Aspire of Perry
For profit - Limited Liability company
46 Beds
BEACON HEALTH MANAGEMENT
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#248 of 392 in IA
Photo by Kathryn Starry
Photo by Kathryn Starry
Photo by Pearl Valley Rehabilitation and Healthcare Center at Perry
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Aspire of Perry has received a Trust Grade of F, indicating significant concerns and poor performance in quality of care. Ranked #248 out of 392 facilities in Iowa, they are in the bottom half, and #8 of 10 in Dallas County, meaning only two facilities in the area are worse. The facility's trend is improving, as they reduced issues from 55 in 2024 to 4 in 2025, which is a positive sign. Staffing is a strength, with a 4/5 rating and good RN coverage, suggesting that nurses are present and attentive, although the turnover rate is concerning at 79%, significantly higher than the state average. However, there have been serious incidents, including a resident choking due to improper food consistency, leading to fatal consequences, and a malfunctioning front door alarm that allowed a cognitively impaired resident to exit the facility unsupervised. While there are some strengths, these critical issues highlight the need for caution when considering this nursing home.
- Trust Score
- F
- In Iowa
- #248/392
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 79% turnover. Very high, 31 points above average. Constant new faces learning your loved one's needs.
- Penalties ○ Average
- $140,738 in fines. Higher than 55% of Iowa facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 61 minutes of Registered Nurse (RN) attention daily — more than 97% of Iowa nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 95 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 37%
Review needed
55 → 4 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 55 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Iowa average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 79%
33pts above Iowa avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $140,738
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: BEACON HEALTH MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (79%)
31 points above Iowa average of 48%
The Ugly 95 deficiencies on record
2 life-threatening 1 actual harm
Jun 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on clinical record review, staff interviews, and policy review the facility failed to ensure a cognitively impaired resident's environment remained free of hazards. The facility further failed t...
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Based on clinical record review, staff interviews, and policy review the facility failed to ensure a cognitively impaired resident's environment remained free of hazards. The facility further failed to ensure the resident received the appropriate consistency of food, which led to the resident choking and as a result dying.
The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 23, 2025 on May 29, 2025 at 10:50 AM. The Facility Staff removed the Immediate Jeopardy on May 29, 2025 through the following actions:
1. CPR audit conducted with 100% nurse compliance and several additional CNA/CMA staff members certified 5/23/25.
2. Diet modification audit conducted to ensure proper diet orders for all residents 5/23/25.
3. Dietary staff meeting called to discuss types of modified diets, how to determine proper texture, resident behaviors during meals times, and staff meal procedures 5/23/25.
4. All-staff education provided regarding types/importance of modified diets, how to determine proper texture, resident behaviors during meals times, staff meal procedures, and review of Heimlich maneuver 5/29/25.
5. Code status audit conducted for all residents to ensure advanced directives are reflected accurately in the chart 5/25/25. BLS CPR class will be offered to all interested staff on 5/31/25.
6. Management daily audit of meal consistency audit conducted for a random mealtime x7 days 5/23/25.
7. All-staff training provided: staff personal food and drink must be stored and consumed in designated staff areas and not in resident living areas 5/29/25.
The scope was lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures.
The facility reported a census of 31 residents.
Findings include:
Review of Resident #1's Electronic Healthcare Record (EHR) page titled assessments revealed a Brief Interview for Mental Status (BIMS) assessment completed 5/22/25 documented a score of 99 indicating a BIMS assessment was unable to be completed as the resident is rarely/never understood. This assessment further revealed an admission date of 5/19/25.
The EHR page titled, Medical Diagnosis, revealed diagnosis of autism, PICA (an eating disorder characterized by the persistent craving and consumption of non-nutritive, non-food substances) in adults, severe intellectual disabilities, and schizoaffective disorder.
The Baseline Care Plan dated 5/19/25 revealed Resident #1 required one person physical assistance with eating. The Care Plan revealed Resident #1 was on a regular mechanical soft diet with ground meat. The Care Plan revealed that Resident #1 required visual supervision for all cares. The Care Plan documented his code status as Do Not Resuscitate (DNR), comfort measures only and to allow a natural death. The initial goals listed on the Care Plan were to ensure safety and maintain ADL's for a long term stay. The Care Plan documented the resident liked to put his hands in his mouth and was at risk for chewing problems. It also documented he needed monitoring at all times.
The Progress Notes for Resident #1 documented the following:
On 5/23/25 at 4:06 PM Staff A walking resident when Administrator joined her. Resident walking through dining room attempting to grab meals so they decided to take him to his room. Kitchen staff delivered his room tray. Staff observed an extra plate had been delivered of regular pizza for Staff A to the resident's room. It was immediately moved to the other end of the dining table in his room. The Administrator thought it was out of his reach. The resident took bites of his food and drank fluids without difficulty. Resident #1 then impulsively stood up from his chair, pushed the table forward with his lower body, lunged across the table past both staff members (Staff A, and the Administrator) and grabbed the regular pizza, wadded the pizza in his right hand and immediately shoved the entire piece of pizza in his mouth. After a couple seconds Resident #1's lips began to turn blue, the Administrator began the Heimlich Maneuver and Staff A called 911. The resident started coughing and spit some of the pizza out of his mouth and started breathing. The resident continued to have food lodged in his throat, resident was conscious at this time. Residents breathing noted to be abnormal, gasping for air, Heimlich Maneuver was continued. An officer arrived on the scene and took over with the Heimlich maneuver. Staff A attempting to open residents mouth however resident was gritting his teeth together which kept his mouth closed preventing any food from exiting his mouth. Heimlich maneuver continued until the resident collapsed. Resident laid on the floor and the officer started Cardiopulmonary Resuscitation (CPR) per choking protocol. The Administrator confirmed on the phone with the Director of Nursing (DON) the resident was a DNR. This was confirmed via phone call with the mother. The mother told the staff to stop CPR once the resident was confirmed to not have a heart beat and was not breathing. All life sustaining support stopped by Emergency Medical Service (EMS). Resident pronounced deceased by EMS and the County Medical Examiner called. The County Medical Examiner stated death accidental with no foul play suspected however the Provider did want the resident's body sent for an autopsy.
Interview 5/28/25 at 1:05 PM with Staff A Certified Medication Aide (CMA) revealed it was the first day taking care of Resident #1. Staff A further revealed that Resident #1 Went to breakfast around 8:30 AM, and other staff was teaching her what to do and not to do since she hadn't worked with Resident #1. Staff A then revealed Resident #1 was trying to take other residents' food in the dining room. Staff A revealed that the Administrator and herself took Resident #1 to his room to eat. Staff then revealed she had asked Staff B Dietary Aide and Staff C Dietary Aide if they could get more food for Resident #1 and to save her a slice of pizza. Staff A revealed that the Administrator and herself were assisting Resident #1 in the bathroom when Staff C delivered Resident #1's mechanical diet along with her slice of pizza. Staff A revealed she had noticed the regular pizza so she immediately placed it on the opposite side of the table in Resident #1's room. Staff A revealed that Resident #1 pushed the table, and quickly grabbed the pizza at the other end of the table and shoved it all into his mouth, hand and all. Staff A further revealed that Resident #1 also had a diagnosis of PICA. Staff A revealed that she did not ask dietary staff to bring her pizza into Resident #1's room as staff are not supposed to eat when assisting with feeding residents, and staff are not supposed to eat in the residents' rooms or dining room. Staff A further revealed that the Administrator attempted abdominal thrusts while she called 911 right away. Staff A revealed a police officer came to the facility and attempted abdominal thrusts on Resident #1. Staff then revealed Resident #1 was breathing, but still had food in his mouth and would not open his mouth while clinching his teeth. Staff A revealed that Resident #1 was gasping at this time. Staff A further revealed that abdominal thrusts were continued until Resident #1 collapsed and then the police officer started CPR until it was revealed that Resident #1 had an order for do not resuscitate (DNR) at which point it was confirmed and Resident #1 passed away.
Interview 5/28/25 at 1:33 PM with Staff B revealed he did not deliver food to Resident #1's room and that Staff C had delivered the food to the room. Staff B then revealed that Resident #1 was on a mechanical soft diet and could have finger foods. Staff B further revealed he had observed Resident #1 attempt to grab things, but did not witness it a lot as he was working in the kitchen.
Interview 5/28/25 at 1:40 PM with Staff C revealed that she did deliver the food to the room for Resident #1 per staff request. Staff C revealed that she brought a mechanical diet for Resident #1 and on a separate plate had a regular piece of pizza for the staff. Staff C revealed that when the food was delivered the staff were assisting Resident #1 in the bathroom so she left the food tray on the table and left the room.
Interview 5/28/25 at 2:00 PM with the Administrator revealed she had gotten to the facility early and was providing help to staff who was providing 1 to 1 support for Resident #1 during waking hours related to his autism. The Administrator then revealed Resident #1 was in the dining room, and was trying to grab other residents' food. The Administrator revealed Staff A and herself decided to send food to Resident #1's room. The Administrator revealed Staff A did ask staff to save her a piece of pizza. The Administrator revealed Staff A and herself helped Resident #1 to the bathroom, and when they came out the food was on a tray on the table. The Administrator then revealed that Staff A escorted Resident #1 to a small table in the resident's room where the food tray was. The Administrator revealed Resident #1 was sat at one side of the table, Staff A was at the corner closest to Resident #1. The Administrator further revealed she was standing next to Staff A on the same side of the table. The Administrator revealed that Staff A's regular slice of pizza was placed on the opposite side of the table furthest away from Resident #1. The Administrator then revealed that staff do not eat in residents' rooms and she was going to relieve Staff A for lunch and Staff A could take her pizza after assisting the resident in his room with his meal. The Administrator then revealed Resident #1 stood up fast and pushed the table with his groin and grabbed the slice of regular pizza and shoved the entire piece into his mouth hand and all. The Administrator revealed that Staff A immediately pulled the Resident #1's hand out of his mouth, and noticed that the resident's lips were turning blue. The Administrator revealed that she initiated the abdominal thrusts as Staff A called 911, and pulled the call light. The Administrator further revealed that Resident #1 was having abnormal breathing and abdominal thrusts were continued. The Administrator revealed that Resident #1 was shaking his head and gritting his teeth as to not let the food come out and was chewing. The Administrator then revealed police had arrived and continued abdominal thrusts until Resident #1 collapsed. The Administrator revealed the officer then initiated CPR per the choking policy and the Administrator called the Power of Attorney (POA) and confirmed that Resident #1 was a DNR to which the POA revealed to let Resident #1 pass.
Interview 5/28/25 at 3:15 PM with Staff D Social Services Director (SSD) revealed that she had witnessed Resident #1 attempt to take other residents' items. Staff D revealed at meals the staff would take Resident #1 outside for a walk, and or take him to his room. Staff D further revealed due to Resident #1's PICA diagnosis he would try to take any item and put it in his mouth. Staff D revealed that when she worked with Resident #1 she would not eat in his room, and revealed that staff are not supposed to eat in residents rooms or in the dining room when they are assisting to feed. Staff D then revealed the pizza that was placed into Resident #1's room should not have been there.
Interview 5/28/25 at 3:30 PM with Staff E Certified Nursing Assistant (CNA) revealed that he never ate around Resident #1. Staff E further revealed that food should not be in the residents' rooms as the attention should be on the residents' and not eating.
Interview 5/28/25 at 3:48 PM with the DON revealed she was not at the facility when Resident #1 had the choking incident. The DON further revealed she had witnessed Resident #1 attempt to take other residents' food. The DON revealed when Resident #1 would attempt to take other residents' food in the dining room area staff would try to redirect Resident #1, and if that redirection did not work then staff would redirect Resident #1 to his room to eat. The DON further revealed Resident #1 was on a mechanical soft diet with ground meat. The DON then revealed staff are not allowed to eat around the resident or in his room. The DON revealed the pizza should have not been in the residents room, and should have been in the break room. The DON then revealed that the pizza should have been taken out of Resident #1's room right away.
Interview 5/29/25 at 7:40 AM with Staff F Register Nurse (RN) revealed he had witnessed Resident #1 several times attempting to take other residents' food in the dining room. Staff F then revealed that staff would try to redirect the resident, and if that would not work the staff would redirect the resident to his bedroom to eat. Staff F further revealed that Resident #1 was on a mechanical soft diet related to Resident #1 being a risk for aspiration. Staff then revealed that staff are not supposed to eat around residents who require assistance with eating, but unfortunately it has happened.
Follow up interview 5/29/25 at 7:50 AM with Staff C revealed the incident happened around 9:00 AM. Staff C then confirmed that the resident #1 was a mechanical diet.
Interview 5/29/25 at 8:10 AM with the County Medical Examiner revealed his office was called for an unexpected death at the facility. The Examiner revealed his assumption was Resident #1 had food bolus asphyxiation. The Examiner revealed the original 911 call was for a resident choking and police got there roughly about the time Resident #1 collapsed. The Examiner further revealed two staff were feeding Resident #1. The Examiner confirmed the original 911 call was at 9:04 AM with the first police officer arriving at 9:07 AM. The Examiner then revealed a second officer arrived at 9:27 AM. The Examiner revealed that nursing staff were trying to complete abdominal thrust, and was trying to do finger sweeps but Resident #1's jaw was clinched. The Examiner revealed staff continued abdominal thrusts. The Examiner revealed that two staff were feeding Resident #1, and told the Examiner that Resident #1 was fast and could put his whole hand in his mouth. He grabbed a whole slice of pizza, and shoved the whole thing in his mouth and was choking on it.
Interview 5/29/25 at 9:03 AM with Staff G CNA revealed Resident #1 was on a mechanical diet. Staff G further revealed she had witnessed Resident #1 attempt and take other residents' food. Staff G revealed staff would then redirect Resident #1, and try to keep Resident #1 from eating other residents' food. Staff G further revealed staff were never allowed to eat in the resident rooms. Staff G revealed she would never eat around Resident #1 as Resident #1 had quick hands.
Follow up interview 5/29/25 at 9:50 AM Staff A CMA revealed the incident happened around 8:40 to 9:00 AM. Staff A further revealed she had witnessed Resident #1 attempt and take food from other residents. Staff A then revealed she was trained on Resident #1 having a mechanical soft diet (chopped up). Staff A revealed the regular slice of pizza Resident #1 took during the incident was triangle shaped. Staff A then revealed there are new people working at the facility, and dietary must have forgotten. Staff A further revealed staff food is not allowed in residents rooms, and if she could have done something different she would have moved the pizza across the room or would have taken the pizza to the breakroom.
Interview 6/2/25 at 4:50 PM with the State Medical Examiner's office revealed that Resident #1's cause of death was food bolus asphyxia, and the preliminary manner was accidental.
Review of a facility provided policy titled, Therapeutic Diets with a revision date of 10/2024 revealed:
-Definition of Mechanically Altered Diet means one in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physicians or delegated registered or licensed dietician order.
-Mechanically altered diets, as well as modified for medical or nutritional needs, will be considered therapeutic diets.
-The Food Service Manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered.
-Residents on therapeutic diets will not receive extra or reduced portions or modifications that are not part of the diet, unless approved by the Attending Physician in conjunction with the Clinical Dietician.
-Any snacks provided must be compatible with the therapeutic diet.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, menu review, staff interviews, and policy review, the facility failed to serve the appropriate portions for five (5) residents (#3, #9, #10, #12, and #13) who received pureed die...
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Based on observation, menu review, staff interviews, and policy review, the facility failed to serve the appropriate portions for five (5) residents (#3, #9, #10, #12, and #13) who received pureed diets. The facility reported a census of 29 residents.
Findings include:
On 6/30/25 at 12:10 pm, Staff A, cook and the Certified Dietary Manager (CDM) indicated the facility had five (5) pureed diets to prepare. The CDM stated one was to accommodate a resident who recently had a dental procedure. Staff A placed 5 servings of fish and two unmeasured amounts of mayonnaise into the blender and pureed them. He added an unmeasured amount of hot water and blended the contents. Staff A spooned the contents into a steam pan, covered it, and placed it in the oven. He did not measure the total volume.
At 12:23 PM, Staff A placed 5 rolls and two unmeasured amounts of butter into the blender and pureed them. He added unmeasured amounts of hot water and blended the contents. He spooned the contents into a steam pan and covered it. He did not measure the total volume.
At 12:32 PM, staff A pureed five 4-ounce servings of coleslaw and spooned it into a steam pan. He did not measure the total volume.
At 12:40 pm, the CDM used a gray handled, 4-oz disher and spooned the coleslaw into 5 bowls. The last bowl contained noticeably less coleslaw. She scooped the pureed fish into the compartmented plates but ran out before the 5th plate serving.
At 2:10 pm, Staff A stated he used the menu serving chart to determine which disher to use for pureed diet serving sizes. He stated he was not familiar with and hadn't been shown the volume method (a formula which measures the final volume of pureed food divided by the number of servings to identify the correct pureed serving size).
The Order Listing Report (resident diet list) confirmed the CDM's statement of residents who received pureed diets.
At 2:11 pm, the CDM stated Staff A should have used the volume method to determine pureed diet serving sizes.
An undated policy titled Pureed Food Preparation directed staff to portion out the number of pureed items needed to prepare pureed meals for all residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and policy review, the facility failed to use sanitary methods during food service to residents. Staff failed to cover facial hair, touched food and food surface...
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Based on observation, staff interview, and policy review, the facility failed to use sanitary methods during food service to residents. Staff failed to cover facial hair, touched food and food surface area with bare hands and transported uncovered food to seven (7) residents' rooms. The facility reported a census of 29.
Findings include:
On 6/30/25 at 11:35 AM, Staff A, Cook, was observed in the kitchen cooking corn without a beard covering. He stated he had been employed for 3 ½ months and received orientation that included the use of hairnets and beard covering. He pointed to the policy on the refrigerator that instructed staff to wear hair and beard covering while in the kitchen. He stated he didn't have a beard cover on because he didn't know he needed one.
At 11:43 AM, the Certified Dietary Manager (CDM) stated staff should be wearing facial hair covering at all times while in the kitchen.
At 12:37 AM, during a continuous meal service observation, Staff A grabbed resident bowls with bare hands and his thumb came in direct contact with the food surface area of the bowls. He also put five (5) compartmented plates on the counter, placed his bare fingers on the food surface area, and repositioned them.
At 12:52 AM, the CDM scooped pureed bread into a bowl for Resident #4 and placed it on the service cart. Her right thumb came in direct contact with the pureed bread.
At 1:27 PM, Staff B, dietary aide (DA) transported lunch trays to 3 residents on the [NAME] hall. The coleslaw, peach cobbler, and drinks were not covered during transport.
At 1:34 PM, Staff B transported lunch trays to 2 residents on the East hall. The coleslaw, peach cobbler, and drinks were not covered during transport.
At 1:41 PM, Staff B transported lunch trays to 2 other residents on the East hall. The coleslaw, peach cobbler, and drinks were not covered during transport.
At 2:11 PM, the CDM stated all food and drinks should be covered when transported to residents' rooms. She also stated that no non-food items should come in contact with food or the food surface area of dishes.
A policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices last approved 10/2024 indicated hair nets and/or chef caps and/or beard restraints must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. It also directed staff to wash hands before coming in contact with any food surface area. It further indicated contact between food and bare (ungloved) hands is prohibited.
A policy titled Food Preparation and Service revised 10/2024 indicated food is covered during transportation and distribution to residents.
Feb 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected multiple residents
Based on clinical record review, resident interviews, staff interviews and facility policy review, the facility failed to conduct resident care conferences and offer residents participation in their p...
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Based on clinical record review, resident interviews, staff interviews and facility policy review, the facility failed to conduct resident care conferences and offer residents participation in their plan of care for 4 of 4 residents reviewed (Residents #2, #3, #4, #5). The facility reported a census of 32 residents.
Findings include:
1. The Quarterly Minimum Data Set (MDS) of Resident #2 dated 1/15/25 documented an admission date to the facility of 7/2/18. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact.
On 2/4/25 at 1:25 pm, Resident #2 stated he remembered being invited to a care conference once but it got concealed and never got rescheduled. He stated he did not recall ever attending a care conference.
Review of Progress Notes for the last five months failed to reveal any documentation of Resident #2 having a care conference during the reviewed period.
2. The Annual MDS of Resident #3 dated 11/30/24 documented an admission date to the facility of 11/23/22. The MDS identified a BIMS score of 13 which indicated cognition intact.
On 2/4/21 at 1:21 pm, Resident #3 stated he was not aware of what a care plan was. He stated he has never been invited to a care conference and would like to know how he can find out what his care plan says.
Review of Progress Notes for the last five months failed to reveal any documentation of Resident #3 having a care conference during the reviewed period.
3. The Quarterly MDS of Resident #4 dated 12/1/24 documented an admission date to the facility of 2/28/20. The MDS identified a BIMS score of 15 which indicated cognition intact.
On 2/4/25 at 12:45 pm, Resident #4 stated she has no memory of ever attending a care conference and was not aware of what a care conference was.
Review of Progress Notes for the last five months failed to reveal any documentation of Resident #4 having a care conference during the reviewed period.
4. The Quarterly MDS of Resident #5 dated 1/29/25 documented an admission date to the facility of 11/3/20. The MDS identified a BIMS score of 15 which indicated cognition intact.
On 2/4/25 at 12:54 pm stated he was not aware of what a care conference was and did not recall ever attending one.
Review of Progress Notes for the last five months failed to reveal any documentation of Resident #5 having a care conference during the reviewed period.
On 2/4/25 at 1:30 pm the Administrator stated the facility conducted an audit of care plans and noted care conferences had been inconsistent. She stated the facility plans to just start them over and the Social Services Director created an invitation template to give to the residents. She said the invitation was approved by her and they would start getting the care conferences scheduled.
The facility policy titled Resident/Family Participation - Assessment/Care Plans, approval date 10/2024, documented the following Policy Statement: Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and person-centered care plan. The policy further documented the following:
1. The resident and/or his/her representative, are invited to attend and participate in the resident's assessment and care planning conference. Notice shall be made by mail, electronic mail and/or telephone in a language that he or she can understand.
2. The resident may request, at any time a care plan meeting and the right to request revisions to the person-centered plan of care.
3. The Social Services Director/Designee or person appointed by the community is responsible for contacting the family and for maintaining records of such notices.
4. Through the comprehensive care planning process keep the resident informed of their total health status in a language that he or she can understand. This includes allowing the resident to view their plan of care at any time and the right to sign off after significant changes to the care plan.
5. Through the care planning meeting inform the resident of the type of care giver or professional that will furnish the care identified in the care plan.
6. Resident participation in their care planning process should be promoted and includes:
a. Review of revisions made to the care plan based upon their current needs and preferences prior to implementation;
b. Participating in establishing goals and outcomes of care, the type, amount and frequency and duration of care;
c. Review and signing of the care plan if they choose;
7. Inform the resident of the risk and benefit of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative option if the resident prefers.
Dec 2024
26 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review the facility failed to provide residents and family with adequate notification of f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review the facility failed to provide residents and family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 2 of 3 residents reviewed (Resident #6 and #34.) The facility reported a census of 33 residents.
Findings include:
1) According to the Significant Change Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status score of 15 (intact cognitive ability.) The resident was totally dependent on staff for toileting hygiene and dressing, and required substantial assistance with sit to stand transfers.
The Care Plan for Resident #6 showed that she was at risk for injury from falls related to impaired mobility. She required assistance of 2 staff with walking.
According to the Beneficiary Protection Notification Review (ABN), Resident #6 started Medicare Part A services on 4/16/24 and coverage terminated on 5/15/24. Question #1 on the form stated: Was an SNF (Skilled Nursing Facility) ABN Form CMS-10055 provided to the resident? the response was yes. The chart for Resident #6 lacked a signed 10055 form.
2) According to the MDS dated [DATE], Resident #34 had a BIMS score of 15 (intact cognitive ability.) The resident was independent with toileting, dressing, transfers and eating. She qualified for Part A Therapies, which included physical therapy.
The Care Plan updated on 10/3/24, showed that Resident #34 had recent radiation/chemotherapy treatments related to breast cancer.
According to the census tab in the electronic chart, Resident #34 was admitted to the facility on [DATE] with Medicare Part A services.
The ABN form for Resident #34, showed she had Medicare Part A Skilled Services beginning, 8/6/24 and scheduled for termination on 8/20/24. A note written on the form indicated that the Power of Attorney (POA) for the resident had been emailed and agreed to the Resident going off skilled services therapy on 8/20/24. The CMS-10055 form was incomplete with none of the options chosen, and the form lacked a signature.
On 12/12/24 at 2:30 PM, the Social Worker (SW) said that she notified the POA that Part A services were ending and she received an email with the response okay. She said that she understood that response to mean that the POA didn't want to continue or pay for services. When asked if she had presented the information on the 10055 form with the daily rate, and appeal options, the SW acknowledged that she should have gotten a signature and verification that the options were presented. The SW said that she couldn't answer for the missing form for Resident #6 because that was before she started working at the facility.
According to the facility policy titled: Beneficiary Notices, revised on 8/2024, the facility would prepare the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN), CMS 10055, and issue to the resident if the resident intended to continue services and the Interdisciplinary Team (IDT) had determined that serviced may not be covered under Medicare. The facility would inform the resident of potential non-coverage and document in the record that the resident understood they were accepting financial liability. Forms should be maintained in the binder in the Social Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, staff and resident interviews and facility policy review, the facility failed to implement interventions to safeguard the dignity and wishes of Resident #...
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Based on observation, clinical record review, staff and resident interviews and facility policy review, the facility failed to implement interventions to safeguard the dignity and wishes of Resident #34 after a Resident to Resident incident between Resident #34 and Resident #18. The facility reported a census of 33.
Findings include:
The Minimum Data Set (MDS) Assessment of Resident #34, dated 8/12/24, identified a Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident experienced delusions during the 7 day look back period. The MDS documented diagnoses that included depression, bipolar disorder, psychotic disorder and schizophrenia.
The MDS Assessment of Resident #18, dated 10/6/24 identified a BIMS score of 15 which indicated cognition intact. The MDS documented the resident exhibited behavioral symptoms not directed toward others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, daily during the 7-day look back period. The MDS documented diagnoses that included anxiety and depression.
On 12/9/24 at 3:06 pm, Resident #34 reported she had recently been standing near the nurses desk, conversing with an employee. She stated Resident #18 was self propelling his wheelchair past her, and his arm went up her leg and then to her right buttocks. She said that he made a statement of not trying to do anything to her. She stated he touched her with his hand, and it was not a brush up with his arm. She said it made her wonder, as nobody expects anything like that to happen.
On 12/9/24 at 2:56 pm, Resident #18 stated he had bumped into Resident #34. He stated it was accidental and he apologized.
The Contact Form for Facility Reported Incidents revealed the date of the incident to be 12/5/24.
The Social Services Progress Note in the Electronic Health Record (EHR) of Resident #34, dated 12/5/24, authored by the Director of Nursing (DON), documented Resident #34 reported Resident #18 touched her bottom and it made her feel uncomfortable. The DON documented she made all necessary notifications. The note failed to document any interventions put in place to keep Resident #34 and Resident #18 separated.
