REHABILITATION CENTER AT HARTSFIELD VILLAGE
Non profit - Corporation
112 Beds
Independent
Data: November 2025
Trust Grade
60/100
#283 of 505 in IN
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Rehabilitation Center at Hartsfield Village has a Trust Grade of C+, which indicates it is slightly above average but still not ideal for families seeking a care facility. It ranks #283 out of 505 nursing homes in Indiana, placing it in the bottom half, but it is #3 out of 20 in Lake County, meaning only two local options are rated better. Unfortunately, the facility is worsening, with the number of identified issues increasing from 13 in 2023 to 14 in 2024. Staffing is a significant strength, receiving a 5/5 star rating with a turnover rate of 30%, which is well below the state average, indicating that staff tend to stay long-term. On the downside, there have been concerning incidents, such as a resident being left with glucose tablets on their nightstand without proper supervision and another resident having an untreated skin tear, highlighting potential gaps in care. Overall, while the facility exhibits strong staffing and a decent trust score, families should weigh these strengths against the identified concerns.
- Trust Score
- C+
- In Indiana
- #283/505
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 30% turnover. Near Indiana's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Indiana facilities.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Indiana. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Bottom 44%
No red flags
13 → 14 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 13 issues
2024: 14 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (30%)
18 points below Indiana average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Indiana average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 30%
15pts below Indiana avg (46%)
Typical for the industry
The Ugly 39 deficiencies on record
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident was assessed to self administer medi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident was assessed to self administer medications for a random observation of a medication left at the bedside. (Resident D)
Finding includes:
On 9/9/24 at 1:53 p.m., Resident D was observed lying in her bed. There was pill in a medication cup on her overbed table. She indicated it was Imodium and the nurse had given it to her.
The resident's record was reviewed on 9/9/24 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to endocarditis, Diabetes Mellitus and anemia.
The Brief Interview for Mental Status assessment, dated 8/31/24, indicated the resident was cognitively intact.
There was not an assessment to self administer medications or a Physician's order to self administer medications.
During an interview on 9/9/24 at 1:58 p.m., the Assistant Director of Nursing (ADON) indicated the resident did not have a self medication assessment and should not have any pills in her room. She entered the room and asked the resident about the medication. The resident indicated it was Imodium and the nurse had given it to her. The ADON removed the medication to verify what it was. She indicated it was an agency nurse on duty and she would speak with her.
The current Pharmaceutical Services Policy indicated, .Residents who have orders for self-administration of medication will have drug delivered by a licensed nurse/QMA
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 F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident's PICC (peripheral inserted central ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident's PICC (peripheral inserted central catheter, a device used to administer medications intravenously) dressing was changed as ordered for 1 of 2 residents reviewed for intravenous care. (Resident B)
Finding includes:
On 9/9/24 at 9:30 a.m., Resident B was observed lying in bed. There was a PICC inserted in his left upper arm. During an interview at that time, QMA 1 indicated the PICC dressing was dated 8/26/24.
The resident's record was reviewed on 9/9/24 at 9:50 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebrae, Parkinson's disease, anemia and weakness.
The admission Minimum Data Set assessment, dated 9/3/24, indicated the resident had significant cognitive impairment and was dependent on staff assistance for toileting and transfers.
A Physician's Order, dated 9/2/24, indicated to change the PICC line dressing every seven days with a transparent dressing.
The September 2024 Treatment Administration Record lacked documentation the PICC dressing had been changed on 9/2/24.
A Progress Note, dated 8/28/24, indicated the resident had been admitted to the facility that day. There was a left upper arm PICC with a dressing dated 8/26/24.
During an interview on 9/9/24 at 9:35 a.m., LPN 1 indicated the dressing was to be changed every seven days, and it was due to be changed that day. The dressing had not been changed since admission.
The document, Care and Maintenance Chart, indicated a PICC dressing should be changed, .On admission, 24 hours after insertion, weekly and PRN (as needed)
This citation relates to Complaint IN00442394.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure infection control measures were in place and im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure infection control measures were in place and implemented related to staff (LPN 1) not donning the appropriate PPE (personal protective equipment) during a dressing change for 1 of 2 residents reviewed for intravenous care. (Resident B)
Finding includes:
On 9/9/24 at 10:41 a.m., LPN 1 was observed changing the PICC (peripheral inserted central catheter) dressing to Resident B's left upper arm. LPN 1 was wearing a face mask and gloves. He did not have a gown on.
There was a sign posted on the resident's door which indicated the resident was on Enhanced Barrier Precautions. All persons entering the room had to sanitize their hands and staff performing direct care were to wear gloves and a gown. There was a PPE bin outside the resident's door with gowns and masks.
During an interview with LPN 1 at the time of the observation, he indicated he thought the sign was for the resident's roommate. LPN 1 then indicated he should have a gown on and donned one at that time.
The resident's record was reviewed on 9/9/24 at 9:50 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebrae, Parkinson's disease, anemia and weakness.
The admission Minimum Data Set assessment, dated 9/3/24, indicated the resident had significant cognitive impairment and was dependent on staff assistance for toileting and transfers.
A Physician's Order, dated 9/2/24, indicated to change the PICC line dressing every seven days with a transparent dressing.
The current policy, Prevention and Management of Multi-Drug Resistant Organisms, indicated, .Enhanced Barrier Precautions .high contact resident care activities: .Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . and, .Gloves and gown prior to the high contact care activity
This citation relates to Complaint IN00442394.
Jun 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to uncovered foley (urinary) catheter bags with urine being seen from t...
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Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to uncovered foley (urinary) catheter bags with urine being seen from the hallway for 1 of 1 residents reviewed for dignity. (Resident 73)
Finding includes:
During random observations on 5/28/24 at 2:52 p.m. and 4:10 p.m., Resident 73 was observed in bed. At those times, his indwelling foley catheter bag was uncovered and hanging on the side of the bed. The urine in the bag could be seen from the hallway.
On 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway.
On 5/30/24 at 9:34 a.m., and 3:00 p.m., the resident's foley catheter bag was uncovered and the urine in the bag could be seen from the hallway.
The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI).
The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter.
A Care Plan, dated 12/17/23, indicated the resident had potential complications related to an urinary indwelling catheter.
Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing (ADON) 1 indicated the foley catheter bag should have been covered in a dignity bag.
The current 1/1/24 Standards of Care for the Resident with an Indwelling Urinary Catheter policy provided by the Administrator on 5/31/24 at 2:25 p.m., indicated the drainage bag was to be covered with a dignity bag.
3.1-3(t)
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to thoroughly investigate and resolve grievances in writing from a resident's family member for 1 of 1 resident reviewed for grievances. (Resi...
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Based on record review and interview, the facility failed to thoroughly investigate and resolve grievances in writing from a resident's family member for 1 of 1 resident reviewed for grievances. (Resident B)
Finding includes:
During an interview with Resident B and her husband on 5/28/24 at 2:57 p.m., they indicated he had a care plan meeting with staff to ensure the staff got his wife dressed and out of bed daily. He indicated the staff left the resident in her room and in the bed several times. Resident B's husband had filed a grievance with the administrator and had not received anything from the staff regarding his complaint. The husband indicated he had requested grievance information and had requested meeting several times to talk about his concerns. The resident's husband also indicated he felt the administrator had avoided responding to him regarding his concerns for his wife's care.
The record for Resident B was reviewed on 5/28/24 at 10:00 a.m. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side,
weakness, dysphagia, oral phase, other lack of coordination, other speech and language deficits following cerebral infarction, unspecified protein-calorie malnutrition, dysphagia following other cerebrovascular disease, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus without complications, hypothyroidism, unspecified, depression, unspecified.
The admission Minimum Data Set (MDS) assessment, dated 4/29/24, indicated the resident was cognitively intact.
Informal notes for resident B, received from the Administrator on 5/31/24 when asked for grievances, indicated the following:
5/6/24: Resident B's husband complained that his wife was in her wheelchair for one hour and spent 23 hours in the bed. He also complained that his wife did not attend the activities because she was in the bed. He stated the CNA told him that she could not transfer his wife unless she was agreeable to the care or transfer. The resident indicated he felt his wife was being kept in bed to make her too tired to attend activities. He also felt the staff did not communicate between shifts. There was no documentation of an investigation, summary, decision of confirmed or not confirmed, corrective action, or date a written decision was issued.
5/8/24: the resident's husband believed the staff continually changed the plan for the resident. Resident B's husband indicated that he wanted more showers for his wife instead of bed baths. The Director of Rehab discussed the involvement of therapy in shower sessions and continually communicated changes to nursing.
5/15/24: a care plan meeting was conducted. Resident B's husband was pleased with the therapy involvement in showers.
5/17/24: Resident B's husband was visibly upset and indicated the CNA's knew nothing about the orders for his wife. The staff attempted to calm Resident B's husband down and were unsuccessful.
5/20/24: Resident B's husband was visibly upset and waiting in the lobby for staff. Resident B's husband indicated the CNA's told him his wife was not scheduled for a shower for that day. Staff confirmed that Resident B's shower days were Monday and Thursday. The staff followed up with Resident B and her husband, and Resident B received her shower for 5/20/24.
5/24/24: Resident B's husband was waiting in the lobby for staff to arrive. Resident B's husband told staff he felt the staff was not listening to him. He began being disruptive and using aggressive language. Security asked Resident B's husband to leave the building until he felt calm enough to visit.
5/27/24: Resident B's husband informed the staff of a concern from Resident B, which related to a dining area attendant. Staff indicated they spoke to Resident B, and Resident B was not familiar with the concern. Staff reassured the resident that they were available if Resident B had any concerns.
5/28/24: the ADON told the Administrator that Resident B expressed to her that she might like to limit visits from her husband. Facility staff offered to help facilitate a conversation with Resident B and her husband. Resident B declined and indicated she would talk to her husband. The administrator reached out to the ombudsman for further support. A message was left and follow up plans were indicated.
5/30/24: the administrator checked in with Resident B and she indicated she was comfortable and had no concerns at this time. The staff indicated that they would continue to monitor the resident.
There was no documentation to indicate written follow up from the facility was provided to Resident B and/or Resident B's representative regarding the concerns and/or grievances filed.
During an interview on 5/31/24 at 4:10 p.m. with the Administrator, she indicated she allowed the staff to have full autonomy when it came to handling the concerns of their residents. She did not keep a grievance log and did not track grievances, she allowed the staff to handle the resolutions for the residents.
During an interview on 6/3/24 at 4:20 p.m. with the Administrator, she indicated Resident B's husband did tell her his concerns, he also emailed his concerns to her, and expressed his desire to schedule a meeting to discuss his concerns.
A Policy titled, Grievance Policy, provided by the Administrator on 6/3/234 at 3:30 p.m., indicated . The facility has named the Administrator or his/her designee as the Grievance Official. The Grievance Official shall oversee the grievance process, receiving, and tracking grievances through to their conclusions. In addition, the Grievance Official shall: Provide written outcomes to the resident/residents representative if requested .
This Federal tag relates to Complaint IN00434235.
3.1-7(a)(2)
3.1-7(a)(3)(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
2. On 5/28/24 at 1:30 p.m., Resident 93 was sitting in his wheelchair in front of the nurse's station. The resident had a Foley catheter and the tubing was observed on the floor.
On 5/28/24 at 2:29 p...
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2. On 5/28/24 at 1:30 p.m., Resident 93 was sitting in his wheelchair in front of the nurse's station. The resident had a Foley catheter and the tubing was observed on the floor.
On 5/28/24 at 2:29 p.m., Resident 93 was observed in the same place. He was watching television by the nurse's station. The Foley catheter tubing remained on the floor.
On 5/28/24 at 3:00 p.m., Resident 93 was observed sitting in his wheelchair in front of the television in the common area. The catheter tubing was observed on the floor.
The record for Resident 93 was reviewed on 5/29/24 at 3:47 p.m. The diagnoses included, but were not limited to, anemia, hypertension (high blood pressure), urinary retention, arthritis, dementia, anxiety, and depression. The resident was dependent with toileting hygiene. The resident had an indwelling catheter.
