:...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure residents were free of abuse for 1 of 1 residents reviewed for abuse. A resident was verbally abused. (Resident B)
Findings include:
On 6/14/21 at 10:40 a.m., Resident B indicated a staff had verbally cussed at them. Resident B asked RN 1 not to pinch their skin up when she gave the insulin injection, and RN 1 cussed at them. Resident B was unsure of the date of the incident, and indicated they reported it to the Administrator.
On 6/15/21 at 9:15 a.m., Resident B's record was reviewed. The resident had diagnoses that included, but were not limited to, Bipolar disorder, unspecified adult maltreatment, confirmed subsequent encounter, adult sexual abuse, confirmed, subsequent encounter, Diabetes Mellitus. An admission MDS (Minimum Data Assessment), dated 3/25/21, indicated Resident B's cognition was intact.
On 6/15/21 at 11:15 a.m., a State Reportable was reviewed, and included, but was not limited to, brief description of incident .5/25/21 allegation was made by therapy staff that RN raised her voice while caring for the resident and used swear words during the verbal allegation . action taken added .5/25/21 RN was removed from the floor, interviewed, and was suspended pending the outcome of an investigation. Administrator and SSD designee followed up with resident who stated she continues to feel safe in the facility. Dr notified. Resident own responsible person. Follow up added .6/2/21 Administrator and Social Services designee spoke with resident immediately after it was reported .interviews with each of the three therapist, who witnessed the interaction, indicated a similar account of the situation the resident described. They reported that the resident made a joke about being gentle when nurse was going to administer her insulin as the resident often does with staff. Nurse raised voice and said that the resident says that to her all the time. Resident stated she was only joking about it when nurse responded that it was *f*cking annoying .At the conclusion of the investigation it was determined that nurse will be terminated.
On 6/16/21 at 7:45 a.m., the Administrator indicated the incident with Resident B was investigated, he would not allow abuse to happen, and RN 1 was let go.
On 6/16/21 at 10:23 a.m., the Director of Staff Development indicated if abuse was alleged the Administrator would be immediately notified, make sure the resident was safe, separate the staff, or other residents, if a staff member, pull them off the floor, start an investigation, interview the staff and resident, suspend staff, 1 on 1 with the resident and assesses for residual effects.
On 6/17/21 at 9:45 a.m., Medical Records provided a copy of the current policy titled Investigation and reporting of alleged violations of Federal and State laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident's property The policy was undated, and included, but was not limited to, it is the policy of the company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident property are reported immediately to the Executive Director (hereinafter ED) of the center and the Director of Rehabilitation (DOR) if it is .employee .Verbal abuse is defined as any use or oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability.
This Federal tag relates to Complaint IN00355019.
3.1-27(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that food was stored and labeled correctly for 2 of 2 kitchen observations and 1 of 1 observations of the activity ref...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure that food was stored and labeled correctly for 2 of 2 kitchen observations and 1 of 1 observations of the activity refrigerator. Food items were not labeled and dated, food items were expired, and non food items were located in the dry storage area. (Kitchen, activity room refrigerator)
Findings include:
On 6/14/21 from 8:15 a.m. to 8:47 a.m. the following were observed during a tour of the kitchen:
1. The reach in refrigerator was observed with an open bag of yogurt on the top shelf. The bag lacked a date or label. At that time, the Dietary Manager indicated that the yogurt should have a date and label and will be discarded.
2. The walk in refrigerator was observed with a milk carton on the floor, under a storage shelf. The Dietary Manager indicated that the milk carton should not be on the floor and would be disposed of.
3. An open bag of smoked polish sausage was observed without a date or label. The Dietary Manager indicated that the sausage should be labeled and would be discarded.
4. An open bag of frozen egg patties was observed in the walk in freezer. The bag lacked a date or label. The dietary manager indicated the egg patties should be labeled and dated and would be discarded.
At that time, the Dietary Manager indicated the facility had a new cook and she had been working to remind the staff to always label and date food items.
5. A pair of slip on shoes were observed under the dry storage area shelf. At that time, the Dietary Manager indicated that an employee had spilled soup on her shoes and had left them under the shelf, she would be picking the shoes up later in the day.
On 6/15/21 at 9:17 a.m. the following was observed in the activity refrigerator:
6. An open bottle of muscle milk that lacked a label or date. The expiration date on the bottle was 1/26/21.
7. An open bottle of chocolate caramel coffee creamer that lacked a date or label. The coffee creamer had an expiration date of 7/29/20.
8. An open package of cheese slices with no date or label.
9. A 74 ounce container of maraschino cherries was open and lacked a date or label.
10. An open bag of mixed nuts dessert topping that lacked a date or label.
11. An open container of Natural Springs hummingbird food that lacked a date or label.
12. A gallon container of orange juice that was open and lacked a date or label. The orange juice had an expiration date of 5/30/21.
At that time, the Activity Director indicated that the items in the refrigerator should have been labeled and dated. The Activity Director indicated that she was responsible for maintaining the activity refrigerator, but she had been very busy, and the refrigerator needed to be cleaned out.
An undated policy, titled Food Safety Requirements was provided on 6/17/21 at 10:14 a.m. The policy stated that .food will also be stored, prepared and served in accordance with professional standards for food service safety . The policy also stated that dry food storage should include keeping foods and beverages in a .clean, dry area off the floor . Practices to maintain safe refrigerated food storage include .labeling, dating, and monitoring refrigerated food, including, but not limited to, leftovers, so it is used by its use-by date, or frozen .
3.1-21(i)(2)
3.1-21(i)(3)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Indiana facilities.
Concerns
- • 42 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Brickyard Healthcare - Woodbridge's CMS Rating?
CMS assigns BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Indiana, 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 Brickyard Healthcare - Woodbridge Staffed?
CMS rates BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Indiana average of 46%.
What Have Inspectors Found at Brickyard Healthcare - Woodbridge?
State health inspectors documented 42 deficiencies at BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER during 2021 to 2025. These included: 1 that caused actual resident harm, 40 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Brickyard Healthcare - Woodbridge?
BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BRICKYARD HEALTHCARE, a chain that manages multiple nursing homes. With 67 certified beds and approximately 52 residents (about 78% occupancy), it is a smaller facility located in EVANSVILLE, Indiana.
How Does Brickyard Healthcare - Woodbridge Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (48%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Brickyard Healthcare - Woodbridge?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Brickyard Healthcare - Woodbridge Safe?
Based on CMS inspection data, BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Brickyard Healthcare - Woodbridge Stick Around?
BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER has a staff turnover rate of 48%, which is about average for Indiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Brickyard Healthcare - Woodbridge Ever Fined?
BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Brickyard Healthcare - Woodbridge on Any Federal Watch List?
BRICKYARD HEALTHCARE - WOODBRIDGE CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.