The Social Services Progress Note in the EHR of Resident #18, effective date 12/6/24, created date 12/10/24 (late entry), authored by the Director of Nursing, documented Resident #18 thought he had bumped the foot of Resident #34 with his wheelchair as he was passing by. The note documented Resident #18 reported he patted her bottom to apologize and denied the touch as being sexual. The note failed to documented any interventions put in place to keep the two residents separated.
The Witness Statements by three facility staff members on duty on 12/5/24 revealed statements were gathered five days later, on 12/10/24. None of the statements documented any interventions put in place to keep the two residents separated.
On 12/10/24 10:54 AM, The Care Plan of Resident #18 was reviewed. The Care Plan revealed a focus area dated 10/5/24 noted alleged inappropriate behavior towards a female. It failed to reveal any documentation of interventions to keep Resident #18 and #34 separated.
On 12/10/24 at 10:56 am, the Care Plan of Resident #34 was reviewed. It failed to reveal any documentation of interventions to keep Resident #34 separated from Resident #18.
On 12/10/24 at 11:43 am, the DON stated no staff had directly witnessed the incident between the two residents. She stated Resident #34 had felt Resident #18 touch her bottom and it made her feel uncomfortable. The DON stated Resident #34 had initially reported this to Staff I, Certified Nurse Aide (CNA) and Staff I then brought Resident #34 to the DON office. The DON further stated Resident #18 had admitted to patting the buttocks of Resident #34 as an apology for bumping into her. She stated she believed Resident #18's intentions were not sexual. She stated Resident #34 is not always the most reliable.
The DON further stated the two residents live on separate hallways. She stated the incident happened on a Thursday and she followed up with Resident #34 the next Monday. She said Resident #34 reported no further concerns. She added the two residents do not eat at the same table or attend the same activities. She stated the care plans had not been updated for either resident as the facility was still in the window for submitting a five day follow up on the incident. She stated she would update the care plans of both residents for staff to monitor the two residents to make sure they are kept apart. She said staff that were on duty on 12/5/24 did receive education but no further staff received any education at that time.
On 12/10/24 at 11:52 am, the State Surveyor was standing at the nursing desk waiting for Staff G, Licensed Practical Nurse (LPN) to complete a phone call. The State Surveyor observed the DON and Staff I, CNA speaking privately in the dining room.
On 12/10/24 at 11:55 am, Staff G, LPN stated when Resident #34 told her concerns to Staff I, CNA, Resident #34 was then taken to the DON office to notify her. She stated the facility has an abuse hotline flyer at the nursing station. She stated no direction was given to her to keep the residents separated but she stated she would consider that a given to do in this situation and kept an eye on the residents.
On 12/10/24 at 12:01 pm, Staff I, CNA stated she was sitting at the nurses station charting on 12/5/24 when Resident #34 came to her and told her Resident #18 had went past her in his wheelchair and had groped her behind. She stated she told Resident #34 she needed to report this to the DON and she took Resident #34 to the DON office. She stated the DON told her to keep the residents separated and to check on the residents every 15 minutes. She stated the 15 minute checks were to be completed every 15 minutes.
On 12/10/24 at 12:08 pm, Staff J, CNA stated she did know have any information on the interaction between Resident #18 and Resident #34. She stated she did not witness anything. She further stated she received no education regarding the two residents and nobody asked her to watch the two of them.
On 12/10/24 at 12:09 pm, Staff A, Certified Medication Aide (CMA) stated he came on duty at 2:00 pm on 12/5/24. He stated he had no knowledge of any incident between the two residents and nobody at the facility had said anything to him about it. He was unaware of any incident prior to the State Surveyor asking him.
On 12/10/24 at 12:49 pm, Resident #34 was observed sitting at the far end of the dining room, near the exit to the patio. Staff J, CNA, stated that was not the resident's normal place to sit in the dining room.
On 12/10/24 at 12:55 pm, Resident #34 stated she was sitting in at a different table because a different resident was sitting in her normal spot when she arrived to the dining room. When asked about how she was feeling regarding Resident #18, Resident #34 replied she felt scared because she felt it could happen again because Resident #18 knew what he was doing.
In a follow up interview on 12/10/24 at 1:00 pm, Resident #18 stated the facility staff asked him what had happened during the incident and he told them. He stated he said he was sorry and the facility staff said ok. He denied receiving any direction or requests to keep distance from Resident #34.
The Care Plan of Resident #18 was updated on 12/10/24 by the DON to keep Resident #18 and Resident #34 separated as much as possible. It directed staff to not sit the two residents together in the dining room or at activities. It additionally directed staff to attempt to keep Resident #18 from going down Resident #34's hallway as much as possible.
The Care Plan of Resident #34 was updated on 12/10/24 by the DON. A revision was made to the Focus Area of risk for behavior problems indicating an incident of reporting to staff a male resident touching her on her bottom. It directed staff to keep Resident #34 and Resident #18 away from each other as much as possible, to not have them next to each other in dining room or activities. It additionally directed staff to discourage Resident #34 from being near Resident #18.
The Facility Policy Resident-to-Resident Altercations F600, revision date 10/2022 documented the following:
Point 2:
a. Separate the residents, and institute measures to calm the situation;
b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation;
c. Provide and document re-direction and provide protection as required by the situation
d. Notify each resident's representative and Attending Physician of the incident;
e. Review the events with the Nursing Supervisor and Director of Nursing, including interventions to try to prevent additional incidents;
f. Consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem;
g. Make any necessary changes in the care plan approaches to any or all of the involved individuals
h. document in the resident's clinical record all interventions and their effectiveness;
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Comprehen...
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Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within federal guidelines for 3 of 14 residents (#24, #31, #34) reviewed for MDS Assessments. The facility reported a census of 33 residents.
Findings include:
1. The Annual (Comprehensive) MDS of Resident #24 documented an Assessment Reference Date (ARD) of 10/30/24. On 12/16/24 the MDS was still displayed as In Progress. Twelve of the eighteen sections of the MDS were not completed. The MDS tab of the resident's Electronic Health Record (EHR) showed his last annual MDS was dated 10/30/23.
2. The Annual (Comprehensive) MDS of Resident #31 documented an ARD of 10/27/24. On 12/16/24, the MDS was still showing as In Progress. Twelve of the eighteen sections of the MDS were not completed. The MDS tab of the EHR showed the last comprehensive MDS, the resident's admission MDS, was dated 10/27/23.
3. The admission (Comprehensive) MDS of Resident #34 documented an ARD of 8/12/24. The MDS recorded the resident had an admission date to the facility of 8/6/24. Page 58 of the MDS recorded a completion date of 8/29/24, the 24th day of the resident's stay.
According to the 2024 Resident Assessment Instrument (RAI) Manual, for an annual (comprehensive) assessment, the Assessment Reference Date (ARD) must be within 366 days of the prior comprehensive assessment. The Assessment must be completed within 14 days of the ARD.
According to the 2024 RAI, for an admission (comprehensive) assessment, the ARD must be no later than the 14th calendar day of the resident's admission date and must be completed by the 14th calendar day of the resident's admission.
On 12/12/24 at 4:30 pm, the Director of Nursing stated she is trying to take over the MDS duties as the facility does not have an MDS Coordinator. She stated she is currently locked out of the system but she will get the assessments caught up.
The Facility Policy MDS Assessment Coordinator F642, review date 11/2017 documented A Registered Nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's assessment (RN).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change within federal guidelines for 3 of 14 residents (#6, #7 and #32) reviewed for MDS Assessments. The facility reported a census of 33 residents.
Findings include:
1. The Census Line portion of the Electronic Health Record (EHR) of Resident #6 documented the resident enrolled in hospice care on 10/3/24. The Significant Change MDS of Resident #6 documented an Assessment Reference Date (ARD) of 10/10/24. Page 58 of the MDS documented the MDS was signed as Assessment Completion on 10/28/24, three and half weeks following hospice admission.
2. The Progress Notes of Resident #7 documented hospice admission on [DATE]. On 12/12/24 at 1:14 pm a staff member of the hospice company verified the admission date for hospice care to be 11/30/24.
The Significant Change MDS for Resident #7 documented an ARD of 12/10/24. On 12/16/24 the MDS was still displayed as In Progress. Thirteen of the eighteen sections of the MDS were not documented as complete.
3. The Census Line portion of the EHR of Resident #32 documented the resident enrolled in hospice care on 11/22/24. The Significant Change MDS of Resident #32 documented as ARD of 12/4/24. On 12/16/24, the MDS was still displayed as In Progress. Twelve of the eighteen sections of the MDS were not documented as complete.
According to the 2024 RAI, a Significant Change (comprehensive) assessment, the ARD must be no later than the 14th calendar day after determination that a significant change in the resident's status occurred. The RAI stated a Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program.
On 12/12/24 at 4:30 pm, the Director of Nursing stated she is trying to take over the MDS duties as the facility does not have an MDS Coordinator. She stated she is currently locked out of the system but she will get the assessments caught up.
The Facility Policy MDS Assessment Coordinator F642, review date 11/2017, documented A Registered Nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's assessment (RN).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Minimum D...
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Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Minimum Data Set (MDS) Assessments within federal guidelines for 2 of 14 residents (#26, #32) reviewed for MDS Assessments. The facility reported a census of 33 residents.
Findings include:
1. The Census Line portion of the Electronic Health Record (EHR) of Resident #26 documented the resident discharged from the facility on 10/22/24. The Discharge MDS of Resident #26 documented an Assessment Reference Date (ARD) of 10/22/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of fifteen sections of the MDS were not documented as complete.
2. The MDS section of the EHR of Resident #32 documented a quarterly MDS with an ARD date of 10/20/24. On 12/16/24 the MDS was showing as export ready. The MDS revealed a completion date of 11/22/24. The facility had not yet transmitted the completed MDS to CMS (Centers for Medicare & Medicaid Services) per federal guidelines.
According to the 2024 RAI, a Quarterly assessment must be transmitted no later than 14 days after the completion date. The RAI also documents a discharge assessment must be dated for the date of the resident's discharge from the facility and must be completed no later than 14 days following the discharge date .
On 12/12/24 at 4:30 pm, the Director of Nursing stated she is trying to take over the MDS duties as the facility does not have an MDS Coordinator. She stated she is currently locked out of the system but she will get the assessments caught up.
The Facility Policy MDS Assessment Coordinator F642, review date 11/2017 documented A Registered Nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's assessment (RN).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual and facility policy review, the facility failed to fully develop and implement a Co...
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Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual and facility policy review, the facility failed to fully develop and implement a Comprehensive Care Plan for 1 of 5 residents reviewed for Unnecessary Medications (Resident #6). The facility reported a census of 33.
Findings include:
The Minimum Data Set (MDS) Assessment of Resident #6 dated 10/10/24 documented diagnoses that included diabetes and heart failure. The MDS documented the resident received insulin injections on 7 out of 7 days of the assessment reference period.
The Active Diagnoses of Resident #6 listed Diabetes Mellitus due to Underlying condition dated 4/15/2023.
The Active Orders of Resident #6 revealed an order for Insulin Glargine, dated 6/8/24, to be administered every night, and an order for Humalog Insulin, dated 6/13/24, to be administered three times a day based on the resident's blood glucose level.
The Comprehensive Care Plan of Resident #6, last reviewed 12/3/24, failed to reveal any documentation of the resident having the diagnosis of diabetes or orders for insulin.
The 2024 RAI, Page N-6, Planning for Care, High-Risk Drug Classes, documented the following:
High-Risk Drug Classes: Use and Indication (includes hypoglycemic drugs and insulin)
•
Target Symptoms and goals for use of these medications should be established for each resident. Progress towards meeting the goals should be evaluated routinely.
On 12/17/24 at 11:27 am, the [NAME] President of Operations stated her expectation is any active diagnosis which have specific medications and/or treatments for the resident should be included on the Care Plan.
The Facility Policy Comprehensive Care Plans, revision date 8/2022 documented the following:
Policy Statement: An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental, cultural and psychological needs is developed for each resident.
Guidelines, Point 2: The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physicians orders. Assessments of residents are ongoing and Care Plans are revised as information about the resident and the resident's condition change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and policy review the facility failed to review and revise 1 of 1 Care Plans for a resident who vapes (a device used for inhaling vapor containing nicotine and...
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Based on record review, staff interview, and policy review the facility failed to review and revise 1 of 1 Care Plans for a resident who vapes (a device used for inhaling vapor containing nicotine and flavoring) at the facility (Resident #21). The facility reported a census of 33 residents.
Findings include:
During an interview on 12/09/24 at 9:29 AM with the Administrator revealed Resident #21 will occasionally vape.
Record review of Resident #21 Care Plan on 12/11/24 lacked instruction and direction regarding her vaping.
During an interview on 12/12/24 at 12:44 PM with the Director of Nursing (DON) revealed she would expect Resident #21 Care Plan inform she vapes with appropriate safety interventions.
Review of the facilities policy, Accident Prevention - Smoking Policy, effective 8/2024 instructed staff for residents whom wish to smoke will be evaluated for safe smoking per community protocol. The policy lacked instruction to implement into the residents Care Plan.
Review of the facilites policy, Comprehensive Care Plans, effective 8/2024 instructed the following:
Each resident's comprehensive Care Plan is designed to:
a. Incorporate identified problem areas;
b. Incorporate risk factors associated with identified problems;
c. Build on the resident's strengths;
d. Reflect the resident's expressed wishes regarding care and treatment goals if applicable;
e. Reflect treatment goals, timetables and objectives in measurable outcomes;
f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels;
g. Enhance the optimal functioning of the resident
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and policy review the facility failed to implement safety interventions for vaping (a mechanical device used for inhaling vapor containing nicotine and flavori...
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Based on record review, staff interview, and policy review the facility failed to implement safety interventions for vaping (a mechanical device used for inhaling vapor containing nicotine and flavoring) for 1 of 1 residents who vapes at the facility (Residents #21). The facility also failed to ensure 1 of 1 residents who leaves for appointments had appropriate caregivers with her (Resident #8). The facility reported a census of 33 residents.
Findings include:
1. During an interview on 12/09/24 at 9:29 AM with the Administrator revealed Resident #21 will occasionally vape.
Record review of Resident #21 Assessments in her Electronic Health Record (EHR) on 12/11/24 lacked nursing assessment of her vaping.
During an interview on 12/12/24 at 12:44 PM with the Director of Nursing (DON) revealed she would expect Resident #21 to have a smoking assessment completed and implement appropriate safety interventions as needed.
Review of the facilities policy, Accident Prevention - Smoking Policy, effective 8/2024 instructed staff of the following:
Residents whom wish to smoke will be evaluated for safe smoking per community protocol.
2. During an interview on 12/09/24 at 1:42 PM with Resident #8 Power of Attorney (POA) revealed on 12/3/24 resident #8 left the facility for a Cardiologist appointment on a bus unaccompanied by facility staff. She revealed she arrived to Resident #8 appointment shortly after she was dropped off by the bus and found her needing assistance to get checked in, as she is unable to do by herself.
During an interview on 12/12/24 at 12:44 PM with the DON revealed she would expect incompetent residents be assisted to appointments.
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** Based on record review, staff interview, and policy review the facility failed to ensure a Gradual Dose Reduction (GDR) was atte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to ensure a Gradual Dose Reduction (GDR) was attempted yearly for 1 of 3 residents reviewed on an antipsychotic medication (Resident #15). The facility reported a census of 33 residents.
Findings include:
1. The Minimum Data Set (MDS) assessment for Resident #15 dated 9/5/24 documented Brief Interview for Mental Status (BIMS) of 13 indicated severe cognitive impairment. The MDS documented he was admitted to the facility on [DATE] and received antipsychotic medications on a daily basis and a GDR has not been attempted. The MDS documented diagnoses of Non-Alzheimer dementia, depression, and bipolar disorder.
Record review of Resident #15 Orders in his Electronic Health Record (EHR) documented on 12/16/24 he had an active order of Seroquel (oral antipsychotic medication) 25 milligrams daily that started on 6/10/2023.
Record review of Resident #15 Care Plan on 12/12/24 documented an intervention to monitor for any psychotropic drug related problems such as dizziness, confusion and consult with pharmacy and his Doctor for dosage reductions when appropriate.
Record review of resident #15 Progress Notes documented on 2/29/24 a Telemed Psych Note Encounter and instructed a gradual dose reduction is not recommended for Resident #15 as this time to prevent decompensation (the failure to generate effective psychological coping mechanisms in response to stress, resulting in personality disturbance or disintegration).
During an interview on 12/10/24 at 11:42 AM with the Director of Nursing (DON) revealed she would expect all psychotropic medications used by residents be routinely monitored.
The facilities policy Tapering Medications and Gradual Drug Dose Reduction, last revised 9/2022 instructed the following:
For any individual who is receiving an antipsychotic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if:
a. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or
b. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time could be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to accurately document narcotic mediation use and failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to accurately document narcotic mediation use and failed to destroy narcotic medication after discontinuation for 2 of 3 residents reviewed (Resident #20, & #6.) The facility reported a census of 33 residents.
Findings include:
On [DATE] at 4:09 PM, Staff B, Certified Medication Aide (CMA) and Staff A, CMA were at the medication cart counting the narcotics and comparing the number of pills to the documentation on The Controlled Medication Utilization Record (CMUR.) They were frustrated, and Staff A told Staff B that she needed to document right away after giving narcotics and not wait until the end of the shift.
1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status score of 15 (intact cognitive ability.) The resident was totally dependent on staff for toileting hygiene and dressing and she required substantial assistance with sit to stand transfers.
The Care Plan for Resident #6 showed that she was at risk for injury from falls related to impaired mobility. She required assistance of 2 with walking and had chronic pain. Staff were directed to use medication as ordered and document side effects.
An order audit report, from the electronic chart, showed that Resident #6 had an order dated [DATE] at 5:11 AM, for Tramadol tablet 50 milligrams (mg) give 1 tablet every 8 hours as needed (PRN) for pain. The order was discontinued on [DATE] at 10:24 AM, and changed to Tramadol 50 mg Three Times a Day (TID) scheduled.
A review of the narcotics storage drawer on [DATE] revealed that the discontinued PRN package of Tramadol had not been destroyed and was still in the drawer.
The CMUR showed that on [DATE], one tab had been taken from the PRN order and on [DATE], 3 tabs had been used from the PRN order.
The CMUR for the Tramadol 50 mg TID order showed no tabs had been dispensed from this bubble package on [DATE], and just one was dispensed on [DATE]. The Medication Administration Record (MAR) for December was inconsistent with the CMUR and indicated that the resident received 3 doses of Tramadol 50 mg on [DATE].
2) The MDS dated [DATE], showed that Resident #20 did not have a BIMS assessment because she was rarely understood. She required substantial assistance with eating, sit to stand, toilet transfers and was totally dependent for hygiene and dressing.
The Care Plan for Resident #20, updated on [DATE], showed that she was at risk for injury due to impaired safety awareness. The resident had chronic pain related to osteo arthritis and used antianxiety medication related to dementia. She was at risk for alterations in nutritional status and had diagnoses that included chronic kidney disease and heart failure.
A review of the narcotic drawer on [DATE] at 4:10 PM, reveled that Resident #20 had 5 bubble pack cards of Ativan tablets with expired orders.
1. 60 tabs of 1 mg Ativan delivered on [DATE] for the order; ½ tab in the morning and 1 mg in the afternoon, 1 mg at bedtime.
2. 30, ½ tabs of Ativan 1 mg. delivered on [DATE] for the order: ½ tab in the morning 1 mg in the afternoon and 1 mg at bedtime. A sticker in the upper left corner read: morning
3. 8, 0.5 mg Ativan tabs delivered on [DATE] for order: 1 tab at 2 PM, 2 tabs at night. A sticker on left corner read: bedtime
4. 8, 0.5 mg tabs Ativan delivered on [DATE] for order: 1 tab at 2 PM, 2 tabs at night. Sticker on left corner read: afternoon
5. 10, 1 mg tabs Ativan delivered on [DATE] for order: 1 tab three times daily and 1 every 4 hours as needed.
The following medication audits were found in the electronic chart orders tab:
1. Order dated [DATE] at 10:10 PM, Ativan 1 mg every 4 hours as needed for agitation/restlessness. Discontinued on [DATE] at 10:18 AM.
2. Order dated [DATE] at 10:07 PM, Ativan 1 mg three times a day for agitation and restlessness. Discontinued on [DATE] at 4:26 PM.
3. Order dated [DATE] at 2:00 PM, Ativan 1 mg one tab in the afternoon. Discontinued on [DATE] at 10:09 PM.
4. Order dated [DATE] at 1:50 AM, Ativan 1 mg in the evening. Discontinued on [DATE] at 1:50 PM.
5. Order dated [DATE] at 4:33 AM, Ativan 0.5 mg. in the morning for anxiety. Discontinued on [DATE] at 10:16 AM.
6. Order dated [DATE] at 4:29 AM, Ativan 1 mg two times a day for anxiety. Discontinued on [DATE] at 10:17 AM.
The CMUR for Ativan 1 mg. three times daily and 1 ever 4 hours as needed, showed that Staff B signed the CMUR on [DATE] and indicated that one tab had been given that day.
On [DATE] at 5:57 AM, Staff E, Registered Nurse (RN) said that when a narcotic medication was discontinued, they destroy the tabs with two nurses and have a new card with the new orders. She looked at the bubble packages in the drawer for Resident #20 and acknowledged that those should not have been in the drawer anymore because the resident was on Hospice and no long swallowing pills, they were using the liquids.
On [DATE] at 2:30 PM, The Director of Nursing (DON) said that she would expect the nurses to destroy any narcotics that had been discontinued and to make sure that this was completed with a second nurse, and signed.
According to a facility policy titled: Medication Storage, last revised on [DATE], Schedule II drugs would be counted at the beginning and end of every shift, with count compared to Scheduled II medications ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide the therapeutic meals as ordered for 3 of 7 res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide the therapeutic meals as ordered for 3 of 7 residents with altered diets (Resident #30, #22 and #3.) Resident #30 had orders for a pureed diet and was served breakfast with visible chunks, Resident's #22 and #3 had orders for a mechanical soft diet and were served crunchy garlic toast. The facility reported a census of 33 residents.
Findings include:
1) According to the Minimum Data Set (MDS) dated [DATE], Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff assistance for toileting hygiene, dressing, personal hygiene, chair to bed transfers. The resident was on a mechanically altered diet and a feeding tube for nutrition.
The Care Plan last updated on 9/23/24, showed that Resident #30 had impaired communication and said very few words. He required assistance with Activities of Daily Living (ADLs) related to an amputation above the left knee and he was bedfast most of the time. He required assistance with eating with pureed foods, as well as tube feedings during the day.
The orders tab in the electronic chart showed an order dated 10/11/23 at 12:04 PM, for a regular diet, pureed texture.
In an observation on 12/10/24 at 8:20 AM, Resident #30 was in a wheel chair at the dining room table. An unidentified staff person assisted him with eating the pureed eggs and toast with green peppers. The eggs contained visible chunks of green peppers that were not creamed as per a pureed textured diet.
2) The MDS dated [DATE], showed that Resident #22 had a BIMS score of 3 (severe cognitive deficit.) The resident required substantial assistance with hygiene, dressing, sit to stand and toilet transfers. She was on a mechanically altered diet and required set up assist with eating.
The Care Plan updated on 9/26/24, showed that Resident #22 had impaired cognitive function/dementia related to metabolic encephalopathy. The resident had oral/dental health problems, edentulous poor oral hygiene. Staff were to serve the diet as ordered, consult with dietitian if changes in chewing or swallowing problems were noted. Resident #22 had nutritional problems related to dysphagia and speech therapy recommended a mechanical soft diet with thin liquids.
3) The MDS dated [DATE], showed that Resident #3 had a BIMS score of 9 (moderate cognitive deficits.) He required substantial assistance with oral hygiene, toileting hygiene, and dressing, and set up assistance only with eating a mechanically altered diet.
The Care Plan updated on 10/3/24, showed that Resident #3 had alterations in cognition related to dementia, staff were to monitor intake to assure an adequate fluid intake to prevent dehydration and to provide and serve diet as ordered.
An order dated 4/8/24 at 10:05 AM, Showed that Resident #3 had a regular diet order with mechanical soft texture, thin consistency, cut up food into smaller pieces.
In a review of the altered diet menu on 12/11/24 at 12:00 PM, Staff C, Cook, and Staff D, Cook, acknowledged that they did not understand the acronyms listed in the different columns of diet texture used by the International Dysphagia Diet Standardization Initiative (IDDSI.) They did not know what SBMM (Small Bite Minced & Moist) meant on the altered menu. They were not sure which column on the menu was related to what they knew as mechanical soft. The Small Bite (SB) column and the Minced and Moist (MM) column required a pureed dinner roll for the bread option on 12/11/24. The SB and MM columns both indicated the lasagna (SBMM) would be small bites, minced and moist.
On 12/11/24 at 12:15 PM, Staff C served Resident #22 and Resident #3 crispy garlic toast.
On 12/11/24 at 4:30 PM, the Dietician said that she had talked to the staff about the different IDDSI codes and what those diets looked like, but she also acknowledged that it was often complicated for the staff to know the differences. She said that serving garlic toast to resident on mechanical soft was concerning and they should have known not to serve crisp bread. The Dietician also said that the chunks of green pepper in the pureed eggs was concerning, they should have pureed the eggs until it was smooth, or just not add the green pepper.
On 12/12/24 at 9:39 AM, The Dietary Manager (DM) said that she was very frustrated with the IDDSI menus and trying to teach staff what foods they could serve on a mechanical soft diet. She said she would reach out to the Dietician and work on finding a solution.
A facility policy titled: Therapeutic Diets, effective on 10/2024, indicated that the mechanically altered diets, as well as diets modified for medical or nutritional needs would be considered therapeutic diets. The regular menu would be modified by the Registered Dietitian for therapeutic diets with the input from the Dietary Manager.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, and interview the facility failed to provide pneumococcal vaccine as requested for 1 of 5 res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and policy review, and interview the facility failed to provide pneumococcal vaccine as requested for 1 of 5 residents reviewed. Resident #34 consented to receive the vaccine and the facility failed to follow through and provide the immunization. The facility reported a census of 33 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) She was independent with toileting, dressing, transfers and eating.
The Care Plan updated on 10/3/24, showed that Resident #34 was receiving radiation/chemotherapy treatments related to breast cancer.
According to the Vaccine tab in electronic chart, Resident #34 was given an influenza vaccine on 10/23/24.
A Pneumococcal Vaccine Informed Consent dated 9/11/24 at 9:56 AM, signed by the Power of Attorney (POA), indicated that they received information and gave consent to receive the vaccine.
On 12/12/24 at 2:30 PM, the Director of Nursing (DON) said that any vaccines received at the facility would be documented in their record. She was not at the facility in September and didn't know why the pneumococcal vaccine had not been administered to Resident #34.
A facility policy titled; Pneumococcal Vaccine, last revised 10/2024 showed that residents would be offered the pneumococcal vaccine to aid in preventing pneumococcal infections. Prior to admission, resident would be assessed for eligibility to receive the pneumococcal vaccine and when indicated would be offered the vaccination unless medically contraindicated or the resident had already been vaccinated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review, the facility failed to provide the Covid-19 immunization booster as requested for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record and policy review, the facility failed to provide the Covid-19 immunization booster as requested for 2 of 5 residents. Resident's #20, and #30 signed consent agreements to get the Covid-19 booster, the facility failed to follow through and provide those immunizations. The facility reported a census of 33 residents.