The admission Minimum Data Set (MDS) Assessment, dated 4/12/24, indicated the resident was not cognitively intact for daily decision making.
A Care Plan, dated 5/15/24, indicated the resident had a potential for complications related to a urinary indwelling catheter.
A Physician's Order, dated 5/15/24, had indicated to insert a Foley catheter related to urinary retention.
During an interview on 5/31/24 at 10:50 a.m., ADON 2 indicated the indwelling foley catheter tubing should not have been on the floor.
A policy titled, Standards of Care for the Resident with an Indwelling Catheter, was provided as current by the Administrator on 5/31/24 at 2:25 p.m. The policy indicated, .Secure the catheter to the patients thigh using a securement device. Hang the collection bag below the level of the bladder to prevent urine reflux to the bladder. To maintain free urinary flow the catheter drainage tube is to be free of kinks .
3.1-41(a)(2)
Based on observation, record review, and interview, the facility failed to ensure foley (urinary) catheter bags and tubing were kept off the floor, for 2 of 2 residents reviewed for catheters. (Residents 73 and 93)
Findings include:
1. During random observations on 5/28/24 at 10:30 a.m. and 11:47 a.m., Resident 73 was observed sitting in a wheelchair. At those times, his indwelling foley catheter bag was observed on the floor under the wheelchair. The catheter tubing was above his waist.
On 5/29/24 at 3:00 p.m., and on 5/30/24 at 3:00 p.m., the resident was observed in bed. At those times, the foley catheter bag was touching the floor.
On 6/3/24 8:50 a.m., the resident was observed sitting in the wheelchair in his room eating breakfast. At that time, the foley catheter bag was in a dignity bag under the wheelchair, however, the tubing was dragging on the floor.
The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI).
The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter.
A Care Plan, dated 12/17/23, indicated the resident had potential complications related to an urinary indwelling catheter. The approaches were to maintain the catheter bag and tubing below the bladder level.
Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention.
Physician's Orders, dated 4/16/24, indicated give Macrobid (an antibiotic) 100 milligrams (mg) daily for chronic UTI.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing (ADON) 1 the foley catheter bag and/or tubing should not have been on the floor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 60)
Finding includes:
On 5/28/2...
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Based on observation, record review, and interview, the facility failed to ensure oxygen was at the correct flow rate for 1 of 1 resident reviewed for oxygen. (Resident 60)
Finding includes:
On 5/28/24 at 1:58 p.m. and 4:05 p.m., Resident 60 was observed in her room. She had oxygen per nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters.
On 5/29/24 at 9:42 a.m. and 1:21 p.m., the resident was again observed in her room with oxygen by the way of a nasal cannula in use. The resident's oxygen concentrator was set at 3 1/2 liters.
On 5/30/24 at 9:40 a.m., the resident was observed in her room. Oxygen per nasal cannula was in use and the oxygen concentrator was set at 3 1/2 liters.
The record for Resident 60 was reviewed on 5/29/24 at 1:34 p.m. Diagnoses included, but were not limited to, pneumonia, emphysema, and congestive heart failure.
The admission Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact and received oxygen therapy.
A Care Plan, dated 5/3/24, indicated the resident required the use of oxygen therapy due to emphysema, congestive heart failure, chronic obstructive pulmonary disease, respiratory failure, pneumonia, and asthma. Interventions included, but were not limited to, oxygen as ordered.
A Physician's Order, dated 5/3/24, indicated the resident was to receive oxygen at 4 liters per minute per nasal cannula continuously every shift.
During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated she would check the resident's oxygen concentrator.
3.1-47(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure blood pressure medication was not administered outside of the physician-ordered parameters for 1 of 5 residents reviewed for unneces...
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Based on record review and interview, the facility failed to ensure blood pressure medication was not administered outside of the physician-ordered parameters for 1 of 5 residents reviewed for unnecessary medications. (Resident 88)
Finding includes:
The record for Resident 88 was reviewed on 5/30/24 at 9:40 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, and anxiety disorder.
The 3/24/24 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making.
Physician's Orders, dated 4/1/24, indicated Verapamil (a medication used to treat chest pain and lower the blood pressure) 120 milligrams (mg) give 60 mg twice a day and hold if the systolic blood pressure (top number) was under 140.
The 4/2024 Medication Administration Record (MAR) indicated the Verapamil 60 mg was administered on the following dates with a blood pressure outside of the ordered parameters:
4/4 at 9:00 p.m. blood pressure of 139/79
4/6 at 9:00 p.m. blood pressure of 122/73
4/7 at 9:00 a.m. blood pressure of 133/74
4/8 at 9:00 a.m. blood pressure of 136/84
4/8 at 9:00 p.m. blood pressure of 130/80
4/9 at 9:00 p.m. blood pressure of 127/89
4/10 at 9:00 a.m. blood pressure of 126/70
4/10 at 9:00 p.m. blood pressure of 122/80
4/11 at 9:00 a.m. blood pressure of 135/81
4/11 at 9:00 p.m. blood pressure of 133/71
4/12 at 9:00 a.m. blood pressure of 122/82
4/12 at 9:00 p.m. blood pressure of 131/79
4/16 at 9:00 p.m. blood pressure of 132/72
4/17 at 9:00 a.m. blood pressure of 130/72
4/20 at 9:00 p.m. blood pressure of 138/83
4/22 at 9:00 p.m. blood pressure of 137/89
4/25 at 9:00 p.m. blood pressure of 131/71
4/26 at 9:00 p.m. blood pressure of 124/79
4/27 at 9:00 a.m. blood pressure of 122/79
4/29 at 9:00 p.m. blood pressure of 133/81
4/30 at 9:00 p.m. blood pressure of 114/83
The 5/2024 MAR indicated the Verapamil 60 mg was administered on the following dates with a blood pressure outside of the ordered parameters:
5/2 at 9:00 p.m. blood pressure of 127/80
5/3 at 9:00 a.m. blood pressure of 128/79
5/5 at 9:00 p.m. blood pressure of 120/70
5/15 at 9:00 p.m. blood pressure of 129/79
5/17 at 9:00 p.m. blood pressure of 113/71
5/20 at 9:00 p.m. blood pressure of 130/77
5/24 at 9:00 a.m. blood pressure of 130/78
During an interview on 5/31/24 at 10:32 a.m., Assistant Director of Nursing 1 indicated nursing staff should have followed the physician's orders for the administration of the Verapamil.
3.1-48(a)(3)
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 record review and interview, the facility failed to maintain clinical records that were complete and accurately documen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented related to dialysis day, dialysis chair time, and dialysis pick up time, for 1 of 1 resident reviewed for dialysis. (Resident 268)
Finding include:
1. The record for Resident 268 was reviewed on 5/28/24 at 1:15 p.m. Diagnoses included, but were not limited to, fracture of nasal bones, subsequent encounter for fracture with routine healing, end stage renal disease, retention of urine, unspecified, dependence on renal dialysis, benign prostatic hyperplasia with lower urinary tract symptoms.
The admission Minimum Data Set (MDS) assessment, dated 5/22/24, was incomplete and in process. The resident was admitted on [DATE].
A Physician's Order, dated 5/22/24, indicated the resident was to receive hemodialysis at [name of] Dialysis Center, on Monday, Wednesday, and Friday. The resident's dialysis pick up time was ordered for 3:00 p.m. The resident's dialysis chair time was ordered for 4:00 p.m.
A Progress Note, dated 5/29/24, indicated the resident received dialysis services on Tuesday, Thursday, and Saturday. The progress notes and the resident's dialysis communication book indicated the resident's dialysis pick up time was signed out at 12:00 p.m., and the resident's dialysis chair time was signed out at 1:00 p.m.
During an interview on 5/31/24 at 2:31 p.m. with Assistant Director of Nursing (ADON) 1, she indicated the resident's dialysis order has not been updated and she would correct the order.
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
2. During a random observation on 5/31/24 at 7:45 a.m., the Wound Nurse was observed standing over Resident 73 finishing a skin treatment. At that time, the Wound Nurse was wearing gloves on both hand...
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2. During a random observation on 5/31/24 at 7:45 a.m., the Wound Nurse was observed standing over Resident 73 finishing a skin treatment. At that time, the Wound Nurse was wearing gloves on both hands. She did not have on an isolation gown. A sign posted on the wall outside of the resident's room indicated enteric/contact isolation: all staff must wash their hands with soap and water and don an isolation gown and gloves prior to entering the room. Another sign posted on the wall indicated enhanced barrier precautions (EBP): if contact was made, a gown and gloves was required prior to touching the resident. A 3 tiered container full of isolation gowns, gloves, and face masks was located right by the resident's room door.
During an interview on 5/31/24 at 7:52 a.m., the Wound Nurse indicated she was aware she needed to wear an isolation gown when performing the wound treatment, however, she was in a hurry this morning.
The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI).
The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling foley catheter.
Physician's Orders, dated 2/12/24, indicated foley catheter 16 French for urinary retention.
Physician's Orders, dated 5/22/24, indicated to cleanse the head of the penis with soap and water and apply triad wound paste every shift.
Nursing Progress Notes, dated 5/24/24 at 2:34 p.m., indicated the resident had 3 foul smelling and mucus filled stool. A new order was obtained to collect a stool specimen.
Nursing Progress Notes, dated 5/26/24 at 1:30 p.m., indicated the doctor was notified the resident tested positive for C-Difficile toxin.
Physician's Orders, dated 5/26/24, indicated contact/enteric isolation.
During an interview on 5/31/25 at 10:50 a.m., Assistant Director of Nursing 1 indicated the Wound Nurse should have donned an isolation gown prior to completing the resident's treatment to his penis area.
The current 1/1/23 Prevention and Management of Multi-Drug Resistant Organisms policy, provided by the Director of Nursing on 6/3/24 at 1:30 p.m., indicated enhanced barrier precautions applied to residents with urinary catheters and gowns and gloves were required for high contact care activity. Contact Precautions applied to residents with infected Multi Drug Resistant Organisms and presence of acute diarrhea.
3.1-18(b)
Based on observation, record review, and interview, the facility failed to ensure infection control practices were in place related to staff failing to sanitize hands in between glove changes for 1 of 1 glucometer use observed and staff failing to donn personal protective equipment (PPE) for a resident in contact precautions during a random infection control observation. (Residents 53 and 73)
Findings include:
1. On 5/29/24 at 4:34 p.m., LPN 1 was preparing to complete a blood sugar check via glucometer for Resident 53. The LPN donned gloves and did not hand sanitize nor wash her hands prior. After obtaining the resident's blood sugar result, the LPN removed her gloves and donned a new pair of gloves, she did not hand sanitize in between glove changes. She proceeded to cleanse the glucometer with a germicidal wipe and she removed her gloves. Again, she did not use hand sanitizer. The LPN prepared the resident's medications and administered them. She sanitized her hands prior to leaving the resident's room.
During an interview on 6/3/24 at 9:47 a.m., Assistant Director of Nursing (ADON) 2, indicated the LPN should have hand sanitized prior to donning her gloves and in between glove changes.
The facility Hand Hygiene policy was provided by the Administrator on 6/3/24 at 10:03 a.m. The policy indicated to decontaminate hands after glove removal and before medication administration.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected multiple residents
4. On 5/28/24 at 10:45 a.m., there were 3 containers of glucose tablets on the resident's night stand next to the bed. The resident indicated she would take them at night if her blood sugar dropped.
...
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4. On 5/28/24 at 10:45 a.m., there were 3 containers of glucose tablets on the resident's night stand next to the bed. The resident indicated she would take them at night if her blood sugar dropped.
On 5/28/24 at 11:50 a.m., glucose tablets were observed in the same place on the resident's nightstand.
On 5/29/24 at 1:00 p.m. and 3:00 p.m., the resident was observed in her room, glucose tablets remained on the nightstand.
On 5/29/24 at 1:37 p.m., the resident was not in her room, the 3 containers of glucose tablets were on the resident's nightstand.
On 5/31/24 at 8:30 a.m., the resident's systane eye drops were not available in the medication cart. The resident indicated the eye drops were in her room but she couldn't give them to herself. The bottle of eye drops was observed on the window ledge. There was no medication label on the bottle and there was no box for the medication in the room. LPN 2 removed the eye drops from the resident's room and indicated she would order a new bottle from the pharmacy
The record for Resident 82 was reviewed on 5/29/24 at 1:00 p.m. The diagnoses included, but were not limited to, diabetes, depression, weakness, Alzheimer's disease, thyroid disorder, and anemia.
The admission Minimum Data Set (MDS) assessment, dated 4/20/24, indicated the resident was cognitively intact for daily decision making. The resident received insulin 7 of 7 days for the last look back period.
A Care Plan, dated 4/14/24, indicated the resident had the potential for hypo/hyperglycemia due to diabetes.
A Physician's Order, dated 4/13/23, indicated to administer a 4-gram glucose chewable tablet as needed for a blood sugar less than 60 with symptoms of hypoglycemia.
A Physician's Order, dated 4/13/23, indicated to administer Systane eye drops once a day in both eyes.
There was no self-medication administration assessment.
There was no Physician order to self-administer medications.
During an interview on 5/30/24 at 1:15 p.m., ADON 1 indicated there were no residents on the unit who were able to self-administer their own medications.
There was no additional information provided.
3.1-11
Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside, for 4 of 4 random observations. (Residents 6, 73, 88, and 82)
Findings include:
1. During random observations on 5/28/24 at 3:50 p.m., 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., and on 5/30/24 at 9:32 a.m., Resident 6 was observed in her room. At those times there was a Breo hand held inhaler, antibiotic ointment cream, and healing ointment cream observed on the window sill.
The record for Resident 6 was reviewed on 5/29/24 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes, COPD, heart disease, high blood pressure, anxiety and depression.
The 4/26/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making.
There was no self-administration of medication assessment located in the clinical record.
The Physician Order Summary for the month of 5/2024 indicated there were no orders for the Breo inhaler or the antibiotic creams. There were no orders for the resident to self-administer her own medication or the healing cream.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications.
2. During random observations on 5/28/24 at 10:30 a.m., 11:47 a.m., 2:52 p.m., and 4:10 p.m., there was a bottle of Nystatin powder observed on Resident 73's night stand.
The record for Resident 73 was reviewed on 5/29/24 at 2:30 p.m. Diagnoses included, but were not limited to, sepsis, high blood pressure, atrial fibrillation, benign prostatic hyperplasia (an enlarged prostate), chronic kidney disease, acute cystitis, and Urinary Tract Infection (UTI).
The 3/23/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making.
There was no self-administration of medication assessment located in the clinical record.
Physician's Orders, dated 4/19/24, indicated Nystatin powder 100,000 unit/gram 1 application topical to scrotum for yeast twice a day upon rising and before bed.
There was no Physician's Order to self-administer his own medications or to leave the medication at the bedside.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications. The Nystatin powder was not supposed to be left in the resident's room.
3. During random observations on 5/28/24 at 10:36 a.m., 11:47 a.m., 2:55 p.m., and 4:10 p.m., 5/29/24 at 8:20 a.m., 1:00 p.m., and 3:00 p.m., and 5/30/24 at 9:35 a.m., there was bottle of Nystatin powder on Resident 88's dresser.
The record for Resident 88 was reviewed on 5/30/24 at 9:40 a.m. Diagnoses included, but were not limited to, heart failure, high blood pressure, and anxiety disorder.
The 3/24/24 admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making.
There was no self-administration of medication assessment located in the clinical record.
Physician's Orders, dated 5/13/24, indicated Nystatin powder 100,000 unit/gram apply to abdominal folds twice a day.
There was no Physician's Order to self-administer her own medications or to leave the medication at the bedside.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated there were no residents on the unit who were able to self-administer their own medications. The Nystatin powder was not supposed to be left in the resident's room.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
4. During random observations on 5/28/24 at 4:00 p.m. and on 5/29/24 at 8:20 a.m., Resident 6 was observed in bed. At those times a bandaid was noted to her left forearm with no date on it. Dried bloo...
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4. During random observations on 5/28/24 at 4:00 p.m. and on 5/29/24 at 8:20 a.m., Resident 6 was observed in bed. At those times a bandaid was noted to her left forearm with no date on it. Dried blood could be seen underneath the bandage.
On 5/29/24 at 1:00 p.m. and 3:00 p.m., the resident was sitting up in her wheelchair beside the bed in her room. The bandaid was no longer there and a skin tear was observed to the left arm. The skin was rolled back and was bloody.
On 5/30/24 at 9:32 a.m., the resident was observed sitting up in the wheelchair in her room. At that time, a clean bandaid was observed over the skin tear.
The record for Resident 6 was reviewed on 5/29/24 at 1:25 p.m. Diagnoses included, but were not limited to, type 2 diabetes, COPD, heart disease, high blood pressure, anxiety and depression.
The 4/26/24 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making.
A Care Plan, dated 4/7/24, indicated the resident was at risk for skin breakdown. The approaches were to notify the nurse and physician of any skin changes and observe the skin with a.m. and p.m. care.
There was no documentation in the nursing progress notes regarding any skin tear to the left forearm.
During an interview on 5/30/24 at 1:15 p.m., Assistant Director of Nursing 1 indicated she was unaware the resident had a skin tear on her left arm. There should have been an assessment of the area and physician's orders to treat and monitor the area.
During an interview on 5/30/24 at 2:00 p.m., the Hospice Nurse indicated the resident had a scab on that arm when she was first admitted , she told the staff to leave it open to air. She was unaware the area had reopened.
Nursing Progress Notes, dated 5/30/24 at 2:11 p.m., indicated a new skin tear was noted on the left forearm that measured 2 centimeters (cm) by 1.6 cm.
Nursing Progress Notes, dated 5/30/24 at 2:34 p.m., indicated the Nurse Practitioner was notified of the new skin tear and orders to cleanse with normal saline and apply an adaptive bandage was ordered.
During an interview on 5/30/24 at 3:00 p.m., RN 1 indicated she had been taking care of the resident today and was unaware she had a skin tear to the left arm. She was not given any information when she came on shift from the night nurse. She measured the skin tear, notified the doctor, family and received an order to treat.
3.1-37(a)
Based on observation, record review, and interview, the facility failed to ensure areas of bruising and skin tears were assessed and monitored for 4 of 6 residents reviewed for skin conditions non-pressure related. (Residents 26, 60, 168, and 6)
Findings include:
1. On 5/29/24 at 9:45 a.m., Resident 26 was observed in her room in bed. An area of reddish purple discoloration was observed on top of the resident's right hand and in between her ring and middle finger. During an interview at that time, the resident indicated she hit her hand on the door frame.
The record for Resident 26 was reviewed on 5/29/24 at 3:56 p.m. Diagnoses included, but were not limited to, Guillain-Barre syndrome and history of falling.
The admission Minimum Data Set (MDS) assessment, dated 5/8/24, indicated the resident had short and long term memory problems and was dependent on staff for transfers.
The 5/2024 Physician's Order Summary (POS) indicated there was no order to monitor the bruising. The resident was to have weekly skin assessments on Wednesday.
There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration.
The weekly skin assessment was signed out as being completed on 5/8, 5/15, 5/22, and 5/29/24 on the 5/2024 MAR. There were special instructions to complete a head to toe assessment and document and measure any bruises or skin tears noted. There was no documentation related to the bruising.
During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed.
A Physician's Order, dated 5/31/24, indicated to monitor the bruise to the right and left third metacarpophalangeal joint until resolved every shift.
2. On 5/29/24 at 9:43 a.m., Resident 60 was observed in her room seated in her chair. A light purple discoloration was observed on the top of her right hand.
The record for Resident 60 was reviewed on 5/29/24 at 1:34 p.m. Diagnoses included, but were not limited to, atrial fibrillation (irregular heartbeat) and hypertensive heart disease with heart failure.
The admission Minimum Data Set (MDS) assessment, dated 5/10/24, indicated the resident was cognitively intact. She needed partial to moderate assistance for transfers.
The 5/2024 Physician's Order Summary (POS) indicated there was no order to monitor the bruising.
There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration.
During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed.
A Physician's Order, dated 5/30/24, indicated to monitor the bruise to the right hand until resolved every shift
Nurses' Notes, dated 5/31/24 at 8:37 a.m., indicated the resident had bruising to the right hand, light purple in color and no pain was noted with tactile stimulation. The resident's family stated the bruise was from a previous IV insertion.
3. On 5/29/24 at 9:36 a.m., Resident 168 was observed in his room seated in a high back wheelchair. The resident was observed with multiple areas of reddish/purple discoloration to his bilateral arms and a dressing was in place to his left upper arm.
The record for Resident 168 was reviewed on 5/29/24 at 2:18 p.m. Diagnoses included, but were not limited to, Parkinson's disease, atrial fibrillation (irregular heartbeat), and anemia.
The 5 day Minimum Data Set (MDS) assessment, dated 5/21/24, indicated the resident was cognitively intact and required partial to moderate assistance with transfers.
A Care Plan, dated 5/14/24, indicated the resident was at risk for complications associated with aspirin and antiplatelet therapy. Interventions included, but were not limited to, observe skin with each encounter for bruising and skin tears.
The admission assessment dated , 5/14/24, indicated the resident had bruises to the left upper arm, left antecubital, left lower arm, left wrist, left hand, right upper arm, right antecubital, front of neck, right side of neck, right elbow, right wrist, and right hand
A Physician's Order, dated 5/20/24, indicated the resident was to have weekly skin assessments on Mondays.
The 5/2024 Physician's Order Summary (POS), indicated there was no order to monitor the bruising and there was no order for the dressing to the left upper arm.
There was no documentation in the nursing progress notes nor on the 5/2024 Medication Administration Record (MAR) related to the discoloration.
During an interview on 5/30/24 at 2:45 p.m., Assistant Director of Nursing (ADON) 1 indicated bruises should have been documented when they were observed.
A Physician's Order, dated 5/30/24, indicated the resident's left arm was to be cleansed with normal saline, pat dry, and apply foam dressing every Monday, Wednesday, and Friday and as needed (PRN).
A Physician's Order, dated 5/30/24, indicated to monitor the bruises to the resident's left forearm every shift until resolved.
A Physician's Order, dated 5/31/24, indicated to monitor the scattered bruising to the resident's right forearm every shift until resolved.
Mar 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the resident's family was notified of a change in condition, for 1 of 3 residents reviewed for notification of change. (Resident H)
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Based on record review and interview, the facility failed to ensure the resident's family was notified of a change in condition, for 1 of 3 residents reviewed for notification of change. (Resident H)
Finding includes:
The record for Resident H was reviewed on 3/19/24 at 4:25 p.m. Diagnoses included, but were not limited to, sepsis, chronic respiratory failure, atrial fibrillation, anemia, heart failure, cirrhosis of the liver, alcohol abuse, and chronic kidney disease.
A Nurse's Note, dated 2/26/24 at 9:31 a.m., indicated the Nurse Practitioner (NP) was notified due to the resident not being easily aroused, and only able to verbalize some words but was very lethargic. The NP indicated she would be in to assess the patient.
A Nurse Practitioner (NP) Progress Note, dated 2/16/24 at 11:03 a.m., indicated the patient was being evaluated for increased lethargy and dyspnea (shortness of breath). Nursing staff indicated the patient refused oral intake this morning, and his breathing appeared labored. Labs were repeated this morning and results were pending. The patient was noted to awaken to verbal stimuli, however he had increased confusion, and respirations were tachypneic (rapid shallow breathing), but did not appear to be in distress.
A Nurse's Note, dated 2/26/24 at 11:59 a.m., indicated the NP was made aware of the resident's hemoglobin of 6.9. A new order was obtained to check his Hemoglobin and Hematocrit stat (immediately).