Findings include:
1) According to the Minimum Data Set (MDS) dated [DATE], Resident #20 did not have a Brief Interview for Mental Status (BIMS.) assessment because she was rarely understood. She required substantial assistance with eating, sit to stand, toilet transfers and was totally dependent for hygiene and dressing. The MDS showed that her Covid-19 vaccination was up to date.
The Immunization tab for Resident #20, showed that Resident #20 received dose 2 of the Covid-19 vaccine which was administered on 4/8/21.
The care plan for Resident #20, updated on 10/13/24, showed that she was at risk for injury due to impaired safety awareness. She had chronic pain related to osteo arthritis and used antianxiety medication related to dementia. She was at risk for alterations in nutritional status and had diagnoses that included chronic kidney disease, heart failure, and history of Covid-19.
A Resident Consent Form for Covid-19 Vaccine (RCFCV) dated 5/13/24, showed that a resident representative gave verbal permission for the resident to get the vaccine.
2) According to the Minimum Data Set (MDS) dated [DATE], Resident #30 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff assistance for toileting hygiene, dressing, personal hygiene and chair to bed transfers. The resident was on a mechanically altered diet and a feeding tube for nutrition.
The care plan last updated on 9/23/24, showed that Resident #30 had impaired communication and said very few words. He required assistance with Activities of Daily Living (ADLs) related to an amputation above the left knee and he was bedfast most of the time. He required assistance with eating pureed foods, as well as tube feedings during the day.
The Immunization tab in the electronic chart lacked documentation of a Covid-19 immunization.
A RCFCV form showed that on 5/13/24, the Power of Attorney (POA) gave permission via telephone, to administer the Covid-19 vaccine to Resident #30.
On 12/12/24 at 2:30 PM, the interim Director of Nursing (DON) acknowledged that the facility did not have any evidence that the Covid-19 booster had been offered to residents. She thought that maybe the pharmacy would have come to the facility to provide those in the fall, but according to the resident files, that had not happened in 2023 or 2024.
According to a facility policy titled: Vaccination of Residents, Including Influenza, Pneumococcal, RSV and COVID-19, effective 10/2024, residents would be offered flu, pneumovax and COVID-19 vaccinations per CDC (Centers for Disease Control) and CMS (Center for Medicaid and Medicare Services) guidelines, based upon availability to the community. The community would offer the COVID-19 vaccination when available to the community.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on record review, resident and staff interviews and policy review the facility failed to ensure 29 of 29 residents who use the facility to manage their personal finances had access to their fund...
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Based on record review, resident and staff interviews and policy review the facility failed to ensure 29 of 29 residents who use the facility to manage their personal finances had access to their funds as desired including evening and weekends. The facility reported a census of 33 residents.
Findings include:
1. The Minimum Data Set (MDS) Assessment for Resident #24 dated 7/27/24 documented a Brief Interview for Mental Status (BIMS) of 15 indicated no cognitive impairment.
During an interview on 12/09/24 at 10:59 AM with Resident #24 revealed he did not have access to his personal fund on the weekend.
2. The MDS assessment for Resident #12 dated 7/20/24 documented a BIMS of 15 indicated no cognitive impairment.
During an interview on 12/10/24 at 11:51 AM with Resident #12 revealed he did not have access to his personal funds when he needs money, and informed it can take several days.
3. The MDS assessment for Resident #4 dated 8/1/24 documented a BIMS of 15 indicated no cognitive impairment.
During an interview on 12/10/24 at 11:35 AM with Resident #4 revealed she requested on 12/4/24 a gift card for $50 and has not received it yet. She then informed the lady in charge of Social Services ran out of cash and could not get it for her yesterday, and ever since she took over they have had problems with getting money and has been going on since June 2024.
During a follow up interview on 12/12/24 at 10:42 AM with Resident #4 revealed she requested on 12/4/24 a gift card for $50 and still has not received it.
During an interview on 12/12/24 at 11:12 AM with the facilities Social Services revealed she spoke with Resident #4 this morning and discussed the $50 gift card.
During an interview on 12/12/24 at 10:30 AM with the facilities Senior Revenue Cycle Manager, revealed the facility had a $300 petty cash supply on hand and when it gets to $150 the facilities Social Services employee is to contact her and ask for more petty cash to keep the balance around $300. She revealed if multiple residents requested cash from their accounts on the same day or over the weekend the facility would have to divide the $300 out evenly and residents may not get the amount of money they request, even if it is in their account. She then informed if a resident requests cash over $99 they will give them a check and that takes around 48 hours to process. She then revealed if all 29 residents that had their personal funds managed by the facility requested $50 dollars on the same day equaling $1,450 the facility would not be able to give the residents their money as they only had $300 in the building at most at a time.
Record review of the facilities job description for Social Services Director, last revised 6/2021 lacked information this position would manage resident personal funds.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, staff interview the facility failed to keep the walls and floors in good repair in hallways and shower room. The facility also failed to keep the facility free of unpleasant ammo...
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Based on observation, staff interview the facility failed to keep the walls and floors in good repair in hallways and shower room. The facility also failed to keep the facility free of unpleasant ammonia odors (urine). The facility reported a census of 33 residents.
Findings include:
During an observation of the facility on 12/09/24 at 12:45 PM a strong unpleasant ammonia (urine) odor was present on the facilities west hallway.
During an observation of the facility on 12/10/24 at 11:51 AM a a strong unpleasant ammonia (urine) odor was present on the facilities south hallway.
During an interview on 12/12/24 at 12:44 PM with the facilities Director of Nursing (DON) revealed the facility should not have a smell of urine.
During onsite observations of the facility on 12/9/24, 12/10/24, 12/11/24, 12/10/24 and 12/16/24 the facilities East hallway had a broken recliner with brown substance in the hallway. Chipped paint on doors, walls, and floor boards as well as broken tile on the flooring were observed.
An observation of the facilities East hallway shower room on 12/16/24 at 2:42 PM revealed the shower room was missing tiles, 8 plus floor tiles stained with a brown substance, gaps in the shower wall that would allow water in, and lacked floor boards.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Employment Screening
(Tag F0606)
Could have caused harm · This affected multiple residents
Based on observation, interviews and record review, the facility failed to ensure that background checks were cleared before staff worked in the resident population. An agency staff worked 3 shifts as...
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Based on observation, interviews and record review, the facility failed to ensure that background checks were cleared before staff worked in the resident population. An agency staff worked 3 shifts as a Certified Nurse Aide (CNA) with a suspended certification due to abuse. The same staff worked 1 shift passing medications as a Certified Medication Aide (CMA) without verification of education or certification as a CMA. The Director of Nursing (DON) started working for the facility before a background check had been completed. The facility reported a census of 33 residents.
Findings include:
1) In an observation on 12/9/24 at 3:31 PM, Staff B, CMA was at the medication cart and fumbled through the med cards to find medications. She went from the second drawer to the third drawer several times, then went to Staff A, CMA for assistance. He looked in the cart and pulled out a bubble pack of pills and handed it to her.
On 12/9/24 at 4:00, Staff B and Staff A were at the medication cart counting the narcotics at shift change. Staff A expressed frustration as he instructed Staff B to document on the narcotic sheet at the time of administration because the count for several narcotics had been off. Staff B said she was taught to document at the end of the shift.
On 12/10/24 at 8:57 AM Staff B said that she had just started at the facility and she did not get any orientation on the medication cart. She said that she was just given the keys and left to figure it out on her own. When asked where she received her medication aide certificate she said I didn't get it around here.
On 12/11/24 at 2:51 PM Staff A said he had trouble with Staff B the previous day on the medication cart because she didn't seem to understand. Staff H, Scheduler, said others had noticed that she was struggling, and many times, she had to ask someone to help her find the medications.
On 12/11/24 at 10:55 AM, Staff H, scheduler, said she did not have a file for Staff B or an orientation checklist. On 12/12/24 at 8:30 AM, Staff H said that some of the staffing agencies that the facility contracted with would provide access to their portal so she could see the staff information, but the Staffing Agency (SA) that hired Staff B had not provided copies of background checks or certification verification. Staff H said that she had reached out to them to get a copy of her file.
A Single Contact License and Background Check (SING) dated 12/11/24 at 12:07 PM, showed that Staff B was ineligible to work in Iowa and further research was required.
A report from the Direct Care Worker website on 12/11/24 at 2:28 PM, revealed that the status of Staff B, Certified Nurse Aide was listed as abuser.
On 12/12/24 at 9:14 AM, a representative from the SA said that she was in charge of the contracts and scheduling for the facilities, and not responsible for taking applications or doing the background checks. She said they had a Human Resources Department and did not understand how Staff B had been sent out to work in a facility when she was ineligible. The SA representative said that she talked to Staff B and asked her about her CMA certification. Staff B just responded that she would get a copy to her, but she would not tell her where she had gotten her education.
As of 12/17/24 at 12:45 PM, the SA had not returned requests to call on 12/12/24 at 11:25, and 12/16/24 at 1:28 PM.
On 12/12/24 at 11:52 AM, the Director of Nursing (DON) said that the day that Staff B was working on the medication cart was horrible. She said that the staff member was confused, and looked like she hadn't ever administered medications before. The DON said that the Agency was responsible for doing the background checks and the facility must be able to trust that they are doing their job to verify licensure and certification. She said that the facility did not have the time to be looking up the background of all agency staff.
An investigation of all the agency staff that were scheduled to work at the facility in the previous 3 months, revealed that Staff K, CNA did not have a valid certification as a nurse aid.
On 12/16/24 at 4:30 PM, the Administrator said that she was in touch with the agency and they did not have verification that Staff K, CNA had a certification. She said that Staff K hadn't actually worked at the facility because she called in sick the one day that she was scheduled.
According to the facility policy titled: Abuse Prevention Program, Prevention of Abuse, review date of 4/2025, the community would establish policies and procedures encompassing all facets of the Abuse Program, including screening. The abuse prevention/intervention program included conduction of background investigations per state regulations.
2. Record review of the Director of Nursing (DON) Single Contact License & Background Check was ran on 11/22/24 and due to further research required not completed until 11/26/24.
Record review of the DON's time sheet revealed she was employed by the facility on 11/22/24 and worked the following hours:
11/22/24 - 8.75 hours
11/23/24 - 9 hours
11/24/24 - 7.5 hours
11/25/24 - 11.5 hours
11/26/24 - 11.5 hours
During an interview on 12/11/24 at 11:42 AM, Staff H, Certified Nurse Aide (CNA), Scheduler, revealed the Administrator instructed the DON she was allowed to start working at the facility but to stay away from residents.
During an interview on 12/12/24 at 12:44 PM, the DON revealed she started at the facility on 11/12/24 and was supposed to meet with Staff N, Human Resources Manager but she was not in the building to do her paperwork. She then informed she is aware a background check needs to be completed but didn't have it done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Quarterly...
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Based on clinical record review, staff interview, guidance from the 2024 Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to complete and transmit Quarterly Minimum Data Set (MDS) Assessments within federal guidelines for 9 of 14 residents (#4, #5, #7, #8, #9, #12, #19, #23, #34) reviewed for MDS Assessments. The facility reported a census of 33 residents.
Findings include:
1. The Quarterly MDS for Resident #4 documented an ARD of 11/1/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the Electronic Health Record (EHR) of Resident #4 documented the prior quarterly MDS had an ARD date of 8/1/24.
2. The Quarterly MDS for Resident #5 documented an ARD of 11/10/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #5 documented the prior quarterly MDS had an ARD date of 8/10/24.
3. The Quarterly MDS for Resident #7 documented an ARD of 10/25/24. On 12/16/24 the MDS was still displayed as In Progress. Ten of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #7 documented the prior MDS, admission MDS, had an ARD date of 7/25/24.
4. The Quarterly MDS for Resident #8 documented an ARD of 11/23/24. On 12/16/24 the MDS was still displayed as In Progress. Ten of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #8 documented the prior quarterly MDS had an ARD date of 8/23/24.
5. The Quarterly MDS for Resident #9 documented an ARD of 11/17/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #9 documented the prior quarterly MDS had an ARD date of 8/17/24.
6. The Quarterly MDS for Resident #12 documented an ARD of 10/20/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #12 documented the prior quarterly MDS had an ARD date of 7/20/24.
7. The Quarterly MDS for Resident #19 documented an ARD of 10/20/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #19 documented the prior quarterly MDS had an ARD date of 7/20/24.
8. The Quarterly MDS for Resident #23 documented an ARD of 11/7/24. On 12/16/24 the MDS was still displayed as In Progress. Nine of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #23 documented the prior MDS, Annual MDS, had an ARD date of 8/7/24.
9. The Quarterly MDS for Resident #34 documented an ARD of 11/12/24. On 12/16/24 the MDS was still displayed as In Progress. Eleven of sixteen sections of the MDS were not documented as complete. The MDS section of the EHR of Resident #34 documented the prior MDS, admission MDS, had an ARD date of 8/12/24.
According to the 2024 RAI, a Quarterly assessment must be completed no later than the 14th calendar day after the ARD date, and the ARD date must be no longer than 92 days following the prior assessment.
On 12/12/24 at 4:30 pm, the Director of Nursing stated she is trying to take over the MDS duties as the facility does not have an MDS Coordinator. She stated she is currently locked out of the system but she will get the assessments caught up.
The Facility Policy MDS Assessment Coordinator F642, review date 11/2017 documented A Registered Nurse (RN) shall be designated the responsibility of conducting and coordinating each resident's assessment (RN).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on clinical record review, staff interview and facility policy, the facility failed to implement and maintain a Restorative Program for 6 of 6 residents reviewed who require assistance to comple...
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Based on clinical record review, staff interview and facility policy, the facility failed to implement and maintain a Restorative Program for 6 of 6 residents reviewed who require assistance to complete their Activities of Daily Living (Resident #1, #8, #9, #19, #30, #32)
Findings Include:
1. The Minimum Data Set (MDS) of Resident #1 dated 8/9/24 revealed the resident required supervision for sitting to standing, chair/bed-to-chair transfers and toilet transfers. The MDS revealed the resident required partial/moderate assistance for tub/shower transfer, total staff assistance for toileting hygiene and substantial assistance for bathing. The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #1 failed to document any restorative nursing programs.
2. The MDS of Resident #8 dated 8/23/24 revealed the resident to be dependent upon staff for bathing. The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #8 documented the resident to be incontinent of bowel and bladder. The Care Plan documented the resident required assistance with bathing, dressing, toileting, and transferring. The Care Plan failed to document any restorative nursing programs.
3. The MDS of Resident #9 dated 8/17/24 revealed the resident to require substantial assistance for eating and bathing. The MDS coded the resident to be dependent upon staff for oral hygiene, toileting hygiene, and dressing. The MDS coded the resident to require substantial assistance for sit to stand and toilet transfers The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #9 failed to document any restorative nursing programs.
4. The MDS of Resident #19 dated 7/20/24 revealed the resident to be dependent upon staff assistance for oral hygiene, toileting hygiene, dressing and bathing. The MDS coded the resident to be dependent upon staff for transfers and required substantial staff assistance for bed mobility. The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #19 failed to document any restorative nursing programs. A Care Plan goal for the resident listed as follows; I will maintain current level of function through the review date. (Target date 2/20/25).
5. The MDS of Resident #30 dated 9/19/24 revealed the resident to be dependent upon staff for bathing, hygiene, dressing, transferring and bed mobility. The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #30 failed to document any restorative nursing programs. The Residents Care Plan identified contractures to the right upper and lower extremities.
6. The MDS of Resident #32 dated 10/20/24 revealed the resident to require substantial staff assistance for dressing, toileting hygiene, and tub/shower transfers. The MDS revealed the resident received no Restorative Therapy services.
The Care Plan of Resident #30 failed to document any restorative nursing programs.
On 12/11/24 at 9:56 am, the Director of Nursing (DON) stated the facility does not have a Restorative Aide on staff. She additionally stated none of the nurses or Certified Nurse Aides performed any Restorative programs and none of the facility's residents currently had any Restorative program. She said the facility is short staff and she is working on hiring and hopes to include a Restorative Aide.
The Facility Policy Goals and Objectives, Restorative Services, Revision date 10/2024 documented a Policy Statement of Specialized rehabilitative service goals and objectives shall be developed for problems identified through resident assessments.
Point 1 - Rehabilitative goals and objectives are developed for each resident and are outlined in his/her plan of care relative to therapy services.
Point 2 - Goals may include, but are not limited to:
a. Assisting the resident in adjusting to his/her abilities
b. Assisting the resident in developing and strengthening his/her physiological and psychological resources;
c. Encouraging the resident to maintain his/her independence and self-esteem;
d. Encouraging the resident to participate in the development and implementation of his/her plan of care; and
e. Other information as may become necessary or appropriate.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review the facility failed to ensure a clean, well maintained kitchen area for food preparation, failed to maintain adequate water temperature on the dishwas...
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Based on observation, interview and record review the facility failed to ensure a clean, well maintained kitchen area for food preparation, failed to maintain adequate water temperature on the dishwasher, and failed to use proper sanitation and glove use during lunch service. The facility reported a census of 33 residents.
Findings include:
In an observation of the kitchen on 12/11 at 11:30 AM, it was discovered that just inside the kitchen, there was a wood counter top with a surface that was peeling off. The kitchen staff said that someone had used a counter top paint, not realizing that the chemical cleaners would cause it to peel. Several of the doors and door frames had chipped and stained paint. The corners of the floors and along the floor base was dirty and stained. The garbage disposal water lines had built up rust and dirt collected around and underneath.
A thermometer below the dishwasher read 110 degrees Fahrenheit (F). Staff D, Dietary Aide acknowledged that the target temperature was 120 but it wasn't getting any higher than 118 F. She said that they had a new water heater in the basement but the maintenance man failed to get it hooked up and he had been terminated. A review of the temperature log posted on the refrigerator showed that the temperatures for the month of December, logged three times a day, on just one occasion had gotten up to 120 degrees F.
On 12/11/24 at 11:30 AM, kitchen staff prepared the lunch and a pan of garlic toast was on a cookie sheet, on the top of the stove. Staff C prepared the pureed meals, beginning with the broccoli. As he scooped the vegetable out of the pan and into the blender, he laid the utensil on the counter without a barrier, where there were visible crumbs.
On 12/11/24 at 12:15 PM, Staff C donned disposable gloves, touched several surfaces, utensils and bread bag, then with the same gloved hands retrieved a piece of bread from the bag. As he prepared a peanut butter sandwich, he set the bread on the counter without a barrier.
On 12/12/24 at 9:39 AM, the Dietary Manager (DM) said that she was aware of the temperatures on the dishwasher not getting above 118 degrees F most of the time. The maintenance man left abruptly and didn't get the new water heater hooked up. She acknowledged the need for paint on the doors and walls, and the need to deep clean stained corners on the floors. The DM said that she hadn't noticed paint chipping off of the wood counter and said that they have stainless steel tables that could be installed. The DM said that the glove use and putting the bread on the counter without barrier are concerns with infection control and she would reeducate staff.
According to the facility policy titled: Handwashing/Hand Hygiene, last revised 10/2022, Staff would follow the Handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. The use of gloves did not replace Handwashing/hand hygiene.
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 observations, clinical record review, staff interviews, guidance from the Centers for Disease Control (CDC) and facility policy review the facility failed to follow infection control standard...
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Based on observations, clinical record review, staff interviews, guidance from the Centers for Disease Control (CDC) and facility policy review the facility failed to follow infection control standards during personal care of a resident (Resident #30) and during medication administration. The facility also failed to properly sanitize the ice machine, develop a water management plan and conduct infection control audits. The facility reported a census of 33 residents.
Findings include:
1. The Minimum Data Set (MDS) of Resident #30, dated 9/19/24 identified a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. The MDS documented the resident to be dependent upon staff to perform toileting hygiene. The MDS recorded the resident to always be incontinent of bowel and bladder. The MDS documented the presence of a feeding tube.
The Care Plan of Resident #30 documented a Focus Area of Enhanced Barrier Precautions in place to decrease transmission of CDC-targeted MDRO's (multi drug resistant organisms), dated 9/23/24. The Care Plan stated this was related to Gastronomy (feeding tube). The Care Plan directed staff to use Personal Protective Equipment (PPE) when providing high-contact resident care activities including changing briefs or assisting with toileting. The Care Plan documented an additional Focus Area requiring assistance with Activities of Daily Living (ADLs) due to amputation of left leg above the knee, revision date 7/2/24. The Care Plan directed staff the resident to be totally dependent for toilet use. The Care Plan documented the resident to be incontinent at all times due to his inability to safely sit on a toilet.
Observation on 12/9/24 at 10:53 am, Resident #30 was lying in bed. A strong odor of urine was noted in the room. His brief was visibly soaked with urine. At the entrance to his room, an Enhanced Barrier Precautions (EBP) sign was on the wall and a fully stocked isolation cart was at the doorway to the room.
An article from the CDC dated 6/28/24 titled Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes documented the following:
Point 1. Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of Multidrug-Resistant Organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).
Point 3. Enhanced Barrier Precautions require the use of gown and gloves only for high-contact resident care activities (unless otherwise indicated as part of Standard Precautions). Residents are not restricted to their rooms and do not require placement in a private room. Enhanced Barrier Precautions also allow residents to participate in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.
On 12/11/24 at 9:25 am, Staff L, Certified Nurse Aide (CNA) was observed wheeling Resident #30 back to his room following breakfast. At 9:28 am, Staff I, CNA joined Staff L to transfer Resident #30 back to his bed.
On 12/11/24 at 9:30 am, the State Surveyor knocked and asked permission to enter the room to observe the staff providing care. Resident #30 was in his specialty wheelchair with a full body mechanical lift sling in place under his body. Staff I and Staff L, CNAs, were both wearing gloves and were in the process of attaching the sling loops to the full body lift. No additional PPE was observed.
At 9:32 am, Staff I removed the disposable bed pad from the resident bed and Staff L placed a new clean bed pad on the bed. The resident was then lowered to the bed and the sling of the full body mechanical lift was disconnected from the lift. At 9:34 am, Staff L reached for a clean incontinent brief which was on the sink vanity at the entrance to the room. Staff I assisted the resident to turn to his right side and Staff L tucked the sling underneath the resident as both staff assisted to lower the resident's pants. Staff I reached to open the tabs on the soiled incontinent brief.
Still wearing the same gloves, Staff L then opened the nightstand drawer and obtained wet wipes. She used her left hand to assist the resident to stay on his side and took wet wipes from the package with her right hand. She then moved the wipes into her left hand and cleansed the resident's buttocks of stool. She repeated this process multiple times due to the resident being incontinent of bowel. Staff I then began to obtain clean wipes from the package and hand them to Staff L. The package of wet wipes was emptied and Staff L obtained a new package from the nightstand drawer and continued cleansing Resident #30's buttocks. Staff L then tucked the soiled incontinent brief underneath the resident and then removed her gloves and placed them in the trash can. Staff L walked into the bathroom and obtained new gloves and placed them on her hands. Staff L failed to do any hand hygiene. Staff L then tucked the clean incontinent brief under the resident. Both staff then assisted the resident to turn to his left side. Staff I removed the heel protector from the resident's foot, removed the full body lift sling from under the resident and placed it directly on the floor next to the bed. Staff I then reached for the wet wipes from the head of the bed and began to cleanse the resident buttocks from her side. She placed the soiled wipes inside of the soiled brief which was lying on the bed with no barrier. After the resident's buttocks were cleaned, Staff L picked up the trash can off the floor. She held it over the bed and Staff I placed the soiled brief in the trash can. Both staff at this time removed their gloves. Neither staff member performed hand hygiene. Neither staff were observed performing any incontinence cares on the front of Resident #30, only on his buttocks.
Staff I then secured the clean brief to the resident. She picked up the heel protector from the bed and placed it on the vanity. She then picked up the full body lift sling off of the floor. Staff L moved the bed back into place and obtained a fall mat from across the room. Staff I continued to hold the soiled full body mechanical lift sling in her hands, and picked up the remote control for the bed to lower the bed to the lowest position and raise the head of the bed. Staff L picked up the trash bag from the trash can. Staff I then put the lift sling back onto the floor and walked to the sink and washed her hands. Staff L then pushed the resident's wheelchair to the hallway, and left the room with the trash bag with no hand hygiene witnessed. Staff I put the resident's call light in his reach and picked the soiled lift sling up off the floor. She carried it down the hall and placed it in the laundry barrel and walked down the hall in the opposite direction of the resident's room. Staff L returned to the room with new trash bags and placed a clean trash liner in the trash can. She then washed her hands prior to exiting the room.
On 12/11/24 at 9:47 am, Staff L was asked by the State Surveyor if she had received any education from the facility regarding Enhanced Barrier Precautions. She stated she had not. When asked if she was aware of why there was signage and a stocked isolation cart at the doorway to Resident #30's room, she stated she was not aware of the reason for that.
On 12/12/24 at 10:33 am, the Interim Director of Nursing (DON) stated she would expect staff to wash their hands or use hand sanitizer prior to beginning personal care for a resident. She stated after touching any equipment, etc, gloves should be changed and hand hygiene performed. She stated gloves are not needed to transfer a resident using a lift. Staff should prepare to perform peri cares, then wash hands and place gloves on. She also stated she gave education to the staff the prior evening regarding enhanced barrier precautions and all staff signed a document that they received education and understood. She stated additional staff were educated on the day shift that morning.
The facility policy titled Perineal Care, revision date 10/2023 documented the following:
Step 1: Place the equipment on the bedside stand, arrange the supplies so they can be easily reached.
Step 2: Wash and dry hands thoroughly.
Step 6: Raise the resident gown or lower the pajamas.
Step 7: Put on gloves
Step 10 b (male resident): Wash perineal area starting with urethra and working outward. Continue to wash the perineal area including the penis, scrotum and inner thighs. Do not reuse the same washcloth or disposable wipes to clean the urethra.
Step 10 f: Instruct or assist the resident to turn on his side with his upper leg slightly bent, if able.
Step 10 h: Wash the rectal area thoroughly, including the area under the scrotum, the anus and the buttocks.
Step 11: Discard disposable items into designated containers.
Step 12: Remove gloves and discard into designated containers. Wash and dry hands thoroughly.
Step 13: Reposition the bed covers. Make the resident comfortable.
Step 14: Place the call light within easy reach of the resident.
Step 15: Return supplies to designated area
Step 16: Clean the bedside stand
Step 17: Wash and dry your hand thoroughly.
2. On 12/12/24 at 1:20, it was discovered that a sign off sheet hung on the side of the ice machine. The form was titled: Ice Machine Cleaning and Sanitizing; Dietary Weekly Cleaning Log. The most recent time that all the ice was emptied and machine sanitized was 10/14/24. The bucket and scoop last sanitized on 11/8/24. Staff F from housekeeping said he wasn't sure who was responsible to complete the task.
3. On 12/10/24 at 7:46 AM, Staff A, Certified Medication Aide (CMA) prepared oral medications for an unidentified resident in the dining room. He put the pills in a small cup and filled a glass with water. He then carried the cup of water to the table with his finger inside the cup of water.