A Nurse's Note, dated 2/26/24 at 2:51 p.m., indicated the resident was being sent to the emergency room for altered mental status and acute kidney injury.
A Nurses' Note, dated 2/27/24 at 12:43 a.m., indicated the resident was admitted to the hospital with the diagnoses of altered mental status, acute kidney injury, anemia, pneumonia, and hypotension.
The Hospital Transfer Form, dated 2/26/24, indicated the time of transfer was 2:30 p.m., due to altered mental status.
There was no documentation the resident's family was notified of the change of condition and the transfer to the hospital on 2/26/24.
During an interview, on 3/20/24 at 9:15 a.m., the Assistant Director of Nursing indicated nursing staff were supposed to notify the resident's family at the time of the change in status.
During an interview, on 3/20/24 at 12:00 p.m., the Director of Nursing indicated the resident's family was not notified of his change of condition and transfer to the hospital.
This citation relates to Complaint IN00429419.
3.1-5(a)(2)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide appropriate social services follow up, related to an outside allegation of exploitation and misappropriation for a resident by fami...
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Based on record review and interview, the facility failed to provide appropriate social services follow up, related to an outside allegation of exploitation and misappropriation for a resident by family and facility staff, for 1 of 3 residents reviewed for change of condition. (Resident B)
Finding Includes:
During a phone interview, on 3/20/24 at 11:13 a.m., the Adult Protective Services (APS) representative indicated she had contacted the assigned facility Social Worker (SW) regarding Resident B and left voice messages. Detailed voicemails were left for the SW on 1/24/24 at 12:16 p.m. and on 1/25 at 1:52 p.m. The SW called the APS representative back on 1/25/24 at 2:10 p.m. During that call, the APS representative discussed the reports of allegations, which included neglect and financial exploitation of Resident B. A psychiatric evaluation was recommended, APS jurisdiction was explained, and documentation for the current healthcare POA was requested. The facility's fax number was provided by the SW, and on 1/29/24 at 12:33 p.m., APS faxed a blank physician report to be completed and faxed back by the SW. The APS representative indicated they never received any further communication or documentation.
The record for Resident B was reviewed on 3/19/24 at 1:18 p.m. Diagnoses included, but were not limited to, hemiplegia, hypertension (high blood pressure), asthma, dysarthria (difficulty speaking), aphasia (difficulty with comprehension), muscle weakness, protein calorie malnutrition and atrial fibrillation (abnormal heart rhythm).
The 1/26/24 admission Minimum Data Set (MDS) assessment, indicated the resident was severely impaired with daily decision making. The resident had impairments in both upper and lower extremities, used a wheelchair and was dependent with oral hygiene, toileting hygiene, shower and bathing, upper and lower body dressing, and all transfers. Eating required substantial/maximum assistance.
There was no Social Service documentation regarding exploitation and misappropriation allegations.
There was no documentation of communication with the APS representative.
During an interview on 3/19/24 at 3:03 p.m., the Administrator indicated there were no grievances for the last 3 months, and Administration empowers the unit managers to handle concerns as they come up.
During an interview, on 3/20/24 at 10:15 a.m., the Social Service Director (SSD) indicated there was no documentation in Resident B's chart about a concern the resident was being financially exploited or neglected. There was also no documentation of communication with APS. The SW formerly assigned to Resident B no longer worked at the facility.
During an interview, on 3/20/24 at 11:54 p.m., the Director of Nursing indicated she was unaware of the situation.
This citation relates to Complaint IN00427268.
3.1-34(a)
Mar 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
2. Interview with Resident 5 on 3/6/23 at 11:52 a.m., indicated he administered his inhalers himself daily and used the albuterol inhaler as needed for asthma attacks. He indicated he kept the inhaler...
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2. Interview with Resident 5 on 3/6/23 at 11:52 a.m., indicated he administered his inhalers himself daily and used the albuterol inhaler as needed for asthma attacks. He indicated he kept the inhalers in his room all of the time and administered them himself. Two inhalers were noted on the bedside table at that time.
On 3/08/23 at 11:16 a.m., an inhaler was noted laying in Resident 5's bed.
Resident 5's record was reviewed on 3/8/23 at 10:38 a.m. Diagnoses included, but were not limited to, pneumonia, chronic obstructive pulmonary disease (COPD), and asthma.
The admission Minimum Data Set (MDS) assessment, dated 2/10/23, indicated the resident was cognitively intact for daily decision making.
A Care Plan, dated 2/6/23, indicated the resident was at risk for respiratory distress related to a diagnosis of COPD. Interventions included, but were not limited to, administer medications as ordered.
A Physician's Order, dated 2/6/23, indicated albuterol sulfate aerosol inhaler 90 micrograms/actuation, 2 puffs four times a day.
A Physician's Order, dated 2/6/23, indicated Trelegy Ellipta 100-62.5-25 micrograms 1 inhalation once a day.
There was no order for self-administration of medications.
There was no assessment for self-administration of medications.
Interview with the Director of Nursing on 3/10/23 at 1:49 p.m., indicated a self-administration of medication assessment was not completed and he did not have orders to self-administer medications.
3.1-11(a)
Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders and an assessment to self-administer their own medications for 2 of residents reviewed for self-administration of medication. (Residents 148 and 5)
Findings include:
1. On 3/6/23 at 3:10 p.m., Resident 148 was observed in his room in bed. An Albuterol Sulfate inhaler was observed on his over bed table. Interview with the resident at that time, indicated it was his emergency inhaler and he must keep it at his bedside. There was also a jar of Vicks Vapo Rub on the table. The resident also indicated he had Melatonin (an herbal sleep aid) that he was taking and the facility didn't know he had it.
On 3/8/23 at 9:58 a.m., the resident was in his room in bed. The Albuterol inhaler remained on the over bed table, as well as the Vicks Vapo Rub. There was also a bottle of Fluticasone nasal spray on the table. The resident indicated his wife brought it from home.
The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation.
The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process.
Physician's Orders, dated 2/20/23, indicated the resident was to receive an Albuterol Sulfate HFA aerosol inhaler 90 micrograms (mcg)/actuation, 2 puffs every 4 hours as needed (prn) for wheezing and Flonase Allergy relief spray 50 mcg, 2 sprays to each nare daily. There was no order for the medications to be left at the bedside for self-administration.
There was also no Physician's Order for the Vicks Vapo Rub or Melatonin.
There was no self-administration of medication assessment completed.
Interview with the Director of Nursing on 3/10/23 at 2:00 p.m., indicated the resident's medications should not have been left at the bedside.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 1 of 24 residents whose MDS assessments were reviewed. (Resident 17)
Find...
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Based on record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment timely for 1 of 24 residents whose MDS assessments were reviewed. (Resident 17)
Finding includes:
The record for Resident 17 was reviewed on 3/8/23 at 10:34 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dementia without behavior disturbance.
The Quarterly Minimum Data Set (MDS) assessment, dated 2/2/23, was in process. The Quarterly assessment was not signed as completed by the MDS Coordinator until 3/9/23.
The previous Quarterly MDS assessment, was dated 11/2/22.
Interview with the MDS Coordinator on 3/8/23 at 3:18 p.m., indicated she was aware the Quarterly assessments were late.
3.1-31(d)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure dependent residents were provided assistance w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure dependent residents were provided assistance with activities of daily living (ADLs) related to shaving for 1 of 6 residents reviewed for ADLs. (Resident 247)
Finding includes:
On 3/6/23 at 2:39 p.m., Resident 247 was observed sitting in her wheelchair in her room. There was facial hair noted along her chin.
On 3/8/23 at 11:08 a.m., Resident 247 was observed sitting in her wheelchair in her room. There was facial hair noted along her chin.
Resident 247's record was reviewed on 3/8/23 at 2:52 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, fracture of nasal bones, syncope and collapse, and hypothyroidism.
The admission Minimum Data Set (MDS) assessment indicated it was still in progress.
A Nurses' Note, dated 3/3/23 at 1:07 p.m., indicated the resident was able to make needs known and required extensive assistance with ADL care.
The Shower Day Skin Audit, dated 3/7/23, indicated the resident received a bed bath.
There was no documentation of facial shaving offered to the resident.
Interview with the Administrator and the Director of Nursing on 3/10/23 at 9:52 a.m., indicated they had no further information to provide.
3.1-38(a)(3)(D)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 5 residents reviewed for skin conditions (non-pressure related)...
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Based on observation, record review, and interview, the facility failed to ensure areas of bruising were assessed and monitored for 1 of 5 residents reviewed for skin conditions (non-pressure related). (Resident 148)
Finding includes:
On 3/6/23 at 3:10 p.m., Resident 148 was observed in his room in bed. The resident had a reddish/purple discoloration to both of his hands.
On 3/8/23 at 9:58 a.m., the resident was observed in his room in bed. The resident had a pink foam dressing to his left forearm as well as a large area of reddish/purple discoloration to the forearm. The discoloration to the resident's hands also remained.
The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation.
The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process.
A Care Plan, dated 2/20/23, indicated the resident was at risk for complications associated with Xarelto (an anticoagulant) therapy. Interventions included, but were not limited to, observe skin with each encounter for bruising and skin tears.
Physician's Orders, dated 2/20/23, indicated the resident was to receive Xarelto 20 milligrams (mg) daily and the bruising to the resident's bilateral arms was to be monitored every shift.
The Treatment Administration Record (TAR) for the dates of February 20 through March 10, 2023, indicated the bruising had not been monitored each shift 2/20-3/6/23.
Interview with the Director of Nursing on 3/10/23 at 1:00 p.m., indicated documentation related to monitoring the bruising to the bilateral arms was not started until 3/7/23.
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure preventative measures were in place related to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure preventative measures were in place related to offloading a resident's foot to prevent further pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident 195)
Finding includes:
Interview with Resident 195 and a previous caregiver for the resident on 3/6/23 at 3:03 p.m., indicated she had an open sore on her heel. The caregiver indicated her foot was never offloaded and was always laying directly on the bed. The resident was currently observed sitting in a wheelchair and her right leg/foot was propped up on the leg rest with a pillow underneath.
On 3/7/23 at 9:40 a.m. the resident was observed lying in bed and her right foot was laying directly on the mattress. It was not offloaded.
On 3/9/23 at 8:02 a.m., until 10:05 a.m., the resident was observed lying in bed and her right foot was laying directly on the mattress. It was not offloaded. At 10:35 a.m., both Wound Nurses were observed during the pressure ulcer treatment. The resident's right heel was observed with a large black Deep Tissue Injury (DTI). There was no drainage noted.
The record for Resident 195 was reviewed on 3/8/23 at 10:50 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, anemia, heart failure, type 2 diabetes, fracture of the right femur, and history of falls.
The admission Minimum Data Set (MDS) assessment, dated 2/24/23, indicated it was still in process.
A Care Plan, dated 2/18/23, indicated the resident was admitted with a DTI to the right heel.
Physician's Orders, dated 2/19/23, indicated Venelex ointment apply a thin layer to the right heel after cleansing with normal saline and pat dry daily and prn.
The Wound Information Assessments indicated on 2/18/23, the right heel DTI measured 4.5 centimeters (cm) by 4.5 cm and was dark purple in color. The most recent measurement on 3/7/23, indicated the DTI remained dark purple in color and was hard to touch. The ulcer remained closed and measured 4.5 cm by 4.5 cm.
Interview with both Wound Nurses on 3/89/23 at 10:45 a.m., indicated the right heel should be offloaded at all times while in bed. The foot should not be directly laying on the bed.
The current 1/1/22 Skin Prevention Plan policy, provided by the Administrator on 3/10/23 at 10:04 a.m., indicated interventions included, but were not limited to, suspend heels with pillows under the calf or use off-loading devices and recheck frequently.
3.1-40(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor a resident's urine output after an indwelling foley cathete...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor a resident's urine output after an indwelling foley catheter was removed to prevent reoccurrence for 1 of 3 residents reviewed for bowel and bladder incontinence. (Resident B)
Finding includes:
The closed record for Resident B was reviewed on 3/9/23 at 3:14 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, urinary tract infection, chronic kidney disease, and hydronephrosis (the swelling of one or both kidneys).