4. On 12/12/24 at 2:20 PM, Corporate Maintenance Manager (CMM) said that he traveled to different facilities to monitor the maintenance departments, and the last time he had been at this facility was the previous week. He said that they had trouble with Maintenance Man (MM) tried on many occasions to direct and teach him, but the monthly checks and documenting just wasn't getting done so they eventually had to let him go. The previous MM told him that he was doing the check, but when the CMM visited the building he found it was not completed.
When asked about the water born pathogen program and where to find the plan and mapping, the CMM said it could be found in the Maintenance Book or Fire Marshall book. A review of both binders found that the water management forms were in the binder but had not been completed.
The facility failed to establish and review water system annually and document in the Infection Control Committee minutes. Failed to demonstrate they had taken measures to minimize risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program.
A facility policy titled; Water Management, Legionella Testing showed that the facility would handle and maintain it's water supply in accordance with recommendations of the CDC (Center For Disease Control), Healthcare Infection Control Practices Advisory Committee and the FDA (Food and Drug Administration.) The community would demonstrate its measures to minimize their risk of Legionella and other opportunistic pathogens in the building water system through a documented water management program. They would complete the review of the water system annually and document in the Infection Control Committee minutes.
5. During an interview on 12/12/24 at 12:38 PM with the DON revealed she has completed audits for infection control, including hand washing and Personal Protective Equipment (PPE) applying and removing but is unable to find them. She also informed she would expect routine and random infection control audits be completed to ensure infection control practices are being followed by all staff.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on facility record review, staff interview and facility policy review, the facility failed to hold quarterly Quality Assurance Process Improvement (QAPI) meetings for 2024. The facility addition...
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Based on facility record review, staff interview and facility policy review, the facility failed to hold quarterly Quality Assurance Process Improvement (QAPI) meetings for 2024. The facility additionally failed to employ a required Quality Assessment & Assurance (QAA) committee member, a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body. The facility reported a census of 33 residents.
Findings include:
On 12/9/24 at 9:29 am, the Interim Director of Nursing (DON) stated the facility did not have an infection preventionist. She stated she is currently enrolled in the course and will be overseeing the role for the facility.
On 12/10/24, the DON provided a Self-Identification & Correction Form. The form identified the facility had no active QAPI program for Monitoring, Performance Improvement Project (PIP) identification of collaboration between departments to ensure that audits/issues are being taken care of. The form identified this was noted on 11/22/24. It identified monthly meetings would begin in January.
On 12/11/24 at 8:56 am, the DON stated the facility's administrator had started at the facility in September of 2024 and there has been no formal QAPI program in the facility under his leadership.
A QAPI binder provided during the survey documented monthly signature sheets for employees in attendance at monthly meetings.
No signature sheets were provided for January through April. Signature sheets for May, June and July were dated 2023 rather than 2024.
The first signature sheet provided for 2024 was dated 8/30/24. No designated Infection Preventionist was listed on the signature sheet.
The second signature sheet provided for 2024 was dated 9/27/24. Neither the Director of Nursing or any nurse was present for this meeting. The Medical Director was noted to have been called an hour after the meeting began.
The facility policy titled Quality Assessment and Performance Improvement Plan and Program F865, revision date 10/2022 identified the following:
Point 5:
a. Develop, implement and maintain an effective, comprehensive, data driven QAPI Program that focuses on indicators of the outcomes of care and quality of life.
b. Maintain evidence of ongoing QAPI Program which include:
i. Reports demonstrating identification ,reporting, investigation, analysis and prevention of adverse events;
ii. Data collection and analysis at regular intervals; and
iii. Documentation demonstrating development, implementation and evaluation of corrective actions or performance improvement activities.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected most or all residents
Based on record review, staff interview and policy review the facility failed to ensure an antibiotic stewardship program was in place for 33 of 33 residents. The facility reported a census of 33 resi...
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Based on record review, staff interview and policy review the facility failed to ensure an antibiotic stewardship program was in place for 33 of 33 residents. The facility reported a census of 33 residents.
Findings include:
Record review of Resident #8 Orders on her Medication Administration Record (MAR) on 12/11/24 revealed she is currently taking an antibiotic, Nitrofurantoin 100 milligrams (mg) twice a day for UTI prophylaxis (an attempt to prevent disease) she started on 12/3/24.
Request was made on 12/12/24 at 12:29 PM to review resident antibiotic tracking logs since January 2024 to December 2024 and the facility was unable to provide the requested documentation.
During an interview on 12/12/24 at 12:32 PM with the Director of Nursing (DON) revealed she started her position in November 2024 and was unable to locate tracking of antibiotic usage for residents from January 2024 to November 2024. She then informed she had a plan in place to start tracking but it will not start until January 2025 and nothing had been tracked for December 2024 thus far. She revealed she write down a few residents that had infections in November 204 but did not verify if lab cultures were completed or McGreers criteria was met (A set of surveillance definitions for infections in long-term care facilities. The criteria are used to identify infections by considering the clinical presentation, microbiologic and radiological information, and any other relevant findings).
Review of the facilities policy dated 12/2024, Infection Prevention and Control Program, instructed a procedure to follow for tracking infections, however the facility was unable to provide documentation it was completed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on staff interviews, job description, and policy review the facility failed to employee a qualified person to serve as the Infection Preventionist (IP) for the facility. The facility reported a ...
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Based on staff interviews, job description, and policy review the facility failed to employee a qualified person to serve as the Infection Preventionist (IP) for the facility. The facility reported a census of 33 residents.
Findings include:
During and interview on 12/09/24 at 9:29 AM with the Administrator revealed the facility did not have an IP employed at the facility but the Director of Nursing (DON) is enrolled in a course.
During an interview on 12/12/24 at 12:44 PM with the DON revealed she does not have and IP certification but is in a class.
Record review of the facilities job description, Infection Preventionist dated 12/2024 instructed the following:
The employee holding this position must be able to perform these tasks satisfactorily:
a. Develops and implements an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment.
b. Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors.
c. Develops and implements written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control.
d. Oversees the facility's antibiotic stewardship program.
e. Oversees resident care activities that increase risk of infection (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, point-of-care blood testing, and medication injections).
f. Leads the facility's Infection and Prevention Control Committee. Develops action plans to address opportunities for improvement.
Record review of the facilities policy, Infection Prevention and Control Program dated 12/2024 documented:
The Infection Prevention and Control Program is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0838
(Tag F0838)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview the facility failed to create and implement a facility assessment timely once identified it did not have one in place to ensure residents needs are met. The ...
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Based on record review and staff interview the facility failed to create and implement a facility assessment timely once identified it did not have one in place to ensure residents needs are met. The facility reported a census of 33 residents.
Findings include:
Record review of a document titled Self-Identification Form and Correction Form dated 12/10/24 but the Director of Nursing (DON) revealed on 11/22/24 she identified the facility does not have a facility assessment. She documented it would be completed by 12/31/24.
During an interview on 12/12/24 at 12:44 PM with the DON revealed the facility did not have a facility assessment completed but hopes to by the end of the month.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0865
(Tag F0865)
Minor procedural issue · This affected most or all residents
Based on record review, staff interview, and policy review the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality assurance and performance improvemen...
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Based on record review, staff interview, and policy review the facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality assurance and performance improvement (QAPI) program that focused on indicators of the outcomes of care and quality of life timely. The facility reported a census of 33 residents.
Findings include:
Record review of a document titled Self-Identification Form and Correction Form dated 12/10/24 by the Director of Nursing (DON) revealed on 11/22/24 she identified the facility does not have a QAPI program in place and on 1/7/24 the facility will begin to meet monthly.
During an interview on 12/12/24 at 12:32 PM with the Director of Nursing (DON) revealed she started her position in November 2024 and had a large binder with a QAPI plan but no one is completing it at this time.
MINOR
(C)
Minor Issue - procedural, no safety impact
QAPI Program
(Tag F0867)
Minor procedural issue · This affected most or all residents
Based on record review, staff interview, and policy review the facility Quality Assurance and Performance Improvement (QAPI) program failed to be implemented resulting in no monitoring of: facility ad...
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Based on record review, staff interview, and policy review the facility Quality Assurance and Performance Improvement (QAPI) program failed to be implemented resulting in no monitoring of: facility adverse events, program systematic analysis and systemic actions, program activities, and quality assessment and assurance. The facility reported a census of 33 residents.
Findings include:
Record review of a document titled Self-Identification Form and Correction Form dated 12/10/24 by the Director of Nursing (DON) revealed on 11/22/24 she identified the facility does not have a QAPI program in place and on 1/7/24 the facility will begin to meet monthly.
During an interview on 12/12/24 at 12:32 PM with the Director of Nursing (DON) revealed she started her position in November 2024 and had a large binder with a QAPI plan but no one is completing it at this time.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and resident and staff interviews, the facility failed to ensure staff interacted with resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and resident and staff interviews, the facility failed to ensure staff interacted with residents in a professional manner for 1 of 4 residents reviewed (Resident #2) for resident rights. The facility reported a census of 33.
Findings include:
The Minimum Data Set (MDS), dated [DATE], revealed Resident #2 with a Brief Interview for Mental Status score of 3 out of 15, indicating a severe cognitive impairment. Diagnoses listed on the MDS include stroke, hemiplegia/hemiparesis, diabetes, depression, schizophrenia, and respiratory failure. Delusional behaviors also noted.
The Care Plan, with a completed date of 9/23/24, listed a focus area related to bladder incontinence. Interventions include, in part; asking/encouraging resident to utilize call light system to report need to use the bathroom. The Care Plan also listed a focus area related to Resident #2 need for staff assistance for personal cares. Interventions include, in part; at least 1 staff member to assist with bathing/showering, dressing, toilet use and surface transferring.
Review of a facility self-report document, with an event date of 11/17/24, stated Resident #2 alleged verbal abuse against Staff A, Certified Nursing Assistant (CNA). The report described Resident #2 as alert and with no signs of injury.
An Incident Note, dated 11/17/24 at 9:30 PM, revealed the following: Resident told this writer, she told the staff [Staff A, CNA] who answered her call light to Go get (Staff B) the staff member said she was not going to get her. and she [Resident #2] told the staff member you don't know how to help This staff asked this resident if she was ok and she said yes.
A Social Services Progress Note, dated 11/18/24 at 2:52 PM, revealed the following: I followed up with resident from last night and she is calm and states that she feels better as long as she does not have to have (Staff A) - CNA work with her. I will continue to follow up.
During an observation on 11/25/24 at 11:00 AM, Resident #2 received cares from two unidentified staff members in her room without difficulties.
During an interview on 11/25/24 at 11:40 AM, Resident #2 detailed events of the incident from 11/17/24. Staff A , CNA responded to Resident #2's call light. Resident #2 asked for Staff B, CNA instead and did not want Staff A's help. Resident #2 stated Staff A attempted to turn off the call light but Resident #2 did not want it turned off. Words were exchanged. As Staff A was leaving the room, Resident #2 heard Staff A responding back with a **** [profanity] you from the hallway. Resident #2 does not recall specifics during the conversation in the room, but stated profanity may have been used by both parties.
During an interview on 11/25/24 at 12:50 PM, Staff A, CNA recalled the events of 11/17/24. At approximately 8:00 PM, Staff A responded to Resident #2's call light. Immediately upon entering the room, Resident #2 stated No, No. Go get (Staff B) with her open hand in the air. Staff A indicated she would alert the requested staff member and that the call light needed to be turned off. Resident #2 responded with No, you are an abuser. Get the ****[profanity] out. Staff A reported turning off the call light and leaving the room. Staff A stated she did not use profanity in the room or out in the hallway.
During an interview on 11/25/24 at 2:30 PM, Staff C, CNA recalled the events of 11/17/24. Staff C reported sitting in Director of Nursing's office when at approximately 8:15 PM, she heard Staff A and another staff member talking. Staff A sounded upset but could not tell what it was about. Staff B then approached Staff C and informed witnessing Staff A freak out on Resident #2, which included the use of profanity. Staff C reported checking on Resident #2 after this report. Resident #2 found crying and stated that Staff A was cursing at her. By the time Staff C left the room, Resident #2 had stopped crying.
During an interview on 11/25/24 at 3:00 PM, Staff B, CNA recalled the events of 11/17/24. Approximately 45 minutes prior to events, Staff B and another staff member in training were in Resident #2's room without incident. Staff B left and attended to other residents. When returned to the nurse's station, Staff B noticed two call lights on, one of which was Resident #2. As walking down the hallway to address call lights, Staff B observed Resident #2's call light turned off and heard an altercation. Staff B reported hearing Resident #2 yelling back at Staff A, CNA and believes there may have been profanity from both parties. Staff B observed Staff A leaving Resident #2's room saying don't *******[profanity] care if requested Staff B shut the **** [profanity] up. Staff B checked on Resident #2 and found her crying. Staff B reported Resident #2 was not herself for the rest of the night and cried herself to sleep.
The policy Exercise of Rights/Resident Rights F 550, last revised 11/2017, stated residents have the right to be treated with respect and dignity that promotes maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality. The policy directed staff to:
a. Residents shall be treated with dignity and respect
b. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth
c. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs
Oct 2024
18 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Antibiotic Stewardship
(Tag F0881)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, staff interview and record review the facility failed to follow an antibiotic stewardship pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, staff interview and record review the facility failed to follow an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 resident (Resident #14). The facility failed to report to the physician an antibiotic that was resistant to a urine culture. The facility reported a census of 33 residents.
Findings include:
The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 documented diagnosis of cerebral palsy, seizure disorder, anxiety and depression. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated that Resident #14 was coded independently for toileting hygiene and always continent.
Review of the Care Plan with a targeted date of 12/7/24 revealed Resident #14 was independent with hygiene, transfers, toileting and mobility. Resident #14 was assisted by one staff member as needed. The facility failed to document Resident #14's complaints of urinary frequency, incontinence, urinary tract infections and antibiotic usage.
Review of facility progress notes dated 8/30/24 showed Resident #14 complained of frequency with urination.
Health Status Note dated 8/31/24 at 1:31 AM documented new order for urinalysis as resident complained of frequency of urination.
Health Status Note dated 9/2/24 5:40 AM documented that the urinalysis lab indicated a urinary tract infection and waiting for culture and sensitivity report.
A Progress Note dated 9/3/24 at 5:26 PM documented the physician ordered an antibiotic Cipro 500 milligrams (mg) twice daily for five days.
Review of culture and sensitivity lab report dated for 9/3/24 showed the antibiotic Cipro was resistant to the microorganism that grew out (Proteus mirabilis). The Progress Notes lacked documentation that the facility notified the physician the antibiotic was resistant.
The facility Progress Note dated 10/2/24 at 8:19 PM showed that Resident #14 complained of urinary frequency again.
The Progress Note on 10/7/24 12:20 PM Resident #14 again was ordered Cipro 250 mg twice daily for five days until culture and sensitivity came back.
Review of culture and sensitivity lab report dated 10/10/24 at 10:03 AM revealed antibiotic Cipro was resistant to the microorganism that grew out (Proteus mirabilis). The second urinalysis had increased bacteria that grew out.
Observation when entering the facility on 10/2/24 observed Resident #14 had a strong urine odor coming from his room and from his wheelchair.
Review of medical records named facility Point of Care Response HIstory for bladder elimination showed Resident #14 has been incontinent for the last 30 days from 9/9/24 to 10/7/24.
On 10/9/24 at 2:53 PM with Staff K, Certified Nursing Assistant (CNA) and Staff J, CNA, reported Resident #14 had recently become incontinent with urine and does wear briefs, Staff K believes this is from his first urinary tract infection that started in September. Staff K revealed Resident #14 has been incontinent a few times and does provide his own cares. Staff K revealed he has to remind Resident #14 at times to wear a brief and will at times let staff assist him with incontinence cares.
Review of a facility fax on 10/9/24 at 4:31 PM from the physician revealed if aware of culture results from 9/3/24, the medication would have been changed.
Interview on 10/10/24 at 4:30 PM with the Physician reported Resident #14 had a urinalysis on 8/31/24. Physician revealed he looked at the results and started him on the antibiotic until the culture results came back. Physician revealed he would have expected the facility to notify him that the antibiotic was resistant so the antibiotic would get changed to the correct one.
Interview on 10/10/24 at 9:27 AM with the Director of Nursing, DON, verified the expectation of the nursing staff would be to notify the physician that the antibiotic was resistant so they could get the proper antibiotic.
The facility policy with a revision date of August 2023 named Antibiotic Stewardship Program revealed the facility is committed to the reduction of antibiotic utilization for our residents, and are focused on monitoring the prescription and utilization of antibiotics for treatment options as well as the adverse actions that are associated with the use of antibiotics. The facility will be tracking of antibiotic starts, monitoring adherence to McGeer criteria, management of treated infections and reviewing antibiotic resistance patterns. The laboratory will alert the facility when certain antibiotic-resistant organisms are identified and will provide education to the nursing staff regarding further diagnostics needed and will provide a monthly antibiogram which is a summary of antibiotic susceptibility patterns from organisms.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficulty in walking and anxiety. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition.
The Care Plan documented a focus as follows; the resident has potential impairment to skin integrity related to incontinence and immobility. The Care plan documented target date of 11/10/24 with the goal that the resident will maintain or develope clean and intact skin by the review date. The Care Plan directed staff as follows; keep skin clean and dry. Use lotion on dry skin. identify/document potential causative factors, and eliminate/resolve where possible.
The Treatment Administration Record dated 9/1/24 to 9/30/24 included the following physician's order; Barrier Cream two times a day for open area to coccyx with start date of 9/3/24.
Interview on 10/3/24 at 10:10 AM with Resident #15 reported she doesn't get changed like she should. Resident #15 reported the staff change me in the morning and then not again until supper time. She stated they have to use the mechanical lift to get me into bed. She stated that the staff give her a diaper to have a bowel movement in. Resident #15 stated that she is not able to walk anymore and this is how it has to be.
Observations are as followed on:
10/8/24 at 8:35 AM with Resident #15 sitting at the breakfast table in her wheelchair.
10/8/24 at 10:08 AM with Resident #15 sitting in her room in her wheelchair working with therapy.
10/8/24 at 10:30 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 11:04 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 11:30 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 1:06 PM with Resident #15 in her wheelchair finishing up her lunch.
Interview on 10/8/24 at 1:30 PM with Resident #15 stated she had not been changed since before breakfast.
Observation completed on 10/8/24 at 2:53 PM with Resident #15 revealed Staff J, Certified Nursing Assistant, (CNA) and Staff K, CNA, completed transfers and peri care. Observations revealed Resident #15 was completely wet and needed a new brief and bed pad.
Interview on 10/10/24 at 9:27 AM with the Director of Nursing (DON) reported the expectation for the staff is to change residents when wet and as needed.
Based on clinical record review, resident interview, staff interview, observation, and policy review the facility failed to respect resident rights related to visits from guests (Resident#1). The facility further failed to provide dignity for a resident requiring incontinence care and repositioning (Resident#15). Dignity concerns were found for two of four residents reviewed. The facility reported a census of 33 residents.
Findings include:
Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and depression.
Interview 9/30/24 at 11:30 AM with Resident #1 revealed that the facility was not letting a friend of his take him out of the facility for visits as well as not allowing this friend to come into the facility to visit. Resident #1 further revealed that this friend had come to the facility with supper and was asked to leave by the Administrator. Resident #1 then revealed he was unsure as to why this friend was asked to leave. Resident #1 revealed that he is his own guardian. Resident #1 then revealed that he has the right to private visitation and he felt as though it isn't right that he cannot see his friend.
Interview 9/30/24 at 3:45 PM with Staff B, Human Resources (HR) revealed that the facility was investigating an allegation involving Resident #1 and Staff C, Registered Nurse (RN). Staff B then revealed the allegation was turned into the facility on 9/12/24 and the facility was still working on the investigation as of 9/30/24. Staff B further revealed that Staff C came to the facility on 9/20/24 to bring Resident #1 supper and that Staff C was asked to leave the facility as an investigation was still being completed.
Follow up interview 10/1/24 at 12:15 PM with Staff B revealed that the facility was currently still working on the investigation involving Staff C. Staff B further revealed that incident was turned into the Director of Nursing (DON) and the Administrator on 9/13/24 via email by Staff D, Social Service Director/Activity Director (SSD/AD).
Interview 10/1/24 at 4:45 PM with Staff E the former Director of Nursing (DON) revealed that she had completed the investigation process 9/13/24 and that the completed investigation had gone missing from her office desk. Staff E further revealed that nothing inappropriate was ever witnessed or between Staff C or Resident #1.
Interview 10/7/24 at 10:18 AM with the Administrator revealed that an investigation should have been completed in a more timely manner. The Administrator further revealed that it is the Residents right to have visitors.
Review of a facility provided policy titled, Resident rights and dignity management, dated October 2023 revealed:
a. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include visits and be visited by others from outside the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 showed the Brief Interview for Mental Status (BIMS...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 showed the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented diagnosis of cerebral palsy, seizure disorder, anxiety and depression.
The Progress Note dated 8/30/24 at 1:31 AM documented Resident #14 complained of frequency with urination.
Progress Note dated 9/2/24 at 5:40 AM showed that the urinalysis lab indicated a urinary tract infection and waiting for culture and sensitivity report.
A Order Note dated 9/3/24 at 5:26 PM revealed the physician ordered an antibiotic Cipro 500 milligrams (mg) twice daily for five days.
Review of culture and sensitivity lab report dated for 9/3/24 showed the antibiotic Cipro was resistant to the microorganism that grew out. The Progress Notes lacked documentation that the facility notified the physician the antibiotic was resistant.
The facility Progress Note dated 10/2/24 at 8:19 PM showed that Resident #14 complained of urinary frequency again.
Review of the facility policy named Physician Services dated January 2024 revealed the facility will follow physician orders for resident care and treatments, including medications, treatments, ancillary services and consultations. Nurses will receive and transcribe physician orders in the following format: verbal written, faxed, emails or per electronic health records. Physician orders include medications including strength, dosage, frequency, route of administration, supporting diagnosis and a stop date when appropriate, treatments, diets, laboratory, radiology, other diagnostic procedures, therapy, restorative care, special medical procedures and devices required for the safety and well-being of the resident.
Interview on 10/10/24 at 9:27 AM with the Director of Nursing, DON, verified the expectation of the nursing staff would be to notify the physician that the antibiotic was resistant so they could get the proper antibiotic.
Based on clinical record review, staff interviews, and policy review the facility failed to notify the family when a fall occurred for 1 of 5 residents reviewed (Resident #4) for falls. The facility also failed to notify the Physician regarding a resident's urine culture results for 1 of 3 residents (Resident #14) reviewed for a Urinary Tract Infection (UTI). The facility reported a census of 33 residents.
Findings include:
1. The Quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 8/17/24 identified a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS identified Resident #4 was independent with bed mobility. The MDS documented Resident #4 required supervision/touching assistance with sit to stand and chair/bed to chair transfers. The MDS documented Resident #2 used a wheelchair and a walker. The MDS included diagnoses of hypertension (high blood pressure), end stage renal disease (kidney), neurogenic bladder, Alzheimer's disease, non-Alzheimer's disease and repeated falls.
An incident report dated 9/1/24 at 5 PM revealed Resident #4 had a fall in the living room. Resident #4 was ambulating without his walker and went to sit on the recliner and missed, causing him to sit on the floor, tip over to his left side and hit his head on the floor. The incident report documented Resident #4's Physician was notified of the fall. The incident report lacked documentation Resident #4's family was notified of the fall with injury.
Review of the clinical record lacked documentation Resident #4's family was notified of the fall on 9/1/24.
On 10/2/24 at 1:34 PM, the acting Director of nursing (DON) acknowledged and verified she could not locate family notification for the fall on 9/1/24. The DON reported she expected the family to be notified after an incident.
A facility policy titled Change in Condition/Incident Reporting dated August 2023 documented if there was a change in condition, the resident's family/responsible party to be notified promptly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident Interview, staff interview, and policy review the facility failed to appropriately implement in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident Interview, staff interview, and policy review the facility failed to appropriately implement interventions to protect residents from potential abuse for 1 of 1 residents (Resident #1) reviewed. The facility reported a census of 33 residents.
Findings include:
Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and depression.
Interview 9/30/24 at 10:00 AM with Staff C, Registered Nurse (RN) revealed that She had been taking Resident #1 out of the facility to go look at sites, have supper, or go to her house to watch television. Staff C then revealed that She was told by the Administrator that this was ok since the beginning of the year. Staff C further revealed that no sexual advances from Resident #1 or herself ever occurred as Resident #1 is like a brother.
Interview 9/30/24 at 11:30 AM with Resident #1 revealed that he had known Staff C and Staff C's family for a very long time. Resident #1 further revealed that he never paid for anything when going out of the facility with Staff C. Resident #1 further revealed that nothing sexual or inappropriate had ever happened when going out of the facility with Staff C.
Interview 9/30/24 at 3:30 PM with Staff D Social Service Director/Activity Director (SSD/AD) revealed that the allegations were turned into Staff B, Human Resources (HR) by email on 9/12/24, and that Staff D felt it was inappropriate for Staff C to be taking Resident #1 to her home to watch television, and for meals. Staff D then revealed that no one in the facility had witnessed any inappropriate behavior, but felt it was wrong due to the fact that Staff C was an employee at the facility.
Interview 9/30/24 at 3:30 PM with Staff B, HR revealed that Staff C, RN was suspended and an investigation was taking place at this time. Staff B further revealed no investigation was completed the first week after this situation was reported. Staff B then revealed that a letter was sent to Staff C the day after the allegations on 9/13/24 informing them that an investigation was taking place and that Staff C was not allowed to be in the facility. Staff B further revealed that Staff E the Director of Nursing (DON) also called Staff C to inform on the situation. Staff B then revealed that Staff C came to the facility on 9/20/24 to bring Resident #1 chicken for supper and was asked to leave as the investigation was still being completed.
Follow up interview 10/1/24 at 12:15 PM with Staff B revealed that the investigation was being completed at this time and would be done within 15 minutes. Staff B further confirmed that this situation was turned into the DON and Administrator on 9/13/24 by email by staff D.
Follow up interview 10/1/24 at 3:11 PM with Staff B, HR revealed that Staff E, the DON at the time had interviewed the 3 staff that Staff B reinterviewed 10/1/24. Staff B further revealed that Staff E had completed the interviews, but the investigation had gone missing. Staff B then revealed that corporate had told Staff B to reinterview the staff that Staff E had interviewed. Staff B further revealed that this investigation should have been completed sooner.
Follow up interview 10/8/24 at 2:36 PM with Staff C, RN revealed that She had never received any letters from the facility stating She could not be in the building, and Staff C had not received a letter to this day. Staff C then revealed She had been taking Resident #1 out since the beginning of the year every other week. Staff C then revealed that Resident #1 was not a personal friend prior to being admitted to the facility, and that Resident #1 was a friend of her brother. Staff C then revealed that she had received a call from a corporate entity who Staff C could not recall the name. Staff C revealed that this person had told her the investigation was all over. Staff C revealed this was prior to coming into the facility with chicken on 9/20/24.
Interview 10/8/24 at 3:37 PM with the Administrator revealed that when there is an allegation of an inappropriate relationship between staff and a resident that the staff should be talked to, and to let them know that it is not appropriate. The Administrator further revealed that any relationship out of work should not continue.
Review of a facility provided policy titled, Neglect and exploitation; Abuse prevention with a date of October 2023 revealed:
a. The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress and that resident safety is protected.
Review of a facility provided policy titled, Business conduct and code of ethics dated 2021 documented:
a. No healthcare professional should ever furnish a service or take any action that would violate a professional code of ethics or practice act.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review the facility failed to appropriately implement in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review the facility failed to appropriately implement interventions to protect residents from potential misappropriation of funds for 1 of 1 residents (Resident #11) reviewed. The facility reported a census of 33 residents.
Findings include:
Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of heart failure, renal insufficiency, anxiety disorder, and depression.
Interview 10/7/24 at 10:18 AM with the Administrator revealed that Resident #11 had received $1,100 dollars from social security in May of this year. The Administrator revealed that He had locked the money up in a lockbox at this time. The Administrator further revealed that Resident #11 did not trust the trust savings account or having it in a lockbox at the facility. The Administrator then revealed that He gave the money to Resident #11. The Administrator then revealed that Resident #11 then gave the money to Staff H Certified Dietary Manager (CDM).
Interview 10/7/24 at 1:34 PM with Staff B Human Resources (HR) revealed that She was unaware how long Staff H was holding Resident #11's money.
Interview 10/8/24 at 2:20 PM with Resident #11 revealed that She did have receipts for her money, and that they had been thrown away. Resident #11 further revealed that when Staff H returned the money to the facility it was not counted in front of Her, but was sure that she had $770 dollars left.
Follow up interview 10/8/24 at 3:37 PM with the Administer revealed that Resident #11's original payment from social security came in the form of a check. The Administrator then revealed He took Resident #11 to His personal bank in town and deposited the money into His account. The Administrator further revealed that He withdrew the money from his account and gave the money to Resident #11. The Administrator then revealed that the money is now in a lockbox in His office with a running balance, and currently has $770 in the lockbox. The Administrator revealed that He was unaware of when Staff H received the money from Resident #11. The Administrator then revealed that when He found out He advised Resident #11 to place the money into the resident trust account Resident #11 had stated She trusted Staff H more than the resident savings account.
Interview 10/8/24 at 3:38 PM with Staff H CDM revealed that Resident #11 gave Staff H the money in total of $1,100. Staff H revealed that when Resident #11 would ask for money Staff H would write it on the outside of the envelope with the date and amount taken out. Staff H further revealed that when Resident #11 would ask for Staff H to buy something the amount would be written on the envelope and the store receipt would be given to Resident #11. Staff H revealed she received the money on May 24th of this year, and brought it back to the facility on October 4th. Staff H then revealed She brought the money back to the facility because She was turned in for having it. Staff H revealed that Administrator and Staff I acting Director of Nursing (DON) told Her to bring the money back. Staff H then confirmed that She had violated the company policy for Holding Resident Funds. Staff H further revealed that She had not held any other residents funds. Staff H then revealed that She did not have permission from anyone at the facility to hold Resident #11's money at home.
Interview 10/9/24 at 8:55 AM with Staff D revealed that Resident #11's money had been brought up several times in morning meetings, and that Staff D reported this sometime in July of this year.
Review of a facility provided policy titled, RFMS Petty Cash Policy with a revision date of 4/10/24 revealed:
a. No staff can hold funds for residents. All funds are either deposited into RFMS or resident can keep.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical documentation, resident interview, staff interview, and facility policy review the facility failed to report a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical documentation, resident interview, staff interview, and facility policy review the facility failed to report allegations of abuse within two (2) hours to the State Survey Agency for 2 of 2 residents (Resident #1, and Resident #11). The facility reported a census of 33 residents.
Findings include:
1. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and depression.
Interview 9/30/24 at 10:00 AM with Staff C, Registered Nurse (RN) revealed that she had been taking Resident #1 out of the facility to go look at sites, have supper, or go to her house to watch television. Staff C then revealed that she was told by the Administrator that this was ok since the beginning of the year. Staff C further revealed that no sexual advances from Resident #1 or Herself ever occurred as Resident #1 is like a brother.
Interview 9/30/24 at 11:30 AM with Resident #1 revealed that He had known Staff C and Staff C's family for a very long time. Resident #1 further revealed that he never paid for anything when going out of the facility with Staff C. Resident #1 further revealed that nothing sexual or inappropriate had ever happened when going out of the facility with Staff C.
Interview 9/30/24 at 3:30 PM with Staff D, Social Service Director/Activity Director (SSD/AD) revealed that the allegations were turned into Staff B, Human Resource (HR) by email on 9/12/24, and that Staff D felt it was inappropriate for Staff C to be taking Resident #1 to her home to watch television, and for meals. Staff D then revealed that no one in the facility had witnessed any inappropriate behavior, but felt it was wrong due to the fact that Staff C was an employee at the facility.
Interview 9/30/24 at 3:30 PM with Staff B revealed that Staff C, RN was suspended and an investigation was taking place at this time. Staff B further revealed no investigation was completed the first week after this situation was reported. Staff B, HR then revealed that a letter was sent to Staff C the day after the allegations on 9/13/24 informing them that an investigation was taking place and that Staff C was not allowed to be in the facility. Staff B further revealed that Staff E the Director of Nursing (DON) also called Staff C to inform on the situation. Staff B then revealed that Staff C came to the facility on 9/20/24 to bring Resident #1 chicken for supper and was asked to leave as the investigation was still being completed.
Follow up interview 10/1/24 at 8:10 AM with Staff B, HR confirmed that this situation was turned into the DON and Administrator on 9/13/24 by email by Staff D, SSD/AD. Staff B then confirmed She did not receive the email until 9/14/24. Staff B revealed that she sent a text message to the Administrator to which he never responded. Staff B then revealed that any possible abuse allegations should be turned into management and then reported to the State Entity within two hours.
Follow up interview 10/1/24 at 12:15 PM with Staff B,HR revealed that the investigation was being completed at this time and would be done within 15 minutes.
Follow up interview 10/1/24 at 3:11 PM with Staff B revealed that Staff E the DON at the time had interviewed the 3 staff that Staff B reinterviewed 10/1/24. Staff B further revealed that Staff E had completed the interviews, but the investigation had gone missing. Staff B then revealed that corporate had told Staff B to reinterview the staff that Staff E had interviewed. Staff B further revealed that this investigation should have been completed sooner.
Interview 10/1/24 at 4:25 PM with Staff E former Director of Nursing (DON) revealed that she had completed an investigation on 9/13/24, but the investigation had gone missing from Her office. Staff E further revealed that she had asked the Administer if this incident was reported to the State Entity as she had not reported it. Staff E, former DON then revealed that she received no response from the Administrator. Staff E then revealed that she was called by the Administrator several days later and asked if she had reported it. Staff E stated she responded to the Administrator that she had not reported it as, she thought the Administrator was going to report the allegation.
Follow up interview 10/8/24 at 2:36 PM with Staff C, RN revealed that She had never received any letters from the facility stating She could not be in the building, and Staff C had not received a letter to this day. Staff C then revealed she had been taking Resident #1 out since the beginning of the year every other week. Staff C then revealed that Resident #1 was not a personal friend prior to being admitted to the facility, and that Resident #1 was a friend of her brother. Staff C then revealed that she had received a call from a corporate entity who Staff C could not recall the name. Staff C revealed that this person had told her the investigation was all over. Staff C revealed this was prior to coming into the facility with chicken on 9/20/24.
Interview 10/8/24 at 3:37 PM with the Administrator revealed that when there is an allegation of an inappropriate relationship between staff and a resident that the staff should be talked to, and to let them know that it is not appropriate. The Administrator further revealed that any relationship out of work should not continue.
2. Review of Resident #11's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of heart failure, renal insufficiency, anxiety disorder, and depression.
Interview 10/7/24 at 10:18 AM with the Administrator revealed that Resident #11 had received $1,100 dollars from social security in May of this year. The Administrator revealed that he had locked the money up in a lockbox at this time. The Administrator further revealed that Resident #11 did not trust the trust savings account or having it in a lockbox at the facility. The Administrator then revealed that he gave the money to Resident #11. The Administrator then revealed that Resident #11 then gave the money to Staff H, Certified Dietary Manager (CDM).
Interview 10/7/24 at 1:34 PM with Staff B Human Resources (HR) revealed that She was unaware how long Staff H was holding Resident #11's money.
Interview 10/8/24 at 2:20 PM with Resident #11 revealed that She did have receipts for her money, and that they had been thrown away. Resident #11 further revealed that when Staff H returned the money to the facility it was not counted in front of Her, but was sure that she had $770 dollars left.
Follow up interview 10/8/24 at 3:37 PM with the Administer revealed that Resident #11's original payment from social security came in the form of a check. The Administrator then revealed he took Resident #11 to his personal bank in town and deposited the money into his account. The Administrator further revealed that he withdrew the money from his account and gave the money to Resident #11. The Administrator then revealed that the money is now in a lockbox in his office with a running balance, and currently has $770 in the lockbox. The Administrator revealed that he was unaware of when Staff H, CDM received the money from Resident #11. The Administrator then revealed that when he found out he advised Resident #11 to place the money into the resident trust account Resident #11 had stated she trusted Staff H more than the resident savings account. The Administrator further revealed that he or the DON should have reported the allegations to the State Entity regarding the first allegation. The Administrator then revealed that he did not report the allegations regarding Resident #11's money related to the fact that he thought it was Resident #11's rights to have anyone watch Resident #11's money. The Administrator then revealed that if Resident #11 had any concerns regarding money he would have gotten it back and then reported to the State Entity.
Interview 10/8/24 at 3:38 PM with Staff H CDM revealed that Resident #11 gave Staff H the money in total of $1,100. Staff H revealed that when Resident #11 would ask for money Staff H would write it on the outside of the envelope with the date and amount taken out. Staff H further revealed that when Resident #11 would ask for Staff H to buy something the amount would be written on the envelope and the store receipt would be given to Resident #11. Staff H revealed she received the money on May 24th of this year, and brought it back to the facility on October 4th. Staff H then revealed She brought the money back to the facility because She was turned in for having it. Staff H revealed that Administrator and Staff I acting DON told her to bring the money back. Staff H then confirmed that She had violated the company policy for Holding Resident Funds. Staff H further revealed that She had not held any other residents funds. Staff H then revealed that She did not have permission from anyone at the facility to hold Resident #11's money at home.
Interview 10/9/24 at 8:55 AM with Staff D, SSD/AD revealed that Resident #11's money had been brought up several times in morning meetings, and that Staff D reported this sometime in July of this year.
Review of a facility provided policy titled, Neglect and exploitation; Abuse prevention dated October 2023 revealed:
a. You must make the report within two hours after you first suspect that a crime has occurred if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious bodily injury involved.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, staff interview, and facility policy review, the facility failed to investi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, staff interview, and facility policy review, the facility failed to investigate and complete a proper investigation for an allegation of abuse for 2 of 2 residents (Resident #1, Resident #11) reviewed for abuse and neglect. The facility reported a census of 33 residents.
Findings include:
Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and depression.
Interview 9/30/24 at 10:00 AM with Staff C, Registered Nurse (RN) revealed that She had been taking Resident #1 out of the facility to go look at sites, have supper, or go to Her house to watch television. Staff C then revealed that She was told by the Administrator that this was ok since the beginning of the year. Staff C further revealed that no sexual advances from Resident #1 or Herself ever occurred as Resident #1 is like a brother.
Interview 9/30/24 at 11:30 AM with Resident #1 revealed that He had known Staff C and Staff C's family for a very long time. Resident #1 further revealed that he never paid for anything when going out of the facility with Staff C. Resident #1 further revealed that nothing sexual or inappropriate had ever happened when going out of the facility with Staff C.
Interview 9/30/24 at 3:30 PM with Staff D Social Services Director/Activity Director (SSD/AD) revealed that the allegations were turned into Staff B Human Resources (HR) by email on 9/12/24, and that Staff D felt it was inappropriate for Staff C to be taking Resident #1 to Her home to watch television, and for meals. Staff D then revealed that no one in the facility had witnessed any inappropriate behavior, but felt it was wrong due to the fact that Staff C was an employee at the facility.
Interview 9/30/24 at 3:30 PM with Staff B, HR revealed that Staff C, RN was suspended and an investigation was taking place at this time. Staff B further revealed no investigation was completed the first week after this situation was reported. Staff B then revealed that a letter was sent to Staff C the day after the allegations on 9/13/24 informing them that an investigation was taking place and that Staff C was not allowed to be in the facility. Staff B further revealed that Staff E the Director of Nursing (DON) also called Staff C to inform on the situation. Staff B then revealed that Staff C came to the facility on 9/20/24 to bring Resident #1 chicken for supper and was asked to leave as the investigation was still being completed.
Follow up interview 10/1/24 at 12:15 PM with Staff B, HR revealed that the investigation was being completed at this time and would be done within 15 minutes. Staff B further confirmed that this situation was turned into the DON and Administrator on 9/13/24 by email by Staff D, SSD/AD.
Follow up interview 10/1/24 at 3:11 PM with Staff B, HR revealed that Staff E the DON at the time had interviewed the 3 staff that Staff B reinterviewed 10/1/24. Staff B further revealed that Staff E had completed the interviews, but the investigation had gone missing. Staff B then revealed that corporate had told Staff B to reinterview the staff that Staff E had interviewed. Staff B further revealed that this investigation should have been completed sooner.
Follow up interview 10/8/24 at 2:36 PM with Staff C, RN revealed that she had never received any letters from the facility stating she could not be in the building, and Staff C had not received a letter to this day. Staff C then revealed she had been taking Resident #1 out since the beginning of the year every other week. Staff C then revealed that Resident #1 was not a personal friend prior to being admitted to the facility, and that Resident #1 was a friend of her brother. Staff C then revealed that She had received a call from a corporate entity who Staff C could not recall the name. Staff C revealed that this person had told her the investigation was all over. Staff C revealed this was prior to coming into the facility with chicken on 9/20/24.
Interview 10/8/24 at 3:37 PM with the Administrator revealed that when there is an allegation of an inappropriate relationship between staff and a resident that the staff should be talked to, and to let them know that it is not appropriate. The Administrator further revealed that any relationship out of work should not continue.
Review of the facility provided investigation revealed witness statement forms with an incident date of 9/12/24 for 3 staff members. These documents further revealed that the completed date of these witness statement forms were completed 10/1/24. No documentation of interviews with Resident #1 or Staff C were completed.
2. Review of Resident #11's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed diagnosis of heart failure, renal insufficiency, anxiety disorder, and depression.
Interview 10/7/24 at 10:18 AM with the Administrator revealed that Resident #11 had received $1,100 dollars from social security in May of this year. The Administrator revealed that He had locked the money up in a lockbox at this time. The Administrator further revealed that Resident #11 did not trust the trust savings account or having it in a lockbox at the facility. The Administrator then revealed that He gave the money to Resident #11. The Administrator then revealed that Resident #11 then gave the money to Staff H Certified Dietary Manager (CDM).
Interview 10/7/24 at 1:34 PM with Staff B Human Resources (HR) revealed that She was unaware how long Staff H was holding Resident #11's money.
Interview 10/8/24 at 2:20 PM with Resident #11 revealed that She did have receipts for her money, and that they had been thrown away. Resident #11 further revealed that when Staff H returned the money to the facility it was not counted in front of Her, but was sure that she had $770 dollars left.
Follow up interview 10/8/24 at 3:37 PM with the Administer revealed that Resident #11's original payment from social security came in the form of a check. The Administrator then revealed He took Resident #11 to His personal bank in town and deposited the money into His account. The Administrator further revealed that He withdrew the money from his account and gave the money to Resident #11. The Administrator then revealed that the money is now in a lockbox in His office with a running balance, and currently has $770 in the lockbox. The Administrator revealed that He was unaware of when Staff H received the money from Resident #11. The Administrator then revealed that when He found out He advised Resident #11 to place the money into the resident trust account Resident #11 had stated She trusted Staff H more than the resident savings account.
Interview 10/8/24 at 3:38 PM with Staff H CDM revealed that Resident #11 gave Staff H the money in total of $1,100. Staff H revealed that when Resident #11 would ask for money Staff H would write it on the outside of the envelope with the date and amount taken out. Staff H further revealed that when Resident #11 would ask for Staff H to buy something the amount would be written on the envelope and the store receipt would be given to Resident #11. Staff H revealed she received the money on May 24th of this year, and brought it back to the facility on October 4th. Staff H then revealed she brought the money back to the facility because She was turned in for having it. Staff H revealed that Administrator and Staff I acting Director of Nursing (DON) told her to bring the money back. Staff H then confirmed that she had violated the company policy for Holding Resident Funds. Staff H further revealed that she had not held any other residents funds. Staff H then revealed that she did not have permission from anyone at the facility to hold Resident #11's money at home.
Interview 10/9/24 at 8:55 AM with Staff D revealed that Resident #11's money had been brought up several times in morning meetings, and that Staff D reported this sometime in July of this year.
Review of a facility provided policy titled, Neglect and exploitation; Abuse prevention dated October 2023 revealed:
a. Any complaint, allegation, observation or suspicion of resident abuse, mistreatment, or neglect, whether physical, verbal, mental or sexual, involuntary, or voluntary, is to be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented.
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
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to coordinate and provide specialized services identif...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to coordinate and provide specialized services identified from the PASRR (Preadmission Screening and Resident Review) level II determination for 3 of 4 (Residents #2, #3, and #12) residents reviewed. Facility reported a census of 33 residents.
Findings include:
1. Review of Resident #2's PASRR dated 7/25/24, indicated diagnosis of Schizophrenia, Major Depressive Disorder, Psychosis, Bipolar Disorder, history of Borderline Personality Disorder, and high concerns for Major Neurocognitive Disorder Dementia. The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services)
Review of Resident #2's Minimum Data Set (MDS) dated [DATE], failed to indicate special services including psychiatric management.
Review of Resident #2's Care Plan completed on 8/22/24, failed to indicate Level II PASRR and specialized services.
Review of facility provided Medication Management Roster (document of current residents receiving psychiatric services) dated 9/26/24, failed to provide Resident #2 as receiving services.
2. Review of Resident #3's PASRR dated 1/1/19, indicated diagnosis of schizophrenia, bipolar disorder, generalized anxiety disorder, and cluster B traits (personality disorders characterized by dramatic, emotional, and erratic behaviors.) The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.
2. Individual therapy by a licensed behavioral health professional (may include mobile therapy.)
Socialization/leisure/recreation activities.
Review of Resident #3's Quarterly MDS dated [DATE], failed to indicate special services including psychiatric services and individual therapy.
Review of Resident #3's Care Plan dated 7/22/24, failed to indicate Level II PASRR and specialized services.
Review of facility provided Medication Management Roster (document of current residents receiving psychiatric services) dated 9/26/24, failed to provide Resident #3 as receiving services.
3. Review of Resident #12's PASRR dated 11/28/20, indicated diagnosis of Schizoaffective Disorder, Anxiety Disorder, and Dementia. The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric medication management by a psychiatrist or a psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.)
Review of Resident #12's MDS dated [DATE], failed to indicate special services including psychiatric services.
Review of Resident #12's Care Plan dated 10/3/24, failed to indicate Level II PASRR and specialized services.
Review of facility provided Medication Management Roster (document of current residents receiving psychiatric services) dated 9/26/24, failed to provide Resident #12 as receiving services.
During an interview on 10/8/24 at 3:30 PM, Staff D, Social Services Director, revealed Staff D is responsible for coordinating Level II PASRR services for residents and is aware not all residents are receiving recommended services as listed in their Level II PASRR.
During an interview on 10/10/24 at 9:27 AM, Staff I, Acting DON, indicated expectations that Care Plans are accurate and completed in a timely manner and special services be coordinated and initiated.
Review of PASRR Policy dated 10/23 revealed, PASRR is a review required under the State Medicaid program that identifies the specialized services for an individual with mental illness and mental retardation (MI/MR) residing in a nursing facility and be offered the most appropriate setting for their needs. PASRR assures that psychological, psychiatric, and functional needs are considered in long term care. The Facility Social Services Director is accountable for this process.
1. Social Worker's responsibility to see that all residents within the nursing facility with MI/MR are to have PASRR documentation of pre-admission screens with identified specialized services.
2. The outcome of the Level II evaluation confirms the need for placement in a skilled nursing facility and provides a set of service recommendations for providers to use in developing the individualized plan of care.
3. Social Services resident care planning should include a review of diagnosis and/or change in status which could include the need for specialized services.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #2's PASRR dated 7/25/24, indicated diagnosis of Schizophrenia, Major Depressive Disorder, Psychosis, Bipo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #2's PASRR dated 7/25/24, indicated diagnosis of Schizophrenia, Major Depressive Disorder, Psychosis, Bipolar Disorder, history of Borderline Personality Disorder, and high concerns for Major Neurocognitive Disorder Dementia. The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP (to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services)
Review of Resident #2's Care Plan completed on 8/22/24, failed to indicate Level II PASRR and specialized services.
3. Review of Resident #3's PASRR dated 1/1/19, indicated diagnosis of schizophrenia, bipolar disorder, generalized anxiety disorder, and cluster B traits (personality disorders characterized by dramatic, emotional, and erratic behaviors.) The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.
Individual therapy by a licensed behavioral health professional (may include mobile therapy.)
Socialization/leisure/recreation activities.
Review of Resident #3's Care Plan dated 7/22/24, failed to indicate Level II PASRR and specialized services.
4. Review of Resident #12's PASRR dated 12/28/20, indicated diagnosis of schizophrenia disorder. The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.
Review of Resident #12's Care Plan dated 10/3/24, failed to indicate Level II PASRR and specialized services.
5. Review of Resident #17's PASRR dated 12/11/17, indicated diagnosis of Depressive Disorder with psychotropic medications. The Level II PASRR indicated the facility will need to provide the following specialized services:
1. Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services.
Review of Resident #17's Care Plan dated 10/2/24, failed to indicate Level II PASRR and specialized services.
6. Review of Resident #18's annual MDS dated [DATE], identified a BIMS of 13, indicating intact cognition. Resident #18's MDS revealed diagnosis of hypertension, benign prostatic hyperplasia, nontraumatic chronic subdural hemorrhage, and adjustment disorder. The MDS also indicated Resident #18 is always continent of bowel and bladder and independent of all mobility including toileting.
Review of Resident #18's Care Plan dated 10/3/24, identified a focus on impaired functional performance with interventions of limited assist/ one person physical assist for continence of bowel and bladder. Resident #18's Care Plan also identified a focus of minimal assistance with ADL ' s with interventions stating Resident #18 is able to use the toilet and transfer independently.
During an interview on 10/8/24 at 3:30 PM, Staff D, Social Services Director, revealed Staff D is responsible for completing MDS sections A (Identification Information), B (Hearing, Speech, and Vision), C (Cognitive Patterns), D (Mood), E (Behavior), F (Preferences for Customary Routine and Activities), and Q (Participation in Assessment and Goal Setting). She is aware Care Plans are not up to date as there were some not updated prior to her starting at the facility in June 2024. Staff D stated due to low staffing she is often pulled from her office and works as a CNA and not able to fully complete her Social Services Director duties.
During an interview on 10/10/24 at 9:27 AM, Staff I, Acting DON, indicated expectations that Care Plans are accurate and completed in a timely manner.
A facility policy titled RAI/Care Planning Management dated October 2023 documented It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. With the objective:
1.
To identify resident's individual needs and care requirements.
2.
To assure that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident.
3.
To assure that all residents are reviewed and reassessed based on their individual needs and OBRA guidelines.
4.
To ensure a timely completion of the RAI/Care Plan process which includes completion of the MDS, CAAs, and Care Plans.
Based on clinical record review, staff interview and policy review the facility failed to develop a Care Plan to address risk factors and interventions for 6 out of 19 residents (Residents #8, #2, #3, #12, #17, #18) reviewed for comprehensive Care Plans. The facility reported a census of 33 residents.
Findings include:
1. Resident #8's Quarterly Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 03,which indicated severely impaired cognition. Resident #8's MDS included diagnoses of anemia, hypertension (high blood pressure), and cerebrovascular accident (CVA) with left sided hemiplegia. The MDS documented Resident #8 was taking an anticoagulant medication during the 7 day look back period.
A Physician order dated 7/30/24 directed staff to administer Apixaban (Eliquis) (anticoagulant) 5 mg (milligrams) by mouth twice a day for cerebral infarction due to embolism of the right middle cerebral artery.
Review of Resident #8's care plan with target date 11/5/24 lacked documentation for the anticoagulant medication, potential side effects and what to monitor for while taking the high risk medication.
On 10/8/24 at 1:00 PM, the acting Director of Nursing (DON) reported she would expect high risk medications to be addressed on the plan of care.
A facility policy titled RAI/Care Planning Management dated October 2023 documented the comprehensive care plan was to be reviewed quarterly. If modification, deletions, additions are necessary, changes should be made at the time of the occurrence. Care plans are to be accessible for the clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficulty in wal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficulty in walking and anxiety. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.
Review of the Progress Notes for Resident #15 showed documentation of a Resident #15 being lowered to the floor on 8/25/24 and 9/4/24.
Review of the Care Plan for Resident #15 with a target date of 11/10/24 failed to place interventions on the care plan.
Observation on 10/9/24 at 2:53 PM with Staff J, Certified Nursing Assistant (CNA) and Staff K, CNA transferring Resident #15 with a mechanical lift.
Review of Care Plan for Resident #15 with a target date of 11/10/24 revealed Resident #15 requires max assistance of 1 staff member for transfers. The facility failed to update Resident #15's transfer status on the care plan.
Interview with Staff K, CNA, revealed Resident #15 started utilizing the mechanical lift a couple weeks ago. Staff K, CNA stated Therapy had initiated the mechanical lift. Staff K, CNA stated that this was placed in the CNA Communication book to update all staff. Staff K, CNA stated the staff are to read the communication book before each shift.
Interview on 10/10/24 at 12:58 PM with the Director of Nursing (DON) stated the expectation for care plans are that they get updated immediately upon admission/change/revised as needed and followed.
Based on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 2 of 19 residents reviewed (Residents #4 and #14). The facility reported a census of 33 residents.
Findings include:
1. The Quarterly Minimum Data Set (MDS) assessment for Resident #4 dated 8/17/24 identified a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS identified Resident #4 was independent with bed mobility. The MDS documented Resident #4 required supervision/touching assistance with sit to stand and chair/bed to chair transfers. The MDS documented Resident #2 used a wheelchair and a walker. The MDS included diagnoses of hypertension (high blood pressure), end stage renal disease (kidney), neurogenic bladder, Alzheimer's disease, non-Alzheimer ' s disease and repeated falls.
Review of Progress notes for September 2024 revealed Resident #4 had two falls that occurred on 9/1 and 9/17/24.