The admission Minimum Data Set (MDS) assessment, dated 11/4/22, indicated the resident was moderately impaired for decision making. The resident was an extensive assist with a 2 person physical assist for bed mobility and toilet use. She had an indwelling foley catheter.
Nurses' Notes, dated 10/19/22 at 7:34 a.m., indicated the resident arrived to the facility around 6:35 p.m. The resident was admitted to the facility for therapy following hospitalization for a fall at home resulting in a right femur fracture. The resident had a foley catheter, 18 French with a 10 cubic centimeters (cc) bulb in place that was due to be removed on 10/21/22.
Nurses' Notes, dated 10/21/22 at 6:26 a.m., indicated at 5:14 a.m., the foley catheter was removed.
Nurses' Notes, dated 10/21/22 at 12:50 p.m., indicated the foley catheter was removed this morning and the resident had been voiding without difficulty. The resident denied pain or discomfort to the abdomen.
Nurses' Notes, dated 10/21/22 at 7:52 p.m., indicated the resident had complaints of generalized pain but not to the abdomen. The resident continued to void without difficulty.
There was no documentation in Nursing Progress Notes on 10/23, 10/24, 10/25, 10/26, and 10/27/22 of the resident being incontinent or continent of urine or even voiding without difficulty after the indwelling foley catheter was removed.
The urine output log indicated nothing was documented on 10/19, 10/20, 10/21, 10/23, 10/24, 10/25, 10/27, and 10/28/22.
On 10/22/22 at 3:09 a.m., a large amount of urine output was recorded and on 10/26/22 at 8:22 a.m., a large amount of urine output was recorded.
Nurses' Notes, dated 10/28/22 at 8:25 p.m., indicated during a wound assessment, the Wound Nurse noted the resident had foul smelling urine. The Nurse Practitioner (NP) was notified and orders were obtained for an urinalysis and culture.
Nurses' Notes, dated 10/28/22 at 10:02 p.m., indicated the resident urinated in the bed pan, however, it was contaminated with bowel movement. The resident was straight cathed for the urine specimen. Urine started coming out and reached 1400 cc before it was stopped by the nurse. The Physician was notified and orders were received to anchor an indwelling foley catheter for urinary retention.
The urine output log indicated the following:
- 10/29/22 large amount of urine.
- 10/30/22 large amount of urine.
- 10/31/22 850 cc of urine
- 11/1/22 large amount of urine.
- 11/2/22 1000 cc of urine at 2:02 p.m. and a large amount at 8:17 p.m.
- 11/3/22 700 cc of urine
- 11/5/22 a large amount of urine.
There was no documentation of any urine output on 11/4, 11/6 or 11/7/22.
Physician's Orders, dated 11/2/22, indicated Cephalexin (an antibiotic) 500 milligrams (mg) 1 tab every 6 hours for a Urinary Tract Infection.
Nurses' Notes, dated 11/7/22 at 2:09 p.m., indicated the resident had increased confusion and increased complaints of pain. This afternoon the writer was informed by the CNA the resident had no urine output for the shift. After the writer was informed about the urine, the therapist notified the writer the resident was not herself, and after they attempted to sit the resident to the side of the bed she turned pale. The resident was having labored breathing, and had complaints of abdomen pain. The resident was sent out 911 to the hospital.
The resident returned to the facility on [DATE].
An NP (Nurse Practitioner) Progress Note, dated 11/16/22 at 10:17 p.m. indicated the patient was sent to the hospital on [DATE] with a chief complaint of shortness of breath and tachycardia. Supplemental oxygen was applied at 4 liters via nasal cannula. A Cat Scan (CT) of the abdomen/pelvis showed severely distended bladder with bilateral hydronephrosis.
Interview with the Director of Nursing on 3/10/23 at 1:30 p.m., indicated urine output for foley catheters did not need to be documented. There was documentation the resident was voiding without difficulty on 10/21/22 after the catheter was removed and the resident did urinate on 10/28/22 as the urine was foul smelling. The facility has no policy for intake and output documentation in general and for indwelling foley catheters.
This Federal tag relates to Complaint IN00395647.
3.1-41(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the meal consumption logs were completed for a resident with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the meal consumption logs were completed for a resident with a history of weight loss for 1 of 1 residents reviewed for nutrition. (Resident 37)
Finding includes:
The record for Resident 37 was reviewed on 3/8/23 at 10:01 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, adult failure to thrive, protein calorie malnutrition, respiratory failure, COPD, heart failure, and dependence on supplemental oxygen.
The admission Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was not cognitively intact and needed supervision with set up assistance with eating. The resident had no oral problems, weighed 108 pounds, and was receiving a therapeutic diet.
A Care Plan, dated 2/16/23, indicated the resident may need supervision to eat and drink at times. The approaches were to monitor and record intake of food/fluids.
A Care Plan, dated 2/9/23, indicated the resident received a regular with no added salt diet. The approaches were to monitor intake, weight, and labs.
An RD's (Registered Dietitian) assessment, dated 2/8/23, indicated the resident weighed 108 pounds at the time of admission. The resident had a Body Mass Index of 19.8 and a score of a 5 (meaning malnourished) on the Nestle Nutrition MNA (mini nutritional assessment). Recommend addition of mighty shakes twice a day with lunch and dinner.
Physician's Orders, dated 2/9/23, indicated mighty shakes for lunch and dinner and weekly weight times 4 weeks.
The weekly weights were 108 pounds on 2/14/23, 100 pounds on 2/22/23, 101 pounds on 3/1/23 and 107 pounds on 3/7/23.
The meal consumption log indicated breakfast was not recorded on 2/11-2/13, 2/21, 2/23-2/27, 3/1, 3/4, 3/6, and 3/7/23. Lunch was not recorded on 2/11-2/13, 2/20, 2/21, 2/23-2/28, 3/1, 3/4. 3/5, 3/6, and 3/7/23 and dinner was not recorded on 2/9-2/13, 2/18, 2/20-2/22, 2/24-2/28, 3/2, 3/3, 3/5, and 3/7/23.
Interview with the Director of Nursing on 3/10/23 at 10:00 a.m., indicated food consumption should be completed after every meal.
3.1-46(a)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed as per Physician's O...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure oxygen tubing was changed as per Physician's Orders and facility policy for 2 of 3 residents reviewed for oxygen therapy. (Residents 37 and 206)
Findings include:
1. On 3/6/23 at 2:25 p.m., 3/7 at 10:11 a.m., and 3/8 at 9:45 a.m., Resident 37 was observed sitting in a wheelchair in her room. At those times, the oxygen tubing and humidification bottle was dated 2/20/23. The resident indicated she wore oxygen at night time.
On 3/9/23 at 8:03 a.m., the resident was observed in bed with her eyes closed. At that time she was wearing oxygen at 2 liters per minute via nasal cannula.
The record for Resident 37 was reviewed on 3/8/23 at 10:01 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, adult failure to thrive, protein calorie malnutrition, respiratory failure, COPD, heart failure, and dependence on supplemental oxygen.
The admission Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was not cognitively intact and received oxygen while a resident.
A Care Plan, dated 2/9/23, indicated the resident was at risk for respiratory distress related to the diagnosis of COPD. The approach was to change oxygen tubing weekly.
Physician's Orders, dated 2/8/23, indicated change oxygen tubing and humidifier bottle every week.
Physician's Orders, dated 2/23/23, indicated oxygen 2 liters per nasal cannula continuously at bed time and prn.
The Treatment Administration Record (TAR) for 2/2023 indicated the oxygen tubing was signed out as being completed on 2/19, 2/26, and 3/5/23. Oxygen therapy was signed out as being administered at 9:00 p.m., 2/23-3/6/23.
Interview with the Respiratory Therapist on 3/9/23 at 10:45 a.m., indicated the oxygen tubing was to be changed every week. She changed the resident's oxygen tubing today as it was dated 2/20/23.
Interview with the Director of Nursing on 3/10/23 at 1:30 p.m., indicated the oxygen tubing was to be changed weekly.
2. On 3/6/23 at 3:30 p.m., 3/7 at 9:45 a.m., 3/8 at 10:19 a.m. and 2:15 p.m., and on 3/9/23 at 7:48 a.m., the oxygen tubing and humidification bottle was dated 2/27/23 for Resident 206.
The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE].
Diagnoses included, but were not limited to fracture of the right humerus, Alzheimer's disease, and acute respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment, dated 3/3/23 was still in progress.
There was no Care Plan for oxygen therapy.
Physician's Orders, dated 2/24/23, indicated change oxygen tubing and humidifier bottle every week.
Physician's Orders, dated 2/24/23, indicated oxygen at 4 liters nasal cannula continuously every shift. The order was discontinued on 3/6/23 and a new order dated 3/6/23 for oxygen at 2 liters prn was obtained.
The Treatment Administration Record (TAR) for 3/2023, indicated the oxygen tubing was signed out as being changed on 3/5/23.
Interview with the Respiratory Therapist on 3/9/23 at 10:45 a.m., indicated the oxygen tubing was to be changed every week.
The current 1/1/22 Oxygen Therapy policy, provided by the Administrator on 3/10/23 at 9:54 a.m. indicated cannula and tubing should be changed weekly or more frequently if grossly soiled or becomes contaminated.
3.1-47(a)(6)
CONCERN
(D)
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 record review and interview, the facility failed to manage medications appropriately related to medications not adminis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage medications appropriately related to medications not administered as ordered by the physician and the side effects of opioid medication not monitored for 2 of 5 residents reviewed for unnecessary medication. (Residents 191 and 206)
Findings include:
1. During an interview with Resident 191 on 3/6/23 at 3:51 p.m., he indicated he goes to dialysis on Tuesdays, Thursdays, and Saturdays. He indicated his chair time was 7:00 a.m.
The record for Resident 191 was reviewed on 3/9/23 at 1:55 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, absence of toes, type 2 diabetes, diabetic neuropathy, end stage renal disease, hypertensive chronic kidney disease, anemia, and dependence on renal dialysis.
The admission Minimum Data Set (MDS) assessment was still in process.
Physician's Orders, dated 2/28/23, indicated Clopidogrel 75 milligrams (mg) daily at 9 a.m. and Carvedilol 25 mg 1 tablet twice a day 9:00 a.m. and 9:00 p.m.
The 3/2023 Medication Administration Record (MAR) indicated the resident missed the 9:00 a.m. dose of both medications on 3/2, 3/4, and 3/7/23 (dialysis days)
Interview with the Director of Nursing on 3/10/23 at 1:30 p.m., indicated she called dialysis and they would like those medications held on dialysis days. There was no order to hold the medications prior to today.
2. The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE].
Diagnoses included, but were not limited to, fracture of the right humerus, Alzheimer's disease, and acute respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment, dated 3/3/23 was still in progress.
A Care Plan, dated 2/24/23, indicated the resident had the potential for constipation related to decreased mobility and medication side effects. The goal was for the resident to have a bowel movement 1 time every 3 days. The approaches were to document all bowel movements in point of care and administer stool softeners per orders.
A Care Plan, dated 2/24/23, indicated the resident had potential for pain related to right humerus fracture. The approaches were to administer medications as needed and report adverse side effects.
Physician's Orders, dated 2/24/23, indicated Hydrocodone (a narcotic pain medication) 5-325 milligrams (mg) every 6 hours PRN (as needed) and Docusate Sodium (a stool softener) 100 mg twice a day PRN.
Physician's Orders, dated 2/28/23, indicated Hydrocodone 5-325 mg daily at 9 a.m.
The Medication Administration Record (MAR) for 2/2023 indicated the resident received a PRN Hydrocodone 5-325 mg tablet on 2/26/23 at 4:20 p.m. and on 2/27/23 at 8:21 p.m. The Docusate tablet PRN was not signed out as being administered 2/24-2/28/23.