The Care Plan with a target date 11/14/2024 documented Resident #4 was at high risk for falls related to gait and balance problems. Review of the care plan revealed the fall care plan was updated on 10/2/24. The care plan documented the following:
-9/1/24 Fall- Resident #4 was transferring without his walker and missed the recliner landing on the floor. Ensure his walker is within reach at all times- created-10/2/24
-9/17/24 unwitnessed Fall- noted Resident #4 was trying to put himself on the floor earlier in the day- created 10/2/24
On 10/3/24 at 10:30 AM, the acting DON verified Resident #4's fall care plan was not reviewed or updated until 10/2/24. The acting DON reported a nurse consultant reviewed Resident #4 ' s medical record and updated the care plan remotely on 10/2/24. She reported her expectation was for the care plan to be updated right away after a fall.
A facility policy titled RAI/Care Planning Management dated October 2023 documented care plans are to be updated in an acute situation when identified, such as falls, falls with injury, new skin alterations, worsening skin conditions, behaviors, resident events, weight loss, infections, uncontrolled pain, allegations of abuse and other concerns that involve resident care/condition. These updates are to be prompt upon notification and should be reviewed and implemented in the daily clinical meeting and as they occur.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficulty in wal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 documented diagnosis of osteoarthritis, difficulty in walking and anxiety. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS revealed Resident #15 is frequently incontinent of urine and bowel.
Review of care plan with a target date of 11/10/24 revealed Resident #15 is totally dependent on one staff member for toilet use and toilet hygiene. Resident #15 uses disposable briefs and to change when wet and as needed. The care plan failed documentation on a repositioning schedule.
Interview on 10/3/24 at 10:10 AM with Resident #15 reported she doesn't get changed like she should. Resident #15 reported the staff changes me in the morning and then not again until supper time. She stated they have to use the mechanical lift to get me into bed. She stated that the staff give her a diaper to have a bowel movement in. Resident #15 stated that she is not able to walk anymore and this is how it has to be.
Observations are as followed on:
10/8/24 at 8:35 AM with Resident #15 sitting at the breakfast table in her wheelchair.
10/8/24 at 10:08 AM with Resident #15 sitting in her room in her wheelchair working with therapy.
10/8/24 at 10:30 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 11:04 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 11:30 AM with Resident #15 sitting in her room in her wheelchair watching television.
10/8/24 at 1:06 PM with Resident #15 in her wheelchair finishing up her lunch.
Interview on 10/8/24 at 1:30 PM with Resident #15 stated she had not been repositioned or changed since before breakfast.
Observation completed on 10/8/24 at 2:53 PM with Resident #15 revealed Staff J, Certified Nursing Assistant, (CNA) and Staff K, CNA, completed transfers and peri care. Observations revealed Resident #15 was completely wet and needed a new disposable brief and bed pad.
Interview on 10/10/24 at 9:27 AM with the Director of Nursing (DON) reported the expectation for the staff is to change residents when wet and as needed.
Based on observation, clinical record review, resident interview, staff interview, and policy review the facility failed to provide an opportunity for bath or shower to 2 of 3 residents (Residents #2, and #3) reviewed. The facility further failed to provide incontinence care for 1 of 3 residents (Resident #15) reviewed. The facility reported a census of 33 residents.
Findings include:
1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed Resident #2 requires supervision or touching assistance with showering/bathing themself.
Interview 10/1/24 at 9:15 AM Interview with Resident #2 revealed that there isn't enough staff at the facility, and that showers don't get completed as often as Resident #2 would like.
Review of Resident #2's Electronic Healthcare Record (EHR) page titled task shower/bath revealed no showers or baths completed 9/1/24 through 10/1/24.
2. Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. The MDS further revealed diagnosis of muscle weakness, cervicalgia (neck pain), bipolar disorder.
Interview 10/1/24 at 8:30 AM with Resident #3 revealed that there is not enough staff at the facility. Resident #3 further revealed that showers are not getting completed regularly and that it had been almost 2 weeks since his last shower. Resident #3 then revealed that he is supposed to be receiving showers two times a week and would like them three times a week. Resident #3 revealed it upsets him, but nothing is being done.
Review of Resident #3's EHR page titled task shower/bath revealed no documentation of showers or baths completed 9/1/24 through 10/1/24.
Interview 10/1/24 at 9:25 AM with Staff F Certified Nursing Assistant (CNA) revealed that when showers are completed they are marked on shower sheets and then charted in the EHR.
Interview 10/1/24 at 10:25 AM with Staff G CNA revealed sometimes showers are missed due to lack of staffing. Staff G then confirmed that Residents had not had their showers/baths as they were not initialed off or marked that they were refused.
Interview 10/1/24 at 10:50 AM with the Administrator revealed concerns with showers/baths not being completed and documented.
Interview 10/1/24 interview with Staff E the Director of Nursing (DON) revealed she had concerns with showers/baths not being completed and her expectations were for showers/baths to be completed.
Review of facility provided policy titled, Resident hygiene bath and shower standard with a revision date of October 2023 revealed:
a. Bathe each resident as needed including a shower at least twice weekly.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Annual MDS assessment for Resident #18 dated 11/30/23, identified a BIMS of 13, which indicated intact cognition. Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Annual MDS assessment for Resident #18 dated 11/30/23, identified a BIMS of 13, which indicated intact cognition. Resident #18's MDS revealed diagnosis of hypertension, benign prostatic hyperplasia, nontraumatic chronic subdural hemorrhage, and adjustment disorder. The MDS also indicated Resident #18 is always continent of bowel and bladder and independent of all mobility.
Review of Resident #18's Care Plan dated 10/3/24, revealed the following:
1. The resident requires skin inspection weekly. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.
2. The resident had potential impairment to skin integrity related to chronic disease processes, obesity, cognitive impairment and will maintain clean and intact skin by the review date.
3. Monitor/document location, size and treatment of skin injury, report to MD.
The Medication Administration Record dated 9/1/24 to 9/30/24 documented the following physician order with the start date of 1/16/24; Weekly Skin Assessment:
1. Assess
2. Check of MAR (Medication Administration Record)/TAR (Treatment Administration Record)
3. Document under assessment- N Adv-Skin only
4. Evaluation- Full assessment every night shift every Tuesday for weekly skin assessment
Review of the September and October 2024 MAR/TAR for Resident #18 lacked documentation that weekly skin assessments were completed as ordered on 10/1/24- Night shift.
Review of document weekly skin assessments for Resident #18 lacked documentation of the head to toe skin assessments on 9/3/24 and 9/17/24. Although assessments were indicated being done on the MAR/TAR for 9/3/24 and 9/17/24 these were not documented, further review of MAR/TAR revealed these skin assessments for Resident #18 were noted to be completed by a CMA (Certified Medication Aide).
A Physician order dated 6/6/24 stated Apply Antifungal external cream to groin topically two times a day for redness until healed.
Review of the September and October 2024 MAR/TAR for Resident #18 lacked documentation that the Antifungal cream was applied as ordered on the following dates:
9/1/24- Day shift
9/3/24- Day shift
9/6/24- Day and Night shift
9/8/24- Night shift
9/9/24- Night shift
9/16/24- Night shift
9/17/24- Day shift
9/21/24- Night shift
9/23/24- Day shift
9/27/24- Day shift
9/30/24- Night shift
10/3/24- Day shift
10/4/24- Day and Night shift
10/8/24- Day shift
During an interview on 10/10/24 at 9:27 AM, Staff I, Acting DON, indicated expectations that Physicians orders be followed, including administering medications, completing ordered treatments, and a licensed nurse to complete skin assessments as ordered and document appropriately.
Review of Physician's Orders Policy dated January 2024, stated Licensed Nurses will follow physician orders for resident care and treatments, including medications, treatments, ancillary services, and consultations.
Review of facility provided Nursing Assessment Quick Reference Guide stated Licensed Nurses will follow the nursing assessment schedule for all required documentation. Variation from baseline of a change of condition warrants notification to physician for additional physician orders.
3. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #20 documented diagnosis of hypertension (high blood pressure), renal insufficiency, neurogenic bladder, and diabetes mellitus. The MDS showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment.
Review of the September 2024 Treatment Administration Record (TAR) for Resident #20 revealed a physician's order of skin prep to the left heel at bedtime for protection. Review of the TAR showed four times where the treatment was not signed off on these dates 9/5/24, 9/12/24, 9/19/24, and 9/26/24. Review of the TAR for October 2025 revealed one time where the treatment was not signed off on 10/5/24.
Interview on 10/9/24 at 11:41 AM with Staff P, Licensed Practical Nurse (LPN) verified that she worked 9/30/24. Staff P, LPN, stated she doesn't recall doing a treatment to Resident #20. Staff P, LPN, stated if it wasn't signed off on the TAR, then it wasn't completed. Staff P stated she probably didn't get to it because of medication change over.
Interview on 10/9/24 at 12:12 PM with Staff Q, Registered Nurse (RN) verified that she worked 10/3/24. Staff Q, RN, stated she did complete the skin assessment on Resident #20. Staff Q reported Resident #20 did not have any open areas. Staff Q stated she waited until the last round to look at her residents. Staff Q stated it was not signed off the TAR because she didn't go back and sign it off.
Interview on 10/9/24 at 3:18 PM with Staff R, RN verified that she worked on 9/8/24, 9/23/24 and 10/5/24. Staff R revealed that she did do the treatment to Resident #20. Staff R stated if they are not signed off I must have been rushing around or got interrupted by another staff member.
Based on clinical record review, staff interviews, and policy review the facility failed to provide interventions necessary for the care and services, to maintain the residents' highest practical physical well-being by not completing treatments as ordered by the physician for 3 of 19 residents reviewed (Residents #12, #18 and #20). The facility reported a census of 33 residents.
Findings include:
1. The Annual Minimum Data Set (MDS) assessment for Resident #12 dated 8/9/24 identified a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognition. The MDS identified Resident #12 was independent with bed mobility. The MDS documented Resident #12 required supervision/touching assistance with sit to stand and chair/bed to chair transfers. The MDS included diagnoses of kidney disease, obstructive uropathy, non-Alzheimer's disease, Parkinson's disease, schizophrenia, injury of right kidney, cyst of kidney, obstructive defects of renal pelvis and ureter, and presence of urogenital implants. The MDS identified Resident #12 had an indwelling catheter.
The Care Plan with a target date of 1/1/25 revealed Resident #12 had a nephrostomy tube (a thin, flexible tube that drains urine directly from the kidney into a bag outside the body) to the right kidney. The care plan directed staff to drain the bag every shift, document output and keep the bag in place for dignity and prevent tubing from being pulled.
A Physician order dated 1/2/24 directed staff to cleanse around the nephrostomy tube two times weekly on shower days and as needed with wound cleanser and apply a dry dressing.
A Physician order dated 6/13/24 directed staff to keep the nephrostomy site taped down and covered with a dressing every shift to keep the site protected.
A Progress note dated 9/17/24 documented the facility placed call to interventional radiology due to Resident #12 dislodged his nephrostomy tube. The facility was advised to cover the area and someone would call the facility in the morning with further instruction. The note documented Resident #12's Physician was notified of the new order from radiology.
A Progress note dated 9/18/24 documented fax received from Resident #12's Physician regarding nephrostomy tube being pulled out with new order received.
A Progress noted dated 9/18/24 documented Resident #12 returned from having the nephrostomy tube replaced with no problems noted. The note documented the nephrostomy tube patent and draining clear yellow urine.
Review of the September and October 2024 Treatment Administration Records (TAR) for Resident #12 lacked documentation that the dressing changes to the nephrostomy tube site were completed on shower days per the physician order.
Review of the September and October 2024 TAR revealed lack of documentation the nephrostomy site was checked to ensure the site was taped down and covered with a dressing every shift per the Physician order on the following dates and times:
9/6- dayshift
9/14- dayshift
9/16- dayshift
9/17- dayshift
9/23- dayshift
10/8- dayshift
Review of the facilities Statement of Deficiencies and Plan of Correction (2567) dated 9/4/24 revealed the facility had submitted a recent plan of correction for F684 with a correction date of 10/3/24.
On 10/9/24 at 8:30 AM, Staff A, LPN (Licensed Practical Nurse) reported she had not look at Resident #12's nephrostomy site and ensured a dressing was in place on the morning of 10/8/24. She reported she was too busy and did not get to it. Staff A verified she could not locate the physician order to change the nephrostomy dressing on shower days on the TAR. Staff A reported the physician order was not transcribed correctly into the computer system so the order was not showing up on the TAR.
On 10/9/24 at 9:20 AM, the acting DON (Director of Nursing) stated she had just learned there was a plan of correction for the facility from September 2024. The acting DON reported staff education and audits were not completed as documented in the plan of correction. The DON verified the plan of correction was not implemented with a corrective action date of 10/3/24. The acting DON reported she would expect treatments to be completed per Physician orders.
A facility policy titled Physician's Orders dated January 2024 documented licensed nurses will follow physician orders for resident care and treatments, including medications, treatments, ancillary services and consultations. It is a standard of the facility that all Physician orders will be appropriately transcribed and noted by a licensed nurse.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interviews and facility policy, the facility failed to administer PRN (as needed) enteral feedings (nutrition through a feeding tube) per the physician order for...
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Based on clinical record review, staff interviews and facility policy, the facility failed to administer PRN (as needed) enteral feedings (nutrition through a feeding tube) per the physician order for 1 of 1 resident reviewed (Resident #9) with a feeding tube. The facility reported a census of 33 residents.
Findings include:
The Quarterly Minimum Data Set (MDS) assessment for Resident #9 dated 9/9/24 identified a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS identified Resident #9 eating performance was not applicable. The MDS identified Resident #9 had a feeding tube and also received a mechanically altered diet. The MDS documented Resident #9's proportion of total calories received through the feeding tube was 51% or more. The MDS included diagnoses of cerebrovascular accident (CVA) and dysphagia (difficulty swallowing).
The Care Plan with a target date 12/22/24 revealed Resident #9 required tubing feeding twice a day related to weight loss. The care plan documented Resident #9 was dependent on staff with the tube feeding and water flushes. The care plan also documented Resident #9 refused to eat at times and resisted feedings related to dementia.
A Physician order dated 9/17/24 directed staff to provide up to two additional tube feedings per day of Jevity formula 1.5 Cal (calorically dense, fiber-fortified therapeutic nutrition) 350 cc (cubic centimeter) if Resident #9 does not eat.
Review of Intakes documented in the clinical record from 9/17/24 to 10/8/24 revealed Resident #9 refused to eat meals on the following days: 9/18, 9/19, 9/21, 9/22, 9/30, 10/1, 10/3, 10/5, 10/6, and 10/7.
Review of the September and October 2024 Treatment Records revealed Resident #9 only received the PRN enteral feeding one time on 9/20/24 at 10:20 AM.
On 10/9/24 at 11:45 AM, Staff A, Licensed Practical Nurse (LPN) reported if Resident #9 refused a meal, the PRN enteral feeding should be offered and documented if given or refused in the medical record.
On 10/9/24 at 12:50 PM, the acting Director of Nursing (DON) reported she would expect the physician order for PRN enteral feedings was followed. She stated she expected when Resident #9 refused to eat the supplement feeding was offered and documented.
On 10/9/24 at 1:40 PM, the acting DON acknowledged and verified the staff was not following the physician order for the PRN enteral feedings. She stated she would expect the feedings to be given when the resident refused to eat. She stated the facility was going to reevaluated Resident #9's nutritional needs, contact the dietician and hospice.
A facility policy titled Physician's Orders dated January 2024 documented licensed nurses will follow physician orders for resident care and treatments, including medications, treatments, ancillary services and consultations.
A facility policy titled Tube Feeding Management titled Administration of Enteral Feedings dated January 2024 documented residents would receive tubing feedings per physician orders including specific tube type, frequency of feeding, amount of feeding, administration route and formula prescribed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinic record review, and policy review, the facility failed to administer anticoagulant medication p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinic record review, and policy review, the facility failed to administer anticoagulant medication per physician order for 1 out of 19 residents (Resident #8) which resulted in a significant medication error. The facility reported a census of 33 residents.
Findings include:
Resident #8's Quarterly Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. Resident #8's MDS included diagnoses of anemia, hypertension (high blood pressure), and cerebrovascular accident (CVA) with left sided hemiplegia. The MDS documented Resident #8 had taken an anticoagulant medication during the 7 day look back period.
A Physician order dated 7/30/24 at 3:49 PM directed staff to administer Apixaban (Eliquis) (anticoagulant) 5 mg (milligrams) by mouth twice a day for cerebral infarction due to embolism of the right middle cerebral artery.
A Progress note dated 8/8/24 at 7:30 AM documented Resident #8 was sent to the hospital with family related to congestion and rhonchi noted throughout lungs. The note indicated Resident #8 was unable to cough up phlegm.
A Progress note dated 8/8/24 at 1:30 PM documented Resident #8 returned from the hospital via ambulance on oxygen at 2 liters with a diagnosis of COVID-19. The note documented COVID-19 precautions were implemented.
A Physician order dated 8/8/24 directed staff to administer Paxlovid (medication used to lessen COVID-19 symptoms) 300 mg-100 mg (milligrams) for 5 days. The prescription directed staff to decrease the Apixaban (anticoagulant) medication dosage by half while on the Paxlovid.
A Progress note dated 8/9/24 at 1:15 PM documented Resident #8 daughter called and expressed frustration that the Paxlovid prescription was not covered by insurance and her mother needed the medication. The note revealed the facility RN (Registered Nurse) called the pharmacy and obtained information about a discount program offered through the Paxlovide website. The RN notified Resident #8's daughter with the information regarding the program and the pharmacy contact information to complete the application.
The August 2024 Medication Administration Record (MAR) revealed Paxlovid medication started on 8/10/24 at hour of sleep (HS) and was completed on 8/15/24 AM (morning).
The August 2024 MAR revealed the Apixaban 5 mg one tablet on 8/1/24 AM and 8/6 PM (evening) was not signed off/blank indicating the medication was not administered per order.
The August 2024 MAR revealed Apixaban 2.5 mg one tablet was administered on 8/8 HS and 8/9 AM while Resident #8 was not receiving the Paxlovid.
The August 2024 MAR documented Apixaban 2.5 mg was put on hold on the following dates and times: 8/9 HS, 8/10 AM and HS, and 8/11 AM.
The August 2024 MAR documented Apixaban 5 mg one tablet was given on 8/10 AM and PM while Resident #8 was receiving the Paxlovid.
The August 2024 MAR documented Apixaban 2.5 mg one tablet on 8/11 HS was blank/not signed off indicating the dose was not given. On 8/12 Apixaban 2.5 mg one tablet AM dose was signed off as a 7 indicating Resident #8 was sleeping and the dose was not administered.
The August 2024 MAR documented Apixaban 2.5 mg one tablet on 8/13 AM, 8/18 AM, 8/24 AM, 8/26 AM, 8/28 AM and 8/31 PM was blank/not signed off indicating the dose was not administered.
The August 2024 MAR documented the Apixaban 2.5 mg dose continued through the rest of the month and was not discontinued after the Paxlovid was completed on 8/15/24.
The August 2024 MAR documented the Apixaban 5 mg one tablet was restarted on 8/16 through the morning of 8/19 and then was discontinued.
The September 2024 MAR revealed Apixaban 2.5 mg was documented as being administered throughout the month of September. On 9/1 PM and 9/8 PM the Apixaban was blank/not signed off indicating the dose was not administered.
A Progress note dated 9/26/24 at 8:32 PM documented the facility sent a fax to Resident #8 's Provider requesting clarification of Apixaban with a new order received.
A Physician fax form dated 9/26/24 documented Resident #8 had an order for Apixaban 2.5 mg twice per day in the computer system and Pharmacy said Resident #8 should be on 5 mg of Apixaban. The fax requested clarification on which order Resident #8 should be on. The response from the Physician documented Resident #8 should be on 2.5 mg twice a day for a couple of weeks to ensure no bleeding and stay at that dose.
On 10/08/24 at 10:48 AM, a Pharmacy employee reported the pharmacy sent the Apixaban dosages on the following dates in July and August 2024:
7/30- Apixaban 5 mg one tablet twice a day
8/8- Apixaban 2.5 mg one tablet twice a day for 5 days
8/13- Eliquis 5 mg one tablet BID for 14 days (28 doses)
8/20- Eliquis 5 mg one tablet BID for 14 days (28 doses)
On 10/08/24 at 9:10 AM, Staff A, LPN (Licensed Practical Nurse) reported she had been back working at the facility for about four weeks. She stated she was working on double noting orders in September that she was trying to catch up on. She stated there were two different orders for the Apixaban and she wanted to make sure Resident #8 was getting the correct dosage. She stated she was not aware of a medication error, she was just clarifying the order. She reported she thought there was 2.5 mg of Apixaban in the medication cart and not the 5 mg.
On 10/8/24, 9:15 AM, the acting DON (Director of Nursing) and Administrator reported they could not locate any documentation regarding medication errors. The Administrator reported he could not find any tracking or documentation in QAPI (quality assurance performance improvement).
On 10/8/24 at 1:00 PM, the acting DON acknowledged and verified the concerns with the Apixaban administration and documentation. She stated she would start an investigation. She stated the only thing she could go off of, was what was documented on the medication administration records. She stated she would expect the nurses to follow physician orders, follow the medication administration rights and ensure orders are transcribed to the MAR correctly.
On 10/8/24 at 1:25 PM, the Pharmacy Representative reported she did not have any records or logs of any Apixaban medication returned for Resident #8. She stated the pharmacy documentation revealed the pharmacy consistently dispensed the Apixaban on an average of 14 days. She verified Apixaban 5 mg BID was sent for 14 days on 7/30, 8/13, 8/20, 8/31, and 9/14.
A facility policy titled Medication Administration Guidelines dated October 2023 documented guidelines assume that all services are provided in accordance with regulatory requirements and standard of professional practice. The policy directed staff upon administering medication, the licensed nurse will compare the label on the medication to the MAR to ensure accuracy. All variances are to be reported to the pharmacy immediately. The policy directed staff to compare the MAR with the label of each medication for the following:
1. Right Person
2. Right Medication
3. Right Date
4. Right Time
5. Right Route
6. Right Dose
7. Right Expiration Date
The policy documented if there was a discrepancy, the medication will not be administered. Instruction will be verified by contacting the physician and pharmacy.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, staff interviews and policy review the facility failed to offer and provide HS (hour ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, staff interviews and policy review the facility failed to offer and provide HS (hour of sleep) snacks for 7 of 7 residents reviewed (Resident #1, #2, #3, #11, #12, #17, and #18). Facility reported a census of 33 residents
Findings include:
The following Minimum Data Set (MDS) assessments identified the Brief Interview for Mental Status (BIMS) Scores:
Resident #1, MDS dated [DATE] had a BIMS score of 15 (intact cognitive ability)
Resident #2, MDS dated [DATE] had a BIMS score of 15 (intact cognitive ability)
Resident #3, MDS dated [DATE] had a BIMS score of 15 (intact cognitive ability)
Resident #11, MDS dated [DATE] had a BIMS score of 15 (intact cognitive ability)
Resident #12, MDS dated [DATE] had a BIMS score of 13 (intact cognitive ability)
Resident #18, MDS dated [DATE] had a BIMS score of 13 (intact cognitive ability)
Review of Resident #1, #2, #3, #11, #12, #17, and #18's Point of Care report for snacks offered for 9/12/24-10/9/24 revealed no documented offer of snacks for the following dates:
9/13/24,
9/15/24,
9/17/24,
9/20/24,
9/24/24,
9/27/24,
10/1/24.
During an interview on 10/9/24 at 7:57 PM, Resident #12 stated sometimes the snack cart has a ton of snacks and sometimes it dif not. Snacks come about 8:15 PM or so.
During observation on 10/9/24 from 7:57 PM - 8:47 PM, no snack cart was present on the floor and no snacks were passed to residents.
Interview on 10/9/24 at 4:30 PM, Staff S, CNA, stated there had been times the snack cart was not brought out for the CNAs to pass and times the CNAs have been too busy or too short staffed to offer them to the residents.
Interview on 10/10/24 at 11:38 AM, Staff J, CNA, stated the snack cart is brought to the nurses station by dietary staff but sometimes a CNA will get it from the kitchen. There has been times when no cart is brought out and is not available for the residents. There has been times there isn't enough staff or the few staff are too busy to get the snack passed before the residents are in bed or asleep.
Observation of posted meal times throughout the facility indicated:
Breakfast 7:45 AM- 9:00 AM
Lunch 12:00 PM (noon)
Dinner 5:45 PM
Review of Between Meal Snack/Bedtime Nourishments Policy stated, between meal snacks and bedtime nourishments are to be offered to all residents unless contraindicated by the physician diet order.
Dietary should develop a snack nourishment stock level for each of the nursing stations. This would consist of the specified number of juice pitchers, cartons of milk, cookies or crackers. Cookies and crackers may be placed in a covered and labeled storage container and delivered to the nurse stations. Nurses should use clean tongs to pass these items when necessary.
According to regulation, nursing is to pass snacks and nourishments from room to room. It is not acceptable to announce that snacks are being served from the nursing station.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review the facility failed to provide nursing staff to a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review the facility failed to provide nursing staff to assure residents safety to provide cares in a timely manner. Residents and staff reported having low staffing caused missed or delayed cares. The facility reported a census of 33 residents.
Findings include:
1. Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and depression.
On 9/30/24 at 11:30 AM Resident #1 reported that the facility did not have enough staff, and that it can take a long time for call lights to be answered. Resident #1 further revealed that call lights can take a long time, and it does not matter what time of day.
2. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS further revealed Resident #2 requires supervision or touching assistance with showering/bathing themselves.
On 10/1/24 at 9:15 AM Resident #2 reported that there isn't enough staff at the facility, and that showers don't get completed as often as Resident #2 would like.
Review of Resident #2's Electronic Healthcare Record (EHR) page titled task shower/bath revealed no showers or baths completed 9/1/24 through 10/1/24.
3. Review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. The MDS further revealed diagnosis of muscle weakness, cervicalgia (neck pain), bipolar disorder.
Interview 10/1/24 at 8:30 AM with Resident #3 revealed that there is not enough staff at the facility. Resident #3 further revealed that showers are not getting completed regularly and that it had been almost 2 weeks since his last shower. Resident #3 then revealed that he is supposed to be receiving showers two times a week and would like them three times a week. Resident #3 revealed it upsets him, but nothing is being done.
Review of Resident #3's EHR page titled task shower/bath revealed no documentation of showers or baths completed 9/1/24 through 10/1/24.
On 10/1/24 at 9:05 AM with Staff N Housekeeping revealed that she feels there is not enough staff nursing or CNA help at the facility. Staff N further revealed that She feels there is definitely not enough staff to take care of the residents.
On 10/1/24 at 10:25 AM with Staff G Certified Nursing Aide (CNA) reported some of the problem with staffing is call ins. Staff G further revealed that there was supposed to be 3 CNAs on most shifts, but due to call ins the facility runs with less. Staff G then revealed that sometimes showers are missed. Staff G further revealed that the facility is using staffing agencies, but it is less than before.
Interview 10/1/24 at 10:50 AM with the Administrator revealed that staffing is a concern at the facility. The Administrator further revealed that he has concerns with showers and baths not being completed.
Interview 10/1/24 at 11:01 AM with Staff L Licensed Practical Nurse (LPN) revealed that there is not enough staff at the facility. Staff L then revealed that she often doesn ' t get all of her work completed during the shift. Staff L further reported that baths and showers are not getting done routinely related to low staffing.