The 3/2023 MAR, indicated the PRN Hydrocodone 5-325 mg was signed out as being administered on 3/1/23 at 7:22 p.m. and on 3/4/23 at 5:32 p.m. The routine dose of Hydrocodone was signed out as being administered 3/1-3/7/23 at 9:00 a.m. The PRN Docusate was not signed out as being administered on 3/1/23.
Nurses' Notes, dated 3/3/23 at 4:19 p.m., indicated the resident had complaints of constipation that morning and was observed trying to dig bowel movement (bm) from her rectum. The NP was notified and gave new orders for Lactulose 30 cubic centimeters (cc) daily as needed as well as Bisacodyl suppository daily as needed.
The bowel movement log indicated the only documented bowel movements from the time the resident was admitted until 3/9/23 were on 3/1 and 3/3/23 which indicated the resident had a large bm. None was recorded on 3/6 and 3/9/23.
There were no other bowel movements documented in the log or Nursing Progress Notes.
Interview with the Director of Nursing on 3/10/23 at 1:45 p.m., indicated she had interviewed some CNAs and they told her the resident had a bowel movement on 3/6 and 3/8/23 in the evening. She was going to inservice Nursing staff to ensure stool softeners were routinely scheduled for residents receiving narcotic pain medication.
3.1-48(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE].
Diagnose...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE].
Diagnoses included, but were not limited to fracture of the right humerus, Alzheimer's disease, and acute respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment, dated 3/3/23 was still in progress.
A Care Plan, dated 2/24/23, indicated the resident was at risk for having changes in her mood. The resident was prescribed Alprazolam (an anti-anxiety medication) and Risperidone (an antipsychotic medication)
Physician's Orders, dated 2/24/23, indicated Alprazolam 0.25 milligrams (mg) twice a day PRN. The medication was discontinued on 3/7/23.
Physician's Orders, dated 3/7/23, indicated Alprazolam 0.25 mg twice a day PRN.
The Medication Administration Record (MAR) for the month of 2/2023 indicated, on 2/27/23 at 4:08 p.m., the resident received the Alprazolam for the reason of other.
The 3/2023 MAR indicated the resident received the Alprazolam on 3/4/23 at 5:32 for a behavior issue.
There was no documentation in Nursing Progress Notes on 2/27 or 3/4/23 of any interventions tried prior to the administration of the PRN anti-anxiety medication.
Interview with the Director of Nursing on 3/10/23 at 1:45 p.m., indicated there was no documentation of what was tried prior to the administration of the Alprazolam.
3.1-48(a)(4)
Based on record review and interview, the facility failed to ensure there was an indication for the use and interventions were attempted prior to administering an as needed (PRN) anti-anxiety medication for 2 of 5 residents reviewed for unnecessary medications. (Residents 148 and 206)
Findings include:
1. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation.
The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process.
A Physician's Order, dated 2/28/23, indicated the resident was to receive Xanax (an anti-anxiety medication) 0.25 milligrams (mg) three times a day as needed (PRN) for anxiety.
The March 2023 Medication Administration Record (MAR) indicated the resident received the prn Xanax on 3/2 at 10:01 a.m. and 8:36 p.m., 3/3 at 9:21 p.m., 3/4 at 8:22 p.m., and 3/6/23 at 5:03 a.m. and 8:55 p.m. The PRN reason was coded as O other. There was no documentation in the nursing progress notes or elsewhere of why the medication was given.
Interview with the Director of Nursing on 3/13/23 at 11:20 a.m., indicated documentation should have been completed indicating why the PRN Xanax was given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications were labeled for 2 of 4 medication carts observed. (A-100 & D-200 carts)
Findings include:
1. On 3/10/23 at 12:24 p.m., t...
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Based on observation and interview, the facility failed to ensure medications were labeled for 2 of 4 medication carts observed. (A-100 & D-200 carts)
Findings include:
1. On 3/10/23 at 12:24 p.m., the A-100 Cart was reviewed with RN 1. There was a stack of Lidocaine 5% patches in a drawer unlabeled. The nurse was unable to find the original label/box. She indicated the box did not fit in the drawer so they had torn off a section of the box that contained the label which indicated whose patches they were. The label section of the box was not found in the cart.
2. On 3/13/23 at 9:55 a.m., the D-200 Cart was reviewed with Agency LPN 1. A bottle of fleet suppositories and a bottle of Tylenol 650 milligrams were in the cart drawer with no labels on either of the bottles. Agency LPN 1 indicated each bottle should have a label with the patient name and the order on them.
Interview with the Director of Nursing on 3/13/23 at 10:19 a.m., indicated she had no further information to provide.
3.1-25(j)
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, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to ensuring multi-use equipment was disinfected aft...
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Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented related to ensuring multi-use equipment was disinfected after resident use for random observations for infection control. (Residents 198 and 52)
Findings include:
1. During a random observation on 3/6/23 at 2:12 p.m., Agency LPN 1 was observed checking Resident 198's blood pressure with a wrist cuff. After obtaining the blood pressure reading, the LPN put the wrist cuff back into a pouch that was around her waist and left the room. She walked out to her medication cart and proceeded to prepare and pour medications for another resident. She did not sanitize the blood pressure cuff.
Interview with Agency LPN 1 at 2:17 p.m., indicated she had forgotten to clean the wrist blood pressure cuff after she used it for the resident.
2. During a random observation on 3/6/23 at 2:37 p.m., CNA 1 was observed checking Resident 52's vital signs with a multi-use blood pressure machine and cuff on wheels. After completing the resident's vital signs check, he pushed the machine towards the medication cart and plugged it into the wall. He did not sanitize or clean the machine after he was finished.
On 3/9/23 at 7:49 a.m., Agency LPN 2 was observed checking vital signs for a resident in the hallway. She checked the resident's blood pressure using a multi-use machine on wheels. After finishing with the resident's vital signs check, she placed all of the equipment back in the basket and documented the information in the computer and went onto the next resident. She did not sanitize the machine.
Interview with Agency LPN 2 on 3/9/23 at 8:30 a.m., indicated she was aware the machine was to be sanitized after each resident.
Interview with the Director of Nursing on 3/13/23 at 10:00 a.m., indicated multi-use blood pressure cuffs should be cleaned after resident contact.
The current 1/1/21, Reusable Medical Equipment policy, provided by the DON on 3/13/23 at 10:20 a.m., indicated all reusable medical equipment should be cleaned and disinfected when visibly soiled and between patient use.
3.1-18(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 12's record was reviewed on 3/8/23 at 3:06 p.m.
The admission Minimum Data Set (MDS) assessment, dated 2/16/23, was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 12's record was reviewed on 3/8/23 at 3:06 p.m.
The admission Minimum Data Set (MDS) assessment, dated 2/16/23, was still in process.
Interview with the MDS Coordinator on 3/8/23 at 3:18 p.m., indicated she was aware the admission MDS assessments were late.
3.1-31(d)(1)
2. The record for Resident 206 was reviewed on 3/9/23 at 8:21 a.m. The resident was admitted to the facility on [DATE].
Diagnoses included, but were not limited to fracture of the right humerus, Alzheimer's disease, and acute respiratory failure with hypoxia.
The admission Minimum Data Set (MDS) assessment, dated 3/3/23, indicated it was still in progress. The MDS was still not completed on 3/13/23.
3. The record for Resident 37 was reviewed on 3/8/23 at 10:01 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, adult failure to thrive, protein calorie malnutrition, respiratory failure, COPD, heart failure, and dependence on supplemental oxygen.
The admission Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was not cognitively intact. The assessment was signed by the RN Coordinator as being completed on 2/24/23.
4. The record for Resident 198 was reviewed on 3/8/23 at 12:25 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, hip replacement.
The admission Minimum Data Set (MDS) assessment, dated 2/23/23, indicated it was still in process and not completed. The RN Coordinator signed the MDS as being completed on 3/10/23.
5. The record for Resident 195 was reviewed on 3/8/23 at 10:50 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, anemia, heart failure, type 2 diabetes, fracture of the right femur, and history of falls.
The admission Minimum Data Set (MDS) assessment, dated 2/24/23, indicated it was still in process. The MDS should have been completed by 3/10/23.
Interview with the MDS Coordinator on 3/8/23 at 3:18 p.m., indicated she was aware the admission MDS assessments were late.
Interview with the Administrator on 3/8/23 at 3:30 p.m., indicated she was aware the MDS assessments were late and not completed. There was an ad for another MDS Coordinator on several job sites, however they had no applicants as of yet.
Based on record review and interview, the facility failed to ensure the admission Minimum Data Set (MDS) assessment was completed within 14 days of admission for 6 of 24 MDS assessments reviewed. (Residents 148, 206, 37, 198, 195, & 12)
Findings include:
1. The record for Resident 148 was reviewed on 3/9/23 at 2:01 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertensive chronic kidney disease, and orthopedic aftercare following surgical amputation. The resident was admitted to the facility on [DATE].
The admission Minimum Data Set (MDS) assessment, dated 2/27/23, was still in process. Sections B, E, G, GG, H, I, L, N, O, and P had not been completed.
Interview with the MDS Coordinator on 3/8/23 at 3:20 p.m., indicated she was aware the MDS assessments were late.
Sept 2019
12 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
Based on observation, record review, and interview, the facility failed to ensure residents received reasonable accommodations related to a call light not being within reach for 1 of 1 random observat...
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Based on observation, record review, and interview, the facility failed to ensure residents received reasonable accommodations related to a call light not being within reach for 1 of 1 random observations. (Resident 248)
Finding includes:
On 9/9/19 at 11:14 a.m., Resident 248 was observed in her room seated in a wheelchair. She was positioned on the right side of her bed near the window. The call light button was observed wrapped around the assist rail on the opposite side, out of her reach. Interview at the time with the resident indicated she was not able to reach her call light and would like to be assisted back to bed. She had been to therapy earlier that morning, and when she was transported back to her room she was not positioned near her call light and/or personal items including the phone. She had no way to ask for assistance other than to yell out. This was not the first time she had been returned to her room after completing therapy and had to wait for hours before she was assisted back to bed, which caused soreness to her buttock and back.
The record for Resident 248 was reviewed on 9/16/19 at 11:33 a.m. Diagnoses included, but were not limited to, epidural hemorrhage, hypertension, and falls.
The admission Minimum Data Set (MDS) assessment, dated 8/27/19, indicated the resident was cognitively intact for decision making, she required extensive 1 person physical assistance with transfers and had a lower extremity impairment on 1 side.
A Care Plan, dated 9/2/19, indicated the resident required assistance to transfer safely due to physical limitations after a hospital stay for a subdural hematoma and a left ankle fracture which required ORIF (open reduction and internal fixation) due to a fall. Interventions included, but were not limited to, keep call light in reach at all times and remind resident as needed to not attempt transfers without assistance.
Interview with the Director of Nursing on 9/16/19 at 2:25 p.m., indicated the resident's call light should have been placed within her reach each time she was escorted back to her room from therapy.
3.1-3(v)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess and monitor residents with signs and symptoms of constipatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess and monitor residents with signs and symptoms of constipation for 2 of 2 residents reviewed for constipation. (Residents 41 and 86)
Findings include:
1. During an interview with Resident 41's daughter on 9/9/19 at 10:55 a.m., indicated her mom received a stool softener nightly, however, she had trouble having a bowel movement and sometimes goes longer than 3 days.
The record for Resident 41 was reviewed on 9/12/19 at 1:54 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, end stage renal disease with dependence on renal dialysis, major depressive disorder, hypothyroidism, type 2 diabetes mellitus with diabetic neuropathy, and high blood pressure.
The admission Minimum Data Set (MDS), dated [DATE], indicated the resident's cognition was not assessed. The resident was frequently incontinent of bowel and had no signs of constipation.
The Care Plan, dated 8/11/19, indicated the resident had the potential for constipation related to decreased mobility and medication side effect. The goal was for the resident to have at least one bowel movement every three days. The approaches were to administer stool softener/laxatives per orders and to document all bowel movements in the point of care.