Interview 10/1/24 at 4:45 PM with Staff E former Director of Nursing (DON) revealed that she had it approved by the corporate office to have more agency CNAs, but this was canceled by the Administrator as the company the agency CNAs were coming from were too expensive. Staff E further reported that she had emailed her concerns about staffing and showers not being completed to the Administrator.
Interview 10/2/24 at 9:15 AM with Staff D, Social Service Director/Activity Director revealed the facility owes a large sum of money to staffing agencies, and nobody will send help. Staff D further revealed that word has gotten out about the facility, and nobody is applying to work there.
On 10/3/24 at 9:30 AM with Staff I acting DON reported the facility was working on adding additional CNAs for the overnight shift. Staff I revealed She would like to have two CNAs each night. Staff I then reported at a minimum there should be 3 aides on day shift and evening shift.
Interview 10/8/24 at 10:35 AM with Staff O previous DON revealed she had worked at the facility from July to August of this year. Staff O revealed that there was only one other Registered Nurse working at the facility while working during this time period, and that the facility had issues with call ins.
Review of facility provided staffing sheets revealed low staffing numbers for 8/30/24, 9/2/24 through 9/20/24, and 9/24/24 through 9/27/24.
Review of the facility assessment provided with an updated date of 10/2/24 documented:
a. Direct care staff at 1 x ratio Days (total licensed or certified)
b. Direct care staff at 1 x ratio Evenings
c. Direct care staff at 1 x ratio Nights.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on record review, staff interviews, facility policy the facility failed to be administered in a manner that enables it to use its resources effectively, and efficiently to attain or maintain the...
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Based on record review, staff interviews, facility policy the facility failed to be administered in a manner that enables it to use its resources effectively, and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility reported a census of 33 residents.
Findings include:
1. Review of facility provided job description titled, Licensed Nursing Home Administrator dated 1/14/15 documented:
a. The primary purpose of the Nursing Home Administrator position is to oversee the day-to-day operation of the facility and to review organizational performance.
b. Oversee that residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents.
c. Oversee that human resource management policies and programs are planned, implemented and evaluated in compliance with governmental entities, laws, and regulations.
d. Maintain responsibility for an adequate number of appropriately trained professional and auxiliary personnel being on duty at all times to meet the needs of the residents.
e. Conduct administrative review of survey outcomes to develop appropriate response ie. preparation of a plan of correction.
During the facility ' s survey of facility reported incidents and complaints conducted from 9/30/24-10/10/24 revealed:
1. The facility failed to protect residents from abuse by failing to ensure all allegations of abuse are reported and investigated.
Interview 9/30/24 at 3:30 PM with Staff D revealed she emailed Staff B about an allegation that Staff C was taking Resident #1 out and to her home and she felt it was inappropriate.
Interview 9/30/24 at 3:45 PM with Staff B revealed that an allegation of abuse was submitted to HR and she reported it to the Administrator and Staff E, previous DON via email on 9/12/24. Staff B said nothing was completed the first week after being turned in.
Interview 10/1/24 at 4:45 PM with Staff E previous DON revealed She had not reported as She thought the Administrator had. Staff E then revealed that the Administrator called Her several days later and asked if She had reported this situation.
Interview 10/8/24 at 3:37 PM with the Administrator confirmed that he received an email written on 9/12/24 about an allegation of abuse from HR. The Administrator then revealed that it was turned into the State Entity on 10/3/24.
2. The facility failed to implement interventions to protect residents from potential misappropriation of funds.
Interview 10/9/24 at 8:55 AM with Staff D revealed that sometime in July of this year she had brought up concerns about a staff member having a resident ' s funds at their home.
Interview on 10/8/24 at 3:38PM Staff H confirmed she that Resdient #11 gave Staff H $1,100.00 to hold onto for her. Staff H revealed she brought the money back because She was turned in for having it and that the Administrator and Staff I acting Director of Nursing (DON) told Her to bring the money back. Staff H confirmed She had violated the company policy for holding resident funds.
Review of a facility provided policy titled, RFMS Petty cash Policy with a revision date of 4/10/24 revealed: a. No staff can hold funds for residents.
3. The facility failed to implement a plan of correction developed by the facility administrator in response to deficiencies cited during a complaint investigation completed on 9/4/24.
Interview 10/9/24 at 9:20 AM with Staff I the acting DON revealed that She had just learned there was a plan of correction in September for the facility. Staff I provided the plan of correction information with a correction date of 10/3/24. Staff I further revealed that She could not locate education or audits completed as documented in the plan of correction.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, staff interviews and policy review the facility failed to provide a clean homelike environment for all t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, staff interviews and policy review the facility failed to provide a clean homelike environment for all the residents living in the facility. The facility reported a census of 33.
Findings include:
Interview on 10/2/24 at 10:29 AM, with Resident #3, reported he doesn't have any mice in his room and hasn't seen them in a while. Resident #3 knows the mice are still in the building and stated his neighbor usually gets them.
Interview on 10/2/24 at 10:50 AM, with Resident #1, revealed once in a while mice are in his room. Resident #1 revealed that he has a sticky trap underneath his heater that the facility put in his room. Resident #1 revealed he moved it to the top of the heater because the mice run down the top of the heater. Resident #1 revealed he did see a mouse the other day in his room. The mouse peaked its head out underneath the heater.
Interview on 10/2/24 at 3:07 PM, with Resident #13, reported he had seen mice in the bathroom. Resident #13 revealed there are holes in the bathroom close to the floor boards, there is one hole on the left side and one hole on the right side. Resident #13 revealed he had mouse droppings in the top drawer where he stored food. Resident #13 revealed they ate my roommates Reese's peanut butter cups. Resident #13 revealed the last time he saw a mouse was within a week ago. Resident #13 revealed he told the housekeeper about the mice and the facility had set a trap in the corner of his room. He stated his next door neighbors had mice in their pants when they picked them up off the floor. Resident #13 revealed this whole side of the hallway is infested with mice.
Observed on 10/2/24 in the bathroom of Resident #13, the two holes, one on the right corner and one on the left corner of the bathroom.
Observed on 10/2/24 mice droppings on the heater of the Social Services office.
Interview on 10/3/24 at 9:45 AM, with Resident #15, revealed she had seen mice in her room and running across the floor.
Interview on 10/3/24 at 12:41 PM with Staff L, Maintenance Supervisor, believes pest control was here last Monday. Staff L thought they usually come once a month.
Interview on 10/3/24 at 3:15 PM with pest control tech #1, revealed the last time he had heard anything about mice was about two months ago. He stated there was an issue in the storage room and an office in one of the back hallways, the same hallway as the food storage pantry. He stated that there are exterior stations (metal boxes) to the outside of the building approximately 14. He stated they spray a solution that lingers for about one month or so and it works pretty well.
Interview on 10/3/24 at 4:30 PM with the pest control tech #2, stated that he had been at the facility twice. Pest control tech #2 stated he did inside and outside treatment. He stated he did check some base stations (metal boxes outside) and checked outside around the building. He stated he did see some mice droppings. He stated the facility does have some openings where the mice could enter. He stated they need to seal these areas up.
Interview on 10/7/24 at 9:55 AM with Staff L, Maintenance Supervisor reported the resident's do inform him about the mice. Staff L has placed sticky traps, but has never caught any mice on them. Staff L revealed he has seen a mouse in his office, but never in any other room. Staff L stated he has seen mice droppings in a resident's room when he had to clean a room out. Staff L revealed he did clean a mouse up from one of the pest control boxes in the attic. Staff L stated he had to put steel wool in a hole in room [ROOM NUMBER] to help prevent the mice from coming in.
Observed on 10/7/24 at 10:45 AM, where the steel wool was placed inside of the hole in room [ROOM NUMBER] to prevent the mice from coming in next to the vanity.
Interview on 10/7/24 at 9:45 AM with Resident #12 stated they had a mouse in their room and the mouse comes from the bathroom. The facility had set sticky traps in the room.
Interview on 10/7/24 at 10:40 AM with Staff F, CNA, stated she hasn't seen any mice in the building for at least a couple of months.
Interview on 10/7/24 10:55 AM with Staff M, Cook/Housekeeping, revealed he was the previous maintenance person and had switched positions in July 2024. Staff M revealed the mice have been an ongoing issue. Staff M revealed this is an old building and we have a lot of holes and it is also next to a field. Staff M feels it has gotten better since the Pest Control Company has come in and sprayed a solution inside and around the building. Staff M revealed he would set sticky traps and put steel wool in the holes in the walls because this is supposed to deter the mice from coming in. Staff M stated he hasn't seen a mouse in over a month or mice droppings.
Interview on 10/7/24 at 2:20 PM with Staff J, CNA, stated she has not physically seen any mice and have not recently seen any signs of them. Staff J stated she knows they will put steel wool into the holes that the mice are coming into.
Review of the facility provided policy titled Pest Control dated 3/2016 revealed the facility strives to protect the residents, staff and visitors from insects and other pests by controlling infestation through contracts with outside pest control agencies. It is the responsibility of all staff members to detect and report immediately the presence of pests to their supervisor. In the event that insects and or pests are noted in a resident's room or on the resident, immediate steps will be taken to prevent or decrease the risk of actual or potential harm.
Interview on 10/7/24 at 2:45 PM, with the Administrator revealed The Pest Control Company comes monthly. Administrator revealed they had set traps in the ceiling, and sprayed a solution around the building. The Administrator revealed they have not gone over recommendations with The Pest Control Company. The Administrator stated they took it upon themselves to have conversations with the residents to keep food in zip lock baggies. The Administrator revealed they are trying to keep the rooms cleaned, by pulling rooms and cleaning underneath the heaters on the walls. Administrator revealed we have bought our own traps, the sticky traps and put them around the building. I have been trying to get a hold of The Pest Control Company and will call again.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review, observation, resident interview, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not completing t...
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Based on record review, observation, resident interview, staff interview, and policy review the facility failed to provide needed services in accordance with professional standards by not completing treatments as ordered by the physician for 3 of 3 Residents (Resident #1, #2, and #3) reviewed. The facility reported a census of 35 residents.
Findings include:
1. Review of the Minimum Data Set (MDS) for Resident #1 dated 5/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The MDS further revealed diagnosis of renal insufficiency, obstructive uropathy, and artificial openings of the urinary tract.
Review of the Electronic Health Record (EHR) document titled, physician's orders, revealed an order dated 6/13/24 to keep Resident #1's nephrostomy site taped down and covered with a dressing every shift for keeping the site protected. The physician's order page further revealed an order dated 7/23/24 for nystop external powder 100000 unit/GM and to apply to the left breast topically every morning and at bedtime for moisture associated skin damage until healed.
Review of the Treatment Administration Record (TAR) for Resident #1 from August 1, 2024 to September 4, 2024 revealed there was no documentation for treatment to the nephrostomy site being completed 9 times in the time period reviewed. The TAR further revealed for the same time period that the nystop had not been administered 18 times.
Observation 9/3/24 at 1:35 PM Resident #1 was observed to have no dressing, or tape to the nephrostomy site. The nephrostomy tube was noted to be unsecured at that time.
Interview 9/3/24 at 1:35 PM Resident #1 revealed the treatment to tape and place a dressing to the nephrostomy site was not completed and this happens often.
2. Review of the MDS for Resident #2 revealed a BIMS score 9 indicating moderate cognitive impairment. The MDS further revealed diagnosis of traumatic brain injury, and need for assistance with personal care.
Review of the EHR document titled, physician's orders, revealed an order dated 6/6/24 for antifungal (clotrimazole) external cream 1% to be applied to Resident #2's groin twice daily for redness until healed.
Review of the TAR for Resident #2 from August 1, 2024 to September 4, 2024 revealed there was no documentation for the antifungal treatment to the groin 24 times.
3. Review of the MDS for Resident #3 dated 6/21/24 revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnosis of renal insufficiency, diabetes mellitus, and need for assistance with personal care.
Review of the EHR document titled, physician's orders, revealed an order dated 5/29/24 for dry gauze and a dressing to be applied to the left heel at bedtime for protection.
Review of the TAR for Resident #3 from August 1, 2024 to September 4, 2024 revealed there was no documentation for the gauze and dressing to the left heel documented 11 times.
Interview 9/4/24 at 8:42 AM Resident #3 revealed that the treatment to Her heel was completed the night prior and was still there, but this doesn't always get done. Resident #3 further revealed the nurses always seem so rushed.
Interview 9/3/24 at 12:10 PM with Staff D Registered Nurse (RN) revealed that treatments for resident's skin have not gotten completed in the past, and that She has signed them off as completed in the TAR.
Interview 9/3/24 at 2:23 PM with Staff A RN revealed that sometimes treatments do not get done as ordered due to being too busy. Staf A further revealed that if She doesn ' t get the treatment completed she will not sign it off in the TAR.
Interview 9/4/24 at 9:18 AM The Director of Nursing (DON) revealed her expectation would be for physician's orders to be followed. The DON further revealed if treatments were not completed She would want to know what the reason was and correct documentation as to why the treatment was not completed.
Interview 9/4/24 at 9:45 AM with the Administrator revealed his expectation is for physician's orders to be followed and completed as they are ordered.
Review of a facility policy related to following physician orders revealed there was no policy to review.
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 F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on record review, observation, Resident interview, staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in ...
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Based on record review, observation, Resident interview, staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 5 (Resident #1, #4, #5) Residents reviewed. The facility reported a census of 35 residents.
Findings include:
Review of facility provided documents titled, Council Members Present, for the months of June, July, and August 2024 revealed concerns from resident council for each month related to call lights. June's documentation revealed call lights needing answered. July's notes revealed call lights slow when agency staffing was in the facility. August notes revealed call lights need to be answered faster.
During continuous observation 9/3/24 from 1:28 PM until 1:50 PM (22 Minutes) a call light was observed to be unanswered on the northwest hallway of the facility
1. Review of the Minimum Data Set (MDS) for Resident #1 dated 5/25/24 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition.
Interview 9/3/24 at 1:35 PM Resident #1 reported that there is not enough staff at the facility. Resident #1 further revealed call lights last longer than 15 minutes, and are usually around 30 minutes to an hour. Resident #1 states there are not enough Certified Nurses Aides (CNAs) ,and the facility has a lot of call ins so there will be days when only one CNA is on the floor.
2. Review of the Annual MDS for Resident #4 dated 8/7/24 revealed a BIMS score of 15 which indicated intact cognition.
Interview 9/3/24 at 1:49 PM Resident #4 reported call lights take forever, and that there is not enough staff at the facility. Resident #4 further revealed that his call light has been on for almost 20 minutes at this time. Resident #4 revealed he watches the clock or television to tell how long it has been. Resident #4 then revealed that sometimes there is just one CNA in the facility, and it can take almost an hour for call lights to be answered.
3. Review of the Annual MDS for Resident #5 dated 6/1/24 revealed a BIMS score of 15 which indicated intact cognition.
Interview 9/3/24 at 1:55 PM Resident #5 reported the facility just doesn't have enough staff. Resident #5 then revealed call lights take over 15 minutes constantly, and that call lights usually are answered closer to 30 minutes at a minimum. Resident #5 further revealed that she watches the clock.
Interview 9/4/24 at 7:55 AM with Staff B CNA revealed that due to staffing it takes a longer amount of time to answer call lights. Staff B then revealed that the CNAs at the facility do their best, but there is definitely not enough staff to answer call lights in a timely manner.
Continuous observation 9/4/24 from 8:10 AM until 8:30 AM (20 minutes) a call light was left unanswered in the northeast hallway of the facility.
Interview 9/4/24 at 8:35 AM with Staff C CNA revealed that the CNAs try to get to call lights within 15 minutes, but they don't always make it. Staff C further revealed that she thinks some of the issue is with staffing.
Interview 9/4/24 at 9:18 AM with the Director of Nursing (DON) revealed her expectation is for call lights to be answered in 15 minutes or less.
Interview 9/4/24 at 9:45 AM with the Administrator revealed his expectation is for call lights to be answered in 15 minutes or less.
Review of a facility provided policy titled, Call Light Standard dated August 2023 documented:
a. Answer the Resident's call light as soon as practicable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and policy review the facility failed to have a medication error rate of 5% or less related to presetting medications for 13 residents. The facility reported a c...
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Based on observation, staff interview, and policy review the facility failed to have a medication error rate of 5% or less related to presetting medications for 13 residents. The facility reported a census of 35 residents.
Findings include:
Observation 9/3/24 at 2:23 PM of the medication cart revealed 13 medication cups with multiple medications (26 medications total) in the cups sitting in the top tray of the medication cart. During this observation Staff D Registered Nurse (RN) stated, This is all trash. Staff D then revealed that She had pre-set stock medications for the next medication pass. Staff D then destroyed the medications. Staff D further revealed that sometimes treatments do not get completed as ordered related to being too busy, but She will not sign them off in the Medication Administration Record or Treatment Administration Record if it does not get completed.
Interview 9/3/24 at 2:50 PM with the Director or Nursing (DON) revealed that her expectation is for medications not to be pre-set, and for medications to be stored and passed correctly.
Review of a facility provided policy titled, Medication Administration Guidelines dated October 2023 documented:
a. Only a licensed nurse will be allowed to administer medication as per state/Federal laws
and regulations (follow state policy on Medication Aides).
May 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, the facility failed to follow a comprehensive Care Plan for t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, the facility failed to follow a comprehensive Care Plan for two of three residents reviewed (Residents #4 and #5). The facility reported a census of 34 residents.
Findings include:
1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of non Alzheimer's dementia and hearing loss.
On 5/6/24 at 1:00 PM, witnessed Resident #4 in her room wearing a wander guard (W/G) (alarm system that activates when resident goes out a door) on her left wrist.
Resident #4's Clinical Physician Orders reviewed on 5/7/24 at 3:33 PM listed an order for W/G, check placement, and functioning every shift.
Resident #4's Elopement Evaluation dated 4/4/24 revealed a score of 2, indicating a risk for elopement.
The Care Plan Focus with a target date of 3/26/24, identified Resident #4 as an elopement risk/wanderer. The facility applied a wander guard on 3/23/24 and checked placement and functioning every shift.
Resident #4's April 2024 and May 2024 Treatment Administration Record lacked documentation that someone checked her W/G placement and functioning.
2. Resident #5 MDS assessment dated [DATE] identified a BIMS score of 3 indicating severe cognitive impairment. The MDS included diagnoses of non Alzheimer's dementia and blindness of right eye. Resident #4 used a wander/elopement alarm daily.
On 5/7/24 at 12:50 PM witnessed Resident #5 wandering up and down the hallway wearing a W/G on her left ankle.
Resident #5's Clinical Physician Orders reviewed on 5/7/24 at 3:33 PM listed an order for W/G, check placement, and functioning.
Resident #5's Elopement Evaluation dated 4/10/24 revealed a score of 4, indicating a risk for elopement.
The Care Plan Focus with target date of 4/29/24, described Resident #5 as an elopement risk/wanderer due to her wandering aimlessly. The Intervention dated 1/28/23 directed she had a W/G due to wandering and risk for elopement.
Resident #5's April 2024 and May 2024 TAR lacked documentation of W/G checked for placement and functioning.
Interview on 5/8/24 at 10:45 AM, Staff C, Licensed Practical Nurse (LPN), reported they check the residents' W/G every shift, sometimes throughout the shift. Staff C stated she checks the wander guards by taking the resident by door to see if the W/G goes off and then signs off on the resident's TAR. Staff C reviewed Resident #4 and #5's TAR and confirmed the TAR didn't have the W/G.
Interview on 5/8/24 at 4:30 PM, the Director of Nursing (DON) explained she expected the staff to follow the Care Plan by checking and documenting all the wander guards every shift.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, resident, and staff interview the facility failed to maintain a safe, clean, comf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, resident, and staff interview the facility failed to maintain a safe, clean, comfortable and homelike environment. Observations revealed dirty air conditioners, dirty fans in residents' rooms, loose floor tiles, missing base board trim in a residents' bathroom, leaking ceilings in the hallway, and a resident's room. The facility reported a census of 34.
Findings include:
On 5/6/24 at 10:30 AM observed the following:
a. A barrel in the south hallway under 2 missing ceiling tiles. The barrel contained broken tiles.
b. In the south hallway, 2 trash cans, a basin with pads underneath, water covering the bottom of the trash cans, and basin.
c. Between rooms [ROOM NUMBERS] in the south hallway, ceiling tiles around the vent appeared a light brownish discoloring and looked like they historically got wet.
Interview on 5/6/24 at 11:10 AM, Resident #11 stated the ceilings still leak and have for a long time. Resident #11 reported the facility is replacing the tiles but it still leaks. Resident #11 explained the south hallway had 3 areas, he puts out the trash cans and basins when it rains.
Interview on 5/6/24 at 11:35 AM, the Activity Director (AD) stated she worked at the facility since January 2024 and the hallway ceiling leaked when they had a heavy rain. The AD stated she knows the facility has requested bids for the roof, but no one has repaired the roof since she worked at the facility.
On 5/6/24 at 2:35 PM, witnessed a resident in room [ROOM NUMBER] with the pedestal fan on. The fan had a large amount of dust balls on it, hanging off the blade covers, and completely covered the running air conditioner (A/C).
Interview on 5/7/24 at 9:20 AM, Staff A, Housekeeper, stated she worked at the facility since December 2023 and the roof has leaked since she started there. Staff A stated mainly in the south hall in the 2 areas and they put basins out for the leaks and is not aware of any roof repairs since she started.
On 5/7/24 at 1:00 PM observed Resident #11's room. On the floor noted a basin with water in it, the A/C filter screen partially covered in dust with inside of A/C with black spotted areas and dead bugs in it. In addition, the adjoining bathroom between Rooms #4 and #6 lacked base boards and had loose, sliding tiles on floor. Resident #11 stated he puts the basin on the floor in his room as the ceiling leaks when it rains hard, he doesn't know the last time someone cleaned the A/C. He added the bathroom looked that way for a long time.
Interview on 5/7/24 at 1PM, Resident #12 stated the halls leak when it rains hard, have to put out basins for the leaks, the facility replaces the ceiling tiles but doesn't fix the roof. Resident #12 stated his room did leak but they sprayed something up in there and has stopped for now.
The Resident Rights & Dignity Management policy dated October 2023 directed to provided a safe, clean, comfortable, and home like environment.
Interview on 5/8/24 at 9AM, the Administrator (ADM) stated he started at the facility in April 2023 and the roof has leaked since then. The ADM stated no one has completed roof repairs since he started except for some patching the facility has done themselves. The ADM started getting bids for repair of the roof in March and April 2024. The ADM stated expectation for resident to have a safe, clean environment.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected multiple residents
1F 839 Staff Qualifications SS=E
Based on staff interview, staff record review, resident record review, and facility documentation the facility failed to ensure a staff member had their Certified Medi...
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1F 839 Staff Qualifications SS=E
Based on staff interview, staff record review, resident record review, and facility documentation the facility failed to ensure a staff member had their Certified Medication Aide (CMA) for the state of Iowa. The facility allowed the staff member, Staff B, Certified Nurse Aide (CNA), administer medication to the residents without an Iowa certification. The facility reported a census of 34 residents.
Findings include:
Interview on 5/6/24 at 1:46 PM, Staff B stated she started working at the facility on 4/19/24, as a CMA. She explained she had a Nebraska certification as a CMA but not in Iowa. She reported trying to schedule the challenge test to receive her certification as a CMA in Iowa. Staff B stated she worked as a CMA and passed medications every day she worked, since her start date and until Friday 5/3/24. At that time, the Administrator (ADM) and Director of Nursing (DON) notified her they planned to remove her from the medication cart until she could challenge the CMA test. As she had her CMA certification for Nebraska and not for Iowa. Staff B stated she administered medications to residents on the following days: 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/29/24, 4/30/24, 5/1/24, 5/2/24, and 5/3/24.
Review of Staff B's Certification of Licensure revealed verification of licensure in the state of Nebraska for a CMA issued 8/3/22 with the expiration date of 8/3/24.
Resident #5's April 2024 and May 2024's Medication Administration Records (MAR) included documentation by Staff B indicating she administered medication on the following dates: 4/24/24, 4/25/24, 4/30/24, 5/2/24, and 5/3/24.
Review of Staff B's time sheet revealed she worked on the following dates: 4/19/24, 4/20/24, 4/21/24, 4/23/24, 4/24/24, 4/25/24, 4/26/24, 4/29/24, 4/30/24, 5/2/24, and 5/3/24.
Interview on 5/8/24 at 4:30 PM, the Administrator (ADM) stated the corporate office told the facility, Staff B could work as a CMA with her Nebraska CMA certification. The ADM confirmed Staff B worked as a CMA until the facility received notification on 5/3/24, that she couldn't work as a CMA. The ADM said Staff B has not worked as a CMA since that date. The ADM stated expectation to have proper certification to work as CMA.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observations, facility policy review, resident, and staff interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. The f...
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Based on observations, facility policy review, resident, and staff interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. The facility reported a census of 34 residents.
Findings include:
On 5/6/24 at 11:30 AM, witnessed 4 sticky pest traps under the base boards in the dining room (DR).
On 5/6/24 at 11:40 AM, observed the staff replacing ceiling tiles in the east hall. As they removed the old tiles, a large amount of vermin droppings fell from the ceiling onto the floor.
On 5/8/24 at 11:45 AM, as Resident #7 sat in the DR and stated the facility had the sticky pest traps in the DR for a while. Resident #7 added they thought the facility saw a few mice.
Review of the Pest Control's Company invoices for service dates of 2/28/24, 3/13/24, and 4/12/24 provided documentation of treatment for target pests of ants, bedbugs, beetles, boxelder bugs, carpet ants, and biting midges, with no documentation of treatment for vermin/rodents.
Facility policy, Environmental/Plant Operations, Pest Control dated March 2016 revealed the facility strives to protect the residents from insects and other pests by controlling infestation through contracts with outside pest control agencies.
Interview on 5/8/24 at 9:00 AM, the Administrator (ADM) confirmed he observed the large amount of vermin droppings on the floor after the tile removal on 5/6/24. The ADM stated the traps are in the DR as the staff have reported they have observed mice. The ADM stated the facility did have an exterminator that comes monthly and he knows he treats the inside and outside of the building.
Mar 2024
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure residents with impai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure residents with impaired cognition couldn't exit the facility unattended for 1 of 1 resident reviewed for elopement (Resident # 1). The facility's front door alarm malfunctioned during the prior 30 days, despite the facility knowing about the malfunctioning alarm, the facility didn't get the alarm repaired. Due to the malfunctioning of the alarm, the facility staff didn't know a cognitively impaired resident left the building. Due to the proximity to the Highway 14, a major four lane highway (55+ miles per hour), this resulted in a likelihood of Resident #1 received a serious illness, injury, or death. When the door alarm malfunctioned, the facility staff had to disarm the alarm and re engage the alarm, for the alarm to function. The facility had at least 3 cognitively impaired residents who wandered the facility, with at least 2 residents without a wandering alert device, thus relying only on the front door alarm to notify staff if the resident left the building. This failure resulted in a likelihood of serious injury or death, therefore, causing an Immediate Jeopardy to the health, safety, and security of the residents.