Physician's Orders, dated 9/5/19, indicated Amitiza (lubiprostone) (a medication used to treat chronic constipation) 8 micrograms (mcg) twice a day at 9:00 a.m. and 9:00 p.m., Lactulose (a laxative used to treat constipation) 10 grams/15 milliliters (ml) administer 15 ml twice a day prn (as needed) for constipation Miralax (polyethylene glycol 3350) powder (a laxative used to treat constipation) 17 gram/dose administer 17 grams once a day and Senna (a laxative used to treat constipation) 8.6 milligrams (mg) 1 tablet twice a day prn constipation.
The bowel movement (bm) record indicated the resident did not have a bowel movement on 8/25, 8/26, 8/27, and 8/28/19. A large bm was recorded on 8/29/19. There was no documentation recorded at all on 8/30 and 8/31/19. The resident had no bm on 9/1, 9/2, and 9/3/19. A medium bm was recorded on 9/4/19. The resident had no bm on 9/6 and 9/9 and there was no documentation at all on 9/7 and 9/8/19. A large bm was recorded on 9/10/19.
The Medication Administration Record (MAR), dated 8/9-8/31/19, indicated the lactulose 10 grams/15 ml twice a day prn and the Senna 8.6 mg twice a day prn constipation were not signed out as being administered.
The MAR for 9/2019 indicated the lactulose 10 grams/15 ml twice a day prn and the Senna 8.6 mg twice a day prn constipation were not signed out as being administered.
Interview with the Director of Nursing on 9/16/19 at 9:00 a.m., indicated the resident did not have a bowel movement at least every three days and the facility did not have a bowel protocol policy.
2. During an interview with Resident 86 on 9/10/19 at 10:23 a.m., he indicated he was constipated. There were times where it had been longer than 3 days to have a bowel movement (bm).
The record for Resident 86 was reviewed on 9/11/19 at 10:50 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, lung cancer, atrial fibrillation, high blood pressure, type 2 diabetes mellitus, and hypothyroidism.
The admission Minimum Data Set (MDS) assessment, dated 8/23/19, indicated the resident was alert and oriented. The resident needed extensive assist with 2 person physical assist for toileting and was frequently incontinent of bm.
The Care Plan, dated 8/16/19, indicated the resident had the potential for constipation related to decreased mobility and medication side effects. The goal indicated the resident will have at least 1 bm every 3 days. The approaches were to administer stool softeners and/or laxative per orders and document all bowel movements in point of care.
Physician's Orders, dated 8/16/19, indicated Docusate (a stool softener) 100 mg (milligrams) twice a day and Lactulose (a laxative used to treat constipation) 10 grams/15 ml prn (as needed) constipation.
Physician's Orders, dated 9/3/19, indicated Docusate Sodium 100 mg 1 tablet daily for constipation, Senna plus (a laxative used to treat constipation) 8.6-50 mg at night time for constipation and Bisacodyl 10 mg rectal suppository prn for constipation.
The bowel movement record indicated the resident did not have a bm on 8/31, 9/1, and 9/2/19. A large bm was recorded on 9/3/19. The resident did not have a bm on 9/5 and 9/6 and there was no documentation at all on 9/7/19. A small bm was recorded on 9/8/19.
A Nurse Practitioner (NP) Note, dated 9/3/19 at 3:50 p.m., indicated Patient was seen for complaint of constipation, patient states he did try some lactulose earlier with no results. Patient is on Colace daily. Patient is alert and able to communicate his needs, he is in no distress. Constipation-due to allergy history, patient unable to take Miralax. we will continue Colace 100 mg every a.m. New order given for Senna Plus 1 tablet at night, continue daily lactulose as needed. Patient educated to report any further constipation to nursing staff and he does verbalize understanding. Nursing to monitor for constipation.
The Medication Administration Record (MAR) for 8/2019 and 9/2019, indicated the Bisacodyl suppository was not signed out as being administered prn. The lactulose 10 gram/15 ml was administered on 8/30 at 4:30 a.m. and was not effective, on 9/1 at 6:50 a.m. and was not effective, on 9/2 at 4:26 a.m. and was not effective, and on 9/5 at 9:12 a.m. and was not effective.
Interview with the Assistant Director of Nursing (ADON) for the first floor on 9/11/19 at 11:00 a.m., indicated she gives a report of residents who have not had a bowel movement at least 1 times in 3 days to the nurses every morning Monday thru Friday.
Interview with the Director of Nursing on 9/11/19 at 12:28 p.m., indicated the resident did not have a bowel movement at least 1 time every 3 days. There was no constipation or bowel protocol policy.
3.1-37(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor nutritional status per the plan of care related to the lack...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor nutritional status per the plan of care related to the lack of documentation of meal intakes for 1 of 2 residents reviewed for nutrition. (Resident 205)
Finding includes:
During an interview on 9/9/19 at 11:13 a.m., Resident 205's spouse indicated his wife needed to be fed and assisted with meals. He was worried because she had lost 2 pounds a week since she had been admitted .
The record for Resident 205 was reviewed on 9/11/19 at 1:55 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), and dementia without behavioral disturbance.
The admission Minimum Data Set (MDS) assessment, dated 8/29/19, indicated the resident was moderately impaired for decision making. The resident had no oral problems and weighed 112 pounds with no weight loss.
The Care Plan, dated 9/4/19, indicated the resident could feed herself at meals with set up. The approaches were to monitor and record intake.
Physician's Orders, dated 8/22/19, indicated regular diet with no added salt.
The resident's weight on 8/22/19 indicated 112 pounds, on 9/4/19 indicated 110 pounds, and on 9/11/19 indicated 108 pounds.
The meal intake record, indicated there were no intakes recorded for the following meals:
8/26 dinner
8/27 breakfast and lunch
8/30 dinner
8/31 dinner
9/1 breakfast
9/2 breakfast and lunch
9/3 breakfast and lunch
9/5 dinner
no documentation on 9/6
9/7 dinner
9/8 dinner
9/11 dinner
Interview with the Director of Nursing on 9/16/19 at 9:00 a.m., indicated the meal intake records for some of the meals were incomplete.
3.1-35(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received a respiratory inhaler as ordered by the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received a respiratory inhaler as ordered by the Physician for 1 of 1 residents reviewed for respiratory care. (Resident 205)
Finding includes:
During an interview on 9/09/19 at 11:19 a.m., Resident 205's spouse indicated his wife did not receive her inhaler for over a week after admission.
The record for Resident 205 was reviewed on 9/11/19 at 1:55 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, Chronic obstructive pulmonary disease (COPD), and dementia without behavioral disturbance.
The admission Minimum Data Set (MDS) assessment, dated 8/29/19, indicated the resident was moderately impaired for decision making and received oxygen while a resident.
A Care Plan, dated 8/22/19, indicated the resident was at risk for respiratory distress related to the diagnosis of COPD. The approaches were administer medication as ordered.
A Physician's Order, dated 8/22/19, indicated Trelegy Ellipta (fluticasone-umeclidin-vilanter) (an inhaler used to improve and prevent bronchospasms in adults with COPD), 100-62.5-25 micrograms (mcg) inhale 1 puff daily at 9:00 a.m.
The Medication Administration Records (MAR), dated 8/2019 and 9/2019, indicated there were parenthesis around the nurses' initials for the following days for the Trelegy inhaler: 8/23, 8/24, 8/25, 8/27, 8/28, 8/29, 8/30, 8/31, 9/1, and 9/2/19. The initials in parentheses indicated the medication was not administered or not charted and to see reasons/comments.
A Nurse's Note, dated 8/31/19 at 11:32 a.m., indicated the resident was receiving 4 liters of oxygen via nasal cannula. She received therapy for strengthening with monitoring of oxygen saturations due to decreasing with activity. Staff spoke with the pharmacy and the Trelegy was pending due to the cost of $574.42 with no alternative medication. Staff left a message with the Physician for follow-up.
A Nurse's Note, dated 9/01/19 at 6:55 p.m., indicated the pharmacy was contacted at this time regarding Trelegy Ellipta. The medication was not sent due to a high cost-billing issue.
Interview with the Director of Nursing (DON) on 09/12/19 at 2:49 p.m., indicated there was no additional information regarding why the resident did not receive the inhaler from the pharmacy as ordered.
3.1-47(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to no indication for an increase in a psychotropic medication for 1 of 5 re...
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Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to no indication for an increase in a psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 79)
Finding includes:
The record for Resident 79 was reviewed on 9/12/19 at 1:44 p.m. Diagnoses included, but were not limited to dementia, major depressive disorder, anxiety, and delusional disorder.
The Quarterly Minimum Data Set (MDS) assessment, dated 8/15/19, indicated she was moderately impaired for decision making.
Physician's Orders indicated the following:
- Seroquel (quetiapine) (an antipsychotic medication), 12.5 mg (milligrams), dated 7/11/18 until 7/13/18. Give 12.5 mg by mouth at bedtime for dementia sundowning.
- Seroquel 12.5 mg, dated 7/13/18 until 7/25/18, give 12.5 mg by mouth at bedtime for dementia psychosis,
- Seroquel 25 mg, dated 7/25/18 until 2/8/19, give 25 mg by mouth at bedtime for dementia psychosis.
- Seroquel 25 mg, dated 2/8/19, give 25 mg by mouth twice daily for dementia psychosis.
A revised Care Plan, dated 8/31/19, indicated the resident was at risk for potential adverse consequences related to antipsychotic medication usage. The interventions included, but were not limited to, have a gradual dose reduction review at least quarterly and administer Abnormal Involuntary Movement Scale (AIMS) test quarterly and as warranted for symptoms.
There was only one gradual dose reduction for Seroquel recommended by the pharmacist on 1/29/19 and declined by the Physician on 2/15/19 due to the resident experiencing sundowning with increased agitation.
There was no documentation in the nursing notes for behavioral concerns to support frequent increased agitation and sundowning prior to increasing dosages or quarterly.
There was only one AIMS test completed dated 4/5/19 since the resident had been on Seroquel. There were no AIMS test completed prior to increasing dosages or quarterly.
Interview with the Director of Nursing (DON) on 9/13/19 at 3:11 p.m., indicated behavioral charting is by exception by nursing. The resident went to the hospital in February 2019 and returned with an increase in her Seroquel. She did not know why there was an increase because there is no additional information. There was only one progress note for a Neurology follow up visit from the Nurse Practitioner which was dated 7/25/19.
3.1-48 (b)(1)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
2. On 9/9/19 at 3:13 p.m., Resident 44 was observed in bed. At that time, there were two eye drop medications at the bedside labeled as Systane Ultra and Refresh tears.
On 9/11/19 at 9:48 a.m., Resid...
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2. On 9/9/19 at 3:13 p.m., Resident 44 was observed in bed. At that time, there were two eye drop medications at the bedside labeled as Systane Ultra and Refresh tears.
On 9/11/19 at 9:48 a.m., Resident 44 was observed in bed. At that time, there was an eye drop medication at the bedside labeled as Systane Ultra. Interview at the time with the resident indicated she is unable to self administer the eye drops due to limited range of motion and the nursing staff administered the drops for her. The nurses sometimes left the eye drops at the bedside, however, she did not know why.
The record for Resident 44 was reviewed on 9/11/19 at 9:55 a.m. Diagnoses included but not limited to osteoarthritis of right and left shoulder, rhabdomyolysis (breakdown of muscle tissue), and hypertension (elevated blood pressure).
The 14-Day Minimum Data Set (MDS) assessment, dated 8/26/19, indicated the resident was alert and oriented and required extensive assistance with personal hygiene and self performance.
There was no self administration of medication assessment available for review.
There was no Physician's Order for the Systane Ultra eye drops, Refresh Tears, or to self administer her own medications.
Interview with the 2nd floor Assistant Director of Nursing (ADON) on 9/11/19 at 9:50 a.m., indicated residents may have some medications at bedside if they had an order to keep them at the bedside.
Interview with the Director of Nursing (DON) on 9/11/19 at 3:52 p.m., indicated there was no order for the medication and it should not have been left at the bedside.
The current Medication Administration - General Guidelines received from Director of Nursing on 9/11/19 at 10:00 a.m., indicated Administration 2) Medications are administered in accordance with written orders of the prescriber
3.1-25(m)
Based on observation, record review, and interview, the facility failed to ensure over the counter medications were stored properly related to antacid chewable tablets and eye drops being stored at the resident's bedside for 2 of 2 random observations. (Resident 75 and 44)
Findings include:
1. On 9/9/19 at 3:33 p.m. and 9/19/19 at 10:07 a.m., Resident 75 was observed in his room in bed. There was a bottle of Tums (antacid chewable tables) located on his bedside table.
The record for Resident 75 was reviewed on 9/11/19 at 2:08 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, GERD (gastroesophageal reflux disease), anxiety, depression, hypertension, and falls.
The admission Minimum Data Set (MDS) assessment, dated 7/25/19, indicated the resident was alert and oriented for decision making.
There were no Physician Orders related to the administration of the Tums.
There was no Self Administration Assessment related to the Tums.
Interview with the resident on 9/11/19 at 2:59 p.m., indicated the Tums were no longer at the bedside because the nursing staff had removed them. He had his son pick them up from the pharmacy for him and it was his fault that they were left out.
Interview with the Director of Nursing on 9/11/19 at 3:52 p.m., indicated the medications were brought in by the resident's family and he did not have a Physician's Order nor a self administration assessment related to the use of the Tums.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to follow the recipe for a therapeutic pureed diet. This had the potential to affect the 3 residents in the facility who receive...
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Based on observation, record review, and interview, the facility failed to follow the recipe for a therapeutic pureed diet. This had the potential to affect the 3 residents in the facility who received a pureed diet. (The Main Kitchen)
Finding includes:
During an observation of 3 servings of puree, on 9/12/19 at 10:41 a.m., the Lead [NAME] 1 placed 24 ounces of potatoes and one fourth cup of chicken base broth into the blender. She blended the ingredients and checked the consistency. She proceeded to add one fourth teaspoon of thickener to the recipe, blended the ingredients, and checked for consistency. She repeated those same steps six times. The mashed potatoes were not pureed consistency. She continued to add one teaspoon of thickener, blend the ingredients, and check for consistency. She repeated those steps twice. She added a total of tablespoon and a half of thickener to the Potatoes Oven Browned Pureed menu item. The recipe lacked an indication to use thickener.
Interview with Lead [NAME] 1 and the Kitchen Manager at the time indicated Lead [NAME] 1 did not follow the recipe and should not have added thickener to the recipe.
The recipe for Potatoes Oven Browned Pureed was provided by the Kitchen Manager on 9/12/19 at 1:28 p.m. and did not include any thickener in the recipe.
3.1-20(i)(1)
3.1-20(i)(4)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to ensure food was served at an appetizing temperature for 1 of 3 units. This had the potential to affect 36 residents residing ...
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Based on observation, record review, and interview, the facility failed to ensure food was served at an appetizing temperature for 1 of 3 units. This had the potential to affect 36 residents residing on the 100 unit. (The 100 Unit)
Finding includes:
Interview with an anonymous family member on the 100 Unit indicated their family member's room trays were not always delivered on time (anywhere from 1 hour to 1 and 1/2 hours late) and were often served cold.
Interview with Resident 22 on 9/10/19 at 9:53 a.m., indicated her food was not always served hot.
Interview with the resident on 9/12/19 at 9:20 a.m., indicated she was just finishing her breakfast meal and it was once again served cold.
Observation of the 100 Unit breakfast meal on 9/13/19 at 8:50 a.m., indicated Resident 22 did not receive her room tray until 9:18 a.m. Interview at the time indicated her eggs were not ice cold but they were not hot either, they were barely warm. They are just edible.
The last tray on the unit was delivered to room D-106 at 9:22 a.m., interview at that time with the resident in bed B indicated her eggs were cold.
Review of the Meal Time Schedule indicated breakfast was to be served at 8:00 a.m. on each unit.
Interview with the Kitchen Manager on 9/16/19 at 10:55 a.m., indicated he was aware of the system break down with the breakfast meals not being served on time, however, he was not aware residents had concerns of cold food and he was currently working on putting a new system into place.
3.1-21(a)(1)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to serve the breakfast meals on time for 2 of 3 units, which had the potential to affect 83 residents. (The 100 and 200 Units)
F...
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Based on observation, record review, and interview, the facility failed to serve the breakfast meals on time for 2 of 3 units, which had the potential to affect 83 residents. (The 100 and 200 Units)
Finding includes:
Interview with an anonymous family member on the 100 Unit indicated their family member's room trays were not always delivered on time (anywhere from 1 hour to 1 and 1/2 hours late) and were often served cold.
Observation of the 100 Unit dining room on 9/12/19 at 8:46 a.m., indicated the food trays had not yet been served. Interview at the time with Dietary Aide 1 indicated, while looked at his watch, breakfast was to be served about now. The first tray was not served unit 8:53 a.m.
Observation of the 100 Unit dining room on 9/13/19 at 8:40 a.m., indicated the food trays had not yet been served.
Observation of the 200 Unit dining room on 9/13/19 at 8:50 a.m., indicated the food trays had not yet been served. The staff was serving beverages.
Observation of the 100 Unit dining room on 9/16/19 at 8:46 a.m., indicated the first tray was just served from the servery.
Observation of the 200 Unit dining room on 9/16/19 at 8:41 a.m., indicated the first tray was just served from the servery.
Review of the Meal Time Schedule indicated breakfast was to be served at 8:00 a.m. on each unit.
Interview with the Kitchen Manager on 9/16/19 at 10:55 a.m., indicated he was aware of the system break down with the breakfast meals not being served on time and he was currently working on putting a new system into place.
3.1-21(c)
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, record review, and interview, the facility failed to serve food under sanitary conditions related to touching resident's food with bare hands. This had the potential to affect 16...
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Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching resident's food with bare hands. This had the potential to affect 16 residents who were eating in the first floor dining room. (The First Floor Dining Room)
Finding includes:
During a meal observation on 9/12/19 at 8:53 a.m. in the First Floor Dining Room, the following was observed:
a. At 8:57 a.m., CNA 1 was observed passing a tray to a resident. She placed the resident's plate in front of him and assisted with setting up his breakfast. She picked up the resident's toast with her bare hands, buttered it and placed jelly on it as well. She used her bare hands to hold the toast down and cut it in half.
b. At 9:02 a.m., CNA 1 was again observed passing a breakfast tray to a resident. Using her bare hands, she picked up the resident's toast, buttered it and placed jelly on it. She cut the toast in half with her bare hands.
c. At 9:08 a.m., CNA 1 was observed passing a breakfast tray to a resident. She picked up the resident's toast with her bare hands and put jelly on it. She used her bare hands to hold the toast down and cut it in half.
Interview with CNA 1 on 9/12/19 at 9:10 a.m., indicated How am I supposed to cut the toast without touching it? I have to hold it down to cut it.
Interview with the Dietary Food Manager on 9/13/19 at 9:35 a.m., indicated ready to eat food was not to be handled with bare hands.
The current and undated Tray and Dining Room Meal Service policy, provided on 9/12/19 at 4:16 p.m. by the Director of Nursing, indicated, Employees serving food to residents should use suitable utensils such as spatulas, tongs, single use gloves, or dispensing equipment when handling ready to eat foods.
3.1-21(i)(3)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to follow their infection control program related to improper hand hygiene by a Certified Nurse Assistant (CNA) for an isolation...
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Based on observation, record review, and interview, the facility failed to follow their infection control program related to improper hand hygiene by a Certified Nurse Assistant (CNA) for an isolation room. This had the potential to affect 8 residents who were being cared for by the CNA on the A and B Wing. (Resident 299, CNA 2)
Finding includes:
During a random observation on 9/10/19 at 10:37 a.m. for Resident 299, CNA 2 entered Resident 299's room wearing gloves. She collected trash and linen. She removed her gloves and continued to collect trash and linen in the room without wearing gloves. She picked up the resident's tray and left the room without performing hand hygiene. She proceeded to the soil utility room to dispose of trash and linen. She left the soiled utility room and placed the resident's tray on the tray cart. She then washed her hands. There was a See Nurse Before Entering sign posted on the door and a cart with personal protective equipment outside the room.
The record for Resident 299 was reviewed on 9/10/19 at 11:15 a.m. Diagnoses included but, were not limited to Methacillin resistant Staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere, infection following a procedure, and stage 2 pressure ulcer of sacral region.
A Physician's Order, dated 8/24/19, indicated the resident was on contact isolation for a MRSA infection in his left foot.
An interview on 9/11/19 at 10:13 a.m., with the 2nd floor Assistant Director of Nursing (ADON), indicated there was no error in CNA 2's procedure because they are not allowed to wear personal protective equipment in the hallway and the CNA washing her hands at the end of the task was sufficient.
An interview on 9/11/19 at 10:47 a.m. with the Director of Nursing (DON), indicated the CNA should have washed her hands prior to exiting the room.
An interview on 9/12/19 at 10:15 a.m. with CNA 2, indicated she should have washed her hands after removing her gloves and before exiting the resident's room.
The current Transmission Based Precautions policy, received from the DON on 9/11/19 at 10:00 a.m., indicated .8. Before removing gown, gloves, or mask complete all care and be sure linen and trash are bagged 10. Wash hands
3.1-18(a)
3.1-18(b)(1)
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to ensure the nurse staffing sign was prominently posted readily accessible to residents and visitors and displayed the daily staffing pattern f...
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Based on observation and interview, the facility failed to ensure the nurse staffing sign was prominently posted readily accessible to residents and visitors and displayed the daily staffing pattern for 6 of 6 days of the survey.
Finding includes:
On 9/9/19 at 8:23 a.m., 9/10/19 at 8:25 a.m., 9/11/19 at 8:33 a.m., 9/12/19 at 8:38 a.m., 9/13/19 at 8:41 a.m., and 9/16/19 at 8:36 a.m., the daily nurse staffing sign was posted at the entrance of the facility on a wall behind the receptionist desk. The sign did not display the daily staffing pattern including actual time/ hours of the day worked.
Interview with the Director of Nursing on 9/16/19 at 1:53 p.m., indicated she was not aware the sign was not prominently posted and required the breakdown of actual hours worked as the daily staffing pattern.
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 major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Indiana facilities.
- • 30% turnover. Below Indiana's 48% average. Good staff retention means consistent care.
Concerns
- • 39 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Rehabilitation Center At Hartsfield Village's CMS Rating?
CMS assigns REHABILITATION CENTER AT HARTSFIELD VILLAGE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Rehabilitation Center At Hartsfield Village Staffed?
CMS rates REHABILITATION CENTER AT HARTSFIELD VILLAGE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 30%, compared to the Indiana average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Rehabilitation Center At Hartsfield Village?
State health inspectors documented 39 deficiencies at REHABILITATION CENTER AT HARTSFIELD VILLAGE during 2019 to 2024. These included: 38 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Rehabilitation Center At Hartsfield Village?
REHABILITATION CENTER AT HARTSFIELD VILLAGE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 112 certified beds and approximately 97 residents (about 87% occupancy), it is a mid-sized facility located in MUNSTER, Indiana.
How Does Rehabilitation Center At Hartsfield Village Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, REHABILITATION CENTER AT HARTSFIELD VILLAGE's overall rating (3 stars) is below the state average of 3.1, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Rehabilitation Center At Hartsfield Village?
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 Rehabilitation Center At Hartsfield Village Safe?
Based on CMS inspection data, REHABILITATION CENTER AT HARTSFIELD VILLAGE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #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 Rehabilitation Center At Hartsfield Village Stick Around?
REHABILITATION CENTER AT HARTSFIELD VILLAGE has a staff turnover rate of 30%, 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 Rehabilitation Center At Hartsfield Village Ever Fined?
REHABILITATION CENTER AT HARTSFIELD VILLAGE 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 Rehabilitation Center At Hartsfield Village on Any Federal Watch List?
REHABILITATION CENTER AT HARTSFIELD VILLAGE 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.