The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of March 13th, 2024 on March 21st, 2024 at 12:00 PM.
The Facility Staff removed the Immediate Jeopardy on March 21st, 2024 through the following actions:
a. The facility implemented 24-hour continuous monitoring by a staff member of the door with the malfunctioning door alarm 3/21/24.
b. The continuous monitoring will remain in effect until the door alarm is fixed.
c. The facility completed an audit on 3/21/24 of all external facility doors to ensure no other doors malfunctioned.
d. The facility contacted the Door Security Company on 3/21/24.
e. The Door Security Company reported they would come to the facility on 3/22/24 to fix the door alarm.
f. The facility educated all staff on 3/21/24 on the door alarm system. In addition, when they need to immediately notify the Administrator if someone knew of a malfunctioning door alarm.
g. The Administrator or designee will audit door alarms daily to ensure functioning properly.
The facility decreased the scope from a J to a D at the time of the survey.
Findings Include:
Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. The MDS listed Resident #1 walked and transferred independently. The MDS included diagnoses of bipolar disorder (mood disorder), depression, and hypertension (increased blood pressure).
The Care Plan reviewed 3/12/24 reflected Resident #1 transferred and ambulated independently without adaptive devices.
The Health Status Note on 3/13/24 at 1:50 PM indicated the nurse noticed a certified nurse aide (CNA) walk toward the desk and notify the Director of Nursing (DON) that Resident #1 rang the doorbell, and a CNA let him in to the facility. Resident #1 reported he went to see what it's doing outside. Resident #1 wore a short sleeve red shirt and a red long sleeve shirt with sweatpants. The temperature outside measured 68 degrees Fahrenheit (F), but felt like 67 F. Resident #1 alert per self, knows the year, however could not tell the day of the week or month. Resident #1 walked per normal, no edema, no limp noted, skin warm and dry. Resident #1's assessment revealed a soft non-distended, non-tender abdomen with normal bowel sounds. He had no respiratory distress with even, nonlabored respirations. Resident #1 placed on hourly checks for forty-eight hours. The nurse notified the Administrator at 1:52 PM. At 2:45 PM the nurse received an order to apply a wandering alert device and check every shift received. The nurse applied the wandering alert device on his left ankle. At 2:49 PM Resident #1's family called and agreed with the plan of care, they didn't verbalize any concerns.
The Health Status Note dated 3/13/24 at 2:48 PM indicated the event occurred at 2:48 PM and the nurse notified the Administrator at 2:52 PM, got the order for the wandering alert device at 3:52 PM and notified his family notified at 3:49 PM.
The N Adv - Elopement Evaluation dated 3/13/24 at 8:34 PM reflected Resident #1 had an elopement score of 0.
On 3/20/24 at 10:50 AM the Director of Nursing (DON) described Resident #1 as not a wanderer, and he needed to encouragement to leave his room. The staff reported seeing Resident #1 in the dining room at 2:45 PM. The DON explained they had everything in place for elopement risk. Such as, doing 15-minute visual checks and documenting them on the clipboard at the nurse's station. They applied a wandering alert device on Resident #1. The DON reported Staff F, CNA, discovered Resident #1 outside. The door alarm did not activate. Resident #1 did not have any injuries. Resident #1 exited through the front door. Resident #1 rang the doorbell and staff assisted him into the door. The front door is visible from the nurse's station. Resident #1's room is visible to the front door. According to statements DON obtained during the facility investigation, they determined Resident stayed outside for approximately 1 2 minutes.
On 3/20/24 at 11:15 AM Staff H, Maintenance, reported the facility had 2 door alarm systems in place, a door alarm system and a wandering alert system The facility had the wandering alert system located on the patio, the employee entrance, and the front door. The facility tested the wandering alert system at least once a day when Staff H worked during the week, and didn't get tested on the weekend. He explained the facility always had the wandering alert system on. The facility had the wandering alert system in place before the incident on 3/13/24. The door alarm system didn't work on the front door that day, the system had an override malfunction. When opening or closing the front door, it would set off the alarm even after the code was entered in the key pad. Near the front door, the facility had a key pad to override the malfunctioning system, so staff put in a code at the front door to open the door, and if the alarm went off they went to the keypad at the nurse's station to disarm it or shut the alarm off. After shutting off the alarm, then they reentered the key code at the nurse's station to reactivate the front door alarm.
On 3/20/24 at 12:10 PM Staff A, Social Services Director/Activities, reported the DON notified her of the incident. She assisted the DON and Administrator in getting statements, making sure Resident #1 was safe, and gathering information regarding the incident. Staff A added she knew how to alarm and disarm the door system, but didn't have to do it that day. Staff A explained when she started the door system had that malfunction, but she never saw anyone alarm or disarm the door that day.
On 3/20/24 at 1:08 PM Staff H remarked the door malfunctioned for approximately a month or so. Staff H called a door company and they came to the facility on 3/18/24 to look at the alarm. The company reported they would email back with a date they could come fix it. Watched Staff H at the front door, put in the key code before opening the door, light turned green, Staff H opened the front door, and the alarm didn't sound. After he closed the door, the alarm sounded, Staff H went to the nurse's station, got a key from the key box and opened the override system lock box. He entered a key code to shut off the alarm, then entered the key code again to re alarm the front door. The override system displayed disarmed when he entered the code to disarm the alarm. When he re-alarmed it, the screen said alarmed, a red light for alarmed, and green light for disarmed. Staff H added all of the staff had access to the key at the nurse's station.
On 3/20/24 at 11:46 AM Staff G, CNA, revealed she was at the nurse's station for shift change, she noticed Resident #1 went into the dining room. Staff G observed Resident #1 talking to a couple of the other residents in the living room, then she turned back around to the nurse's station. Staff G revealed a few moments later she heard the doorbell ring, and when she turned around, she observed Staff F, CNA, walking through the threshold with Resident #1. Staff F walked Resident #1 to his room and reported he got outside. Staff G explained she didn't know for sure how long the front door alarm malfunctioned that way. She didn't know for sure what happened with the alarm system, but everyone had the job to make sure the front door was alarmed.
On 3/20/24 at 1:30 PM Staff B, Licensed Practical Nurse (LPN), said she didn't know if the door alarm sounded. Staff B added the front door didn't work correctly for only a short time. Staff B revealed all staff have access to alarm and disarm the front door, located at the nurses' station. Staff B reported the facility had residents who sat in the dining/living room area that would say if someone went towards the door. Staff B didn't see anyone alarm or disarm the door at the nurses' station that day.
On 3/20/24 at 2:05 PM Staff E, CNA, explained at the time of the incident, he passed ice water down the east hallway, he briefly looked up and saw Resident #1 walk to the dining room. He heard the doorbell ring and didn't remember hearing the door alarm go off. Staff E revealed he knew how to reset the door alarm and that all staff should check to make sure the door was alarmed. Staff E revealed that Resident #1 didn't usually wander out of his room. Staff E revealed he heard the doorbell ring and came out of a resident's room but didn't know if anyone got outside and didn't see who answered it.
On 3/20/24 at 3:30 PM the Administrator revealed he went to the grocery store to get Gatorade for another resident. When he looked at his watch, it said 2:47 PM, he said as he approached the street, he looked at the building and didn't see anyone outside. The Administrator explained he received a message to get to the facility right away, as Resident #1 got outside. When he returned to the facility, he started the investigation. The Administrator added Resident #1 didn't get close to the front door, he sat at the first table in the dining room if he came out of his room. He stated Staff F found him outside. The Administrator reported the day after the incident, the facility completed an elopement drill and Resident #1 didn't want to participate or get close to the front door. The Administrator reported with encouragement Resident #1 could open the front door during the drill. The Administrator said Staff H completed door checks every morning and the door has been malfunctioning the last couple weeks.
The facility report named Logbook Documentation Doors lacked documentation, indicating the facility didn't check the door alarms on 2/15/24, 2/18/24, 2/24/24, 2/25/24, 2/27/24, 3/3/24, 3/8/24, 3/10/24, 3/16/24 and 3/17/24.
On 3/20/24 at 4:20 PM the DON revealed the facility didn't have cameras. Resident #1 didn't have visitors and never did. In addition, the facility didn't have anything outside to catch his attention. The DON denied hearing the doorbell or the door alarm.
Re interview on 3/20/24 at 4:33 PM Staff G reported Resident #1 didn't have visitors, nothing outside to catch his attention, he had a shed he could see through his window with people going in and out of it. Staff G revealed she didn't hear the door alarm, but did hear the doorbell. When the doorbell sounded, Staff F stood next to her and then Staff F left the area. Staff G assumed Staff F answered the doorbell, but she didn't see Resident #1 outside until Staff F and him crossed the threshold to the dining room.
Re interview on 3/21/24 at 9:30 AM Staff B explained the facility had a stop sign in place before the incident on 3/13/24. All of the facility's exit doors had stop signs in place.
On 3/21/24 at 2:30 PM Staff F, CNA, reported she came to work at 2:00 PM, noticed the front door alarm not alarmed, so she went and alarmed the door. Staff F revealed she knew it wasn't alarmed by the override system at the nurse's station. Staff F revealed that around 2:45 to 3:00 PM the doorbell rang and she went to answer it. As she answered it she saw Resident #1 outside. Staff F, let Resident #1 in, and looked around to see if he was alone. Staff F revealed Resident #1 said he went outside to get fresh air and she asked how he got out here, he said he went through the front door. Staff F revealed the stop sign was not up when she went to answer the door. Staff F revealed she took Resident #1 up to the front desk to let the DON and Staff B, LPN, know. Staff F stated Resident #1 never attempted to leave the building, that he barely left his room. Staff F thought maybe because it was nice out Resident #1 wanted to get out. Staff F said Resident #1 didn't have any injuries, no visitors, and no physician appointment, nothing out of the ordinary that day for him, Staff F stated when she heard the doorbell rang she was coming out of the east hallway, and didn't hear the door alarm before the doorbell. Staff F described the previous door alarm as loud and that it finally went out. Staff F added the new one didn't sound loud enough and needed to be replaced, when asked if she alarmed the door at 2 PM when she came on shift and she didn't hear the door alarm when Resident #1 went outside, she said she felt someone disarmed the door in between the time she alarmed it and when Resident #1 went outside.
The Elopement Management Policy dated 2023 directed clinical processes that address a resident's risk of elopement from the premises or a safe area without authorization and/or necessary supervision to do so.
a. Identification and implementation of individualized approaches to provide the resident with a safe and secure environment.
b. Evaluation of the resident's individualized plan of care and validation of effectiveness of interventions
c. Based on the resident's evaluation, the interdisciplinary Team develops an individualized care plan to prevent elopement. This will include
interventions specific to the risk factors identified. If the facility uses a Wandering alert device or like system, then the Environmental Services Director/designee checks the functionality of that system daily. Environmental Services also checks the security system on a monthly basis through the TELS system.
d. The Environmental Services Director/designee tests and documents that exit doors are secured and that alarms or electronic keypad locks function as designed.
Interview with the Administrator on 3/21/24 revealed they did not start documenting the communication between the door company and the facility regarding the repair of the malfunctioning front door alarm. The first communication documented listed a date of 3/13/24, the day of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to facilitate re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, and facility policy review, the facility failed to facilitate resident rights and choices for 1 of 1 residents reviewed (Resident #6).
Findings include:
Resident #6's Minimum Data (MDS) assessment dated [DATE] identified Resident #6's gender as a male with an admission date of 9/5/23. The MDS reflected a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.
The Care Plan last reviewed 3/14/24 included the following Focuses:
a. Resident #6 was born a male but identified as a female and prefers to be addressed as she/her.
b. Resident #6 had limited physical mobility related to a prior stroke. The Intervention indicated Resident #6 required assistance from one person with dressing, showering, toilet use, and personal hygiene.
On 3/21/24 at 12:52 PM, Resident #6 described herself as transgender. She said the staff failed to assist her with wearing makeup and didn't assist her with shaving daily. She raised her left arm to her face referring to the whiskers/stubble on her face. Resident #6 became emotional in her interview and stated it bothered her a lot, if she's not clean shaven. Resident #6 didn't appear shaved that day and didn't have any visible makeup.
On 3/21/24 at 1:54 PM, Staff C, Certified Nurse Aide, reported Resident #6 regularly got shaved on her shower days and only on other days if she requested. She explained Resident #6 occasionally asked for makeup and a wear a wig but other days she preferred a turban without makeup. She asks her what she wants to wear and abides by whatever she requests on a day by day basis.
On 3/21/24 at 1:58 PM the Social Services Director stated she didn't participate with developing the Care Plan at that time, as she didn't get trained to do that. She offered to give Resident #6 a makeover for a planned activity for the residents but she became hesitant to participate.
On 3/21/24 at 2:02 PM, the MDS Coordinator stated she personalized the Resident's Care Plan based on triggers on the MDS and when anyone reported something to her by other employees. She didn't interview the residents to find out their personal preferences. The Social Services department does interviews regarding the residents' preferences.
The facility policy Resident Rights & Dignity Management, dated October 2023 directed:
Encouraged each resident to participate in his/her assessment and care planning program, including the discussion of his/her diagnosis, treatment options, risks, and prognosis.
The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. In order to accommodate individual resident needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well being to the extent possible and in accordance to the resident's wishes. Residents shall be treated with dignity and respect at all times.
Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self esteem and self worth. Residents shall be groomed as they wish to be groomed (hair, nails, facial hair, etc.)
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 F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on clinical record review, observations, resident, family, and staff interviews reflected the facility failed to get a resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on clinical record review, observations, resident, family, and staff interviews reflected the facility failed to get a resident with difficulty seeing glasses following a change in her insurance for 1 of 1 resident reviewed (Resident #3)
Findings include:
1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview of Mental Status (BIMS) of 11, indicating moderate cognitive impairment.
The Comprehensive Care Plan Focus revised 2/1/23 reflected an area labeled Activities of Daily Living (ADLs). The Intervention listed Resident #3 wore glasses.
On 3/21/24 at 10:44 AM, Resident #3 reported the former Social Worker failed them miserably. She waited several months to get new glasses. At least 8 months earlier, she went to an eye doctor and received a prescription for new glasses. However, she never got new glasses. When she had a change of insurance, the former Social Worker was supposed to assist her in actually getting new glasses, but it never got done. She went to the eye clinic in town in the wheelchair van, had the exam, and chose her frames, but the glasses never got ordered.
On 3/21/24 at 11:20 AM, Staff A, Social Services Director, stated she took over the position of Social Services and Activities Director in February 2024. She explained she tried to catch up on everything not done before she started the position. She didn't know Resident #3 needed new glasses but she would check into it and assist her getting that corrected.
On 3/21/24 at 11:21 AM, Staff B, Licensed Practical Nurse (LPN), explained Resident #3 had an eye exam several months before but never got her glasses. She added they had her prescription for the eye glasses Resident #3's chart. She believed a change in insurance caused the delay.
On 3/21/24 at 12:28 PM, Resident #3's sister stated Resident #3 had very bad vision and wore the same glasses for many years. She didn't know Resident #3 had an eye exam or had inquired about new glasses.
On 3/21/24 at 1:30 PM, the Optometrist's office reported Resident #3 received an eye exam on 5/1/23 and the prescription is still valid.
Sept 2023
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility policy review, the facility failed to notify the Office of the State Long-Term Ombudsman of a resident transfer to the hospital for 1 of 1...
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Based on clinical record review, staff interview and facility policy review, the facility failed to notify the Office of the State Long-Term Ombudsman of a resident transfer to the hospital for 1 of 1 residents reviewed for hospitalizations (Resident #5). The facility reported a census of 24 residents.
Findings include:
The Minimum Data Set (MDS) for Resident #5 dated 7/14/23 documented the resident had a Brief Interview for Mental Status (MDS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnosis including bipolar disorder, schizophrenia and post-traumatic stress disorder (PTSD).
The Care Plan initiated 2/1/23 for Resident #5 revealed the resident had episodes of behaviors such as delusions, paranoia and suicidal ideation's. The Care Plan directed staff to notify the Medical Director as needed and observe the resident for behaviors and changes in behaviors during care and provide psychiatric consults as needed.
Clinical record review revealed Resident #5 transferred to the hospital on the following dates:
a. 9/16/22
b. 10/5/22
c. 12/2/22
d. 1/27/23
e. 5/5/23
f. 6/23/23
Review of the undated facility policy titled, Discharge Plan/Transfers, the facility must send a copy of the written transfer or discharge notification to the representative of the Office of the State Long-Term Care Ombudsman before a resident is transferred or discharged .
The facility failed to provide documentation verifying the Ombudsman was notified regarding Resident #5's following hospitalizations:
a. 9/16/22
b. 10/5/22
c. 12/2/22
d. 1/27/23
On 9/6/23 at 10:04 AM the Administrator documented via electronic mail (Email), the facility was only able to locate verification the Ombudsman was notified regarding the May and June 2023 hospitalizations for Resident #5. The Email further documented the facility lacked verification the Ombudsman was notified regarding the other hospitalizations as expected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility policy review, the facility failed to notify a resident or their representative of a resident transfer to the hospital for 1 of 1 resident...
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Based on clinical record review, staff interview and facility policy review, the facility failed to notify a resident or their representative of a resident transfer to the hospital for 1 of 1 residents reviewed for hospitalizations (Resident #5). The facility reported a census of 24 residents.
Findings include:
The Minimum Data Set (MDS) for Resident #5 dated 7/14/23 documented the resident had a Brief Interview for Mental Status (MDS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnosis including bipolar disorder, schizophrenia and post-traumatic stress disorder (PTSD).
The Care Plan initiated 2/1/23 for Resident #5 revealed the resident had episodes of behaviors such as delusions, paranoia and suicidal ideation's. The Care Plan directed staff to notify the Medical Director as needed and observe the resident for behaviors and changes in behaviors during care and provide psychiatric consults as needed.
Clinical record review revealed Resident #5 transferred to the hospital on the following dates:
a. 9/16/22
b. 10/5/22
c. 12/2/22
d. 1/27/23
e. 5/5/23
f. 6/23/23
Review for the facility policy titled, Bed Hold, effective 12/1/14 documented all residents or their representative will be provided a copy of the bed hold agreement prior to a resident's transfer to a hospital.
On 9/6/23 at 10:04 AM the Administrator documented via electronic mail, the facility was unable to locate bed hold notifications regarding Resident #5's hospitalizations as expected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, family interview, facility policy review and staff interview, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, family interview, facility policy review and staff interview, the facility failed to notify the resident or resident representative of quarterly Care Plan meetings for 2 of 2 residents reviewed for care conference notification (Residents #5 and #18). The facility reported a census of 24 residents.
Findings include:
1. The Minimum Data Set (MDS) for Resident #5 dated 7/14/23 documented the resident had a Brief Interview for Mental Status (MDS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnosis including bipolar disorder, schizophrenia and post-traumatic stress disorder (PTSD).
The Care Plan initiated 2/1/23 for Resident #5 revealed the resident had episodes of behaviors such as delusions, paranoia and suicidal ideation's. The Care Plan directed staff to notify the Medical Director as needed and observe the resident for behaviors and changes in behaviors during care and provide psychiatric consults as needed.
During an interview 9/05/23 at 10:55 AM, Resident #5 revealed she goes to her care conferences when they have them but they haven't had one for over 1 year.
Clinical record review for Resident #5 lacked documentation regarding notification of care conferences.
During an interview 9/06/23 at 12:51 PM the Administrator acknowledged Resident # 5 or her representative were not invited to care plan conferences as expected.
2. MDS dated [DATE] revealed Resident #18 had an admission date of 4/16/22. The MDS documented the resident had a BIMS of 3 indicating severely impaired cognition and had diagnosis including traumatic brain injury and non-Alzheimer's dementia.
The revised 2/10/23 Care Plan for Resident #18, documented the resident had impaired decision-making ability and long and short-term memory loss related to diagnosis of dementia and directed staff to provide oversight during important decision-making tasks. The Care Plan further directed staff to ensure the resident/family are informed at all times.
Review of the facility policy titled, Resident Assessment Instrument (RAI)/Care Planning Management revised July 2022, revealed care conferences are held quarterly and annually with each review. The policy documented invitations are mailed to the family/responsible party one week prior to conference dates. The policy documented the care conference attendees are the Interdisciplinary (ID) team, resident and family/responsible party, and other staff who have vital information to share about the residents being reviewed. The policy further documented all resident or family concerns should be addressed and if for some reason the resident, family or responsible party cannot attend the conference, an alternate method of communicating the information should be implemented (i.e. telephone conference).
Review of Progress Notes for Resident #18 revealed the responsible party was invited to care plan meetings 9/30/22 and 11/22/22 and lacked further documentation regarding invitations.
During an interview 9/5/23 at 11:55 AM, the Guardian for Resident #18 revealed he had been to one care plan meeting since the resident's admission and didn't know if maybe the facility invited his sister instead.
During an interview 9/6/23 at 12:47 PM, the Administrator reviewed the facility was unable to locate verification Resident #18 or their representative was invited to care plan meetings as expected.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review, facility policy review, resident and staff interview, the facility failed to follow physician orders related to a skin treatment for 1 of 1 resident's reviewed for a s...
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Based on clinical record review, facility policy review, resident and staff interview, the facility failed to follow physician orders related to a skin treatment for 1 of 1 resident's reviewed for a skin condition (Resident #15). The facility reported a census of 24 residents.
Findings include:
The Minimum Data Set (MDS) for Resident #15 revealed the resident had a Brief Interview for Mental Status of 14 indicating intact cognition. The MDS documented the resident had diagnosis including diabetes mellitus and lymphedema (swelling in an arm or leg).
The revised 2/10/23 Care Plan for Resident #15 revealed the resident had the potential for impairment to skin integrity and directed staff to complete treatments as ordered.
During an interview 9/5/23 observed an open area to right lower extremity (not left lower extremity). Resident
#15 stated she did not know what caused the open area and further revealed staff applied bandages to the area when they felt like it.
Clinical record review for Resident #15 revealed an order to cleanse the left lower leg, apply telfa and wrap one time a day for scratches and abrasion effective 8/8/23 at 8:00 AM.
Observation 9/06/23 at 12:04 PM revealed the treatment to the left lower leg had not been completed as ordered by the physician.
Review of the August 2023 Treatment Administration Record (TAR) for Resident #15 lacked completion of the treatment as ordered for the left lower leg on the following dates:
a. 8/15/23
b. 8/24/23
c. 8/28/23
Review of the September 2023 TAR for Resident #15 lacked completion of the treatment as ordered for the left lower leg on the following dates:
a. 9/1/23
b. 9/2/23
c. 9/3/23
d. 9/5/23
e. 9/6/23
Review of facility policy titled Physician Services revised August 2022 revealed physician's orders included treatments.
During an interview 9/06/23 at 12:15 PM the Administrator acknowledged the treatment ordered by the physician to Resident #18's left lower extremity was not completed as expected.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview and staff interviews the facility failed to ensure the smoking area is free of acciden...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview and staff interviews the facility failed to ensure the smoking area is free of accident hazards for 1 of 1 residents in the sample. The facility reported a census of 24 residents.
Findings include:
The Minimum Data Set (MDS) dated [DATE] documented Resident #11 a Brief Interview for Mental Status (BIMS) Score of 13 out of 15 indicating cognitively intact.
An observation of the smoking area on 9/5/23 at 3:45 p.m. revealed a gas grill with two propane tanks in the designated smoking area.
During an observation on 9/6/23 at 1:45 p.m. Resident #11 outside in the smoking area with Staff D, Licensed Practical Nurse (LPN) sitting within four feet of the gas grill with two propane tanks smoking a cigarette. Resident #11 reported the grill is always in the smoking area.
An interview on 9/6/23 at 1:50 p.m. the Administrator reported the grill should not be in the smoking area. He reported the staff must have moved the grill.
During an interview on 9/6/23 at 2:13 p.m. Staff D, LPN reported the grill has been in the smoking area as long as she has worked in the building.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on personnel record review, facility policy review and staff interview the facility failed to provide annual employee reviews for 2 of 2 Certified Nurse Aides (CNA). The facility reported a cens...
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Based on personnel record review, facility policy review and staff interview the facility failed to provide annual employee reviews for 2 of 2 Certified Nurse Aides (CNA). The facility reported a census of 46 residents.
Findings include:
A review of employee files found that CNA Staff G was hired at the facility on 3/16/13. The file lacked an annual review in 2022 or 2023. According to the personnel file, CNA Staff H was hired on 8/20/19 and the file lacked an annual review for 2020, 2021 or 2022.
On 9/7/23 at 2:30 PM, the [NAME] President of Operations and the Administrator acknowledged that the two CNA's did not have annual reviews completed.
According to a facility policy titled: Clinical Staff Standard, an employee assessment would be done continuous, process normally culminates into a formal annual performance review. Usually performance would be formally evaluated annually by supervisor.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on clinical record review, pharmacy record review, staff interview, pharmacy interview, and facility policy review, the facility failed to adequately store and account for resident medications f...
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Based on clinical record review, pharmacy record review, staff interview, pharmacy interview, and facility policy review, the facility failed to adequately store and account for resident medications for 1 of 5 residents reviewed (Resident #21). The facility reported a census 46 residents.
Findings include:
According to the Medication Administration Record (MAR) for May of 2023, Resident #21 had an order dated 9/21/22 for Basaglar Kwik Pen solution Pen-injector 100 units per milliliter (ml), (insulin glargine) give 150 units twice a day. The MAR showed that the insulin had been administered twice daily from May 1st through May 16th of 2023.
A facility investigation stated that on the morning of May 16, 2023, Licensed Practical Nurse (LPN) Staff D went to get insulin out of the refrigerator in the medication room for Resident #21 and discovered that there hadn't been any left. She called the pharmacy and was told that it was too soon to reorder.
A review of the Pharmacy Delivery Report documented on 5/11/23, a quantity of 30 Basaglar had been delivered that evening. On 9/6/23 at 10:39 AM a pharmacy technician said that the quantity 30 on the report referred to milliliters and there was 3 milliliters of insulin in each pen so that would have been 10 pens. Each pen had 100 units per ml., with an order for 150 units twice a day, one pen would contain enough insulin for a day.
On 9/6/23 at 6:40 AM, LPN Staff D stated she had actually reordered more insulin pens for Resident #21 on the 10th but noticed on the 11th they hadn't been delivered, she called the pharmacy again and they said they would deliver that night. She advised LPN Staff K that the evening dose had not been given so as soon as the delivery arrived, she was to give that dose.
On 9/6/23 at 5:30 AM LPN, Staff K stated that she received the insulin pens for Resident #21 the evening of 5/11/23. She stated she took 2 out of the package to place them in the medication cart. She put the rest in the refrigerator in the medication room, and thought there had been about 10 pens total. Staff K stated that she would always look at what was being delivered and then she would sign either a hard copy or the screen on an iPad that was presented by the delivery staff. She verified remaining insulin for 2 other residents that were in the refrigerator.
On 9/7/23 at 8:55 AM, LPN Staff L stated she worked on the 12th but did not take any insulin out of the refrigerator for Resident #21.
According to the facility investigation narratives, LPN Staff A stated that she worked on the 12th and the 13th and did not need to get any insulin out of the refrigerator. She worked again on the 14th and got one pen out of the frig and there were just 2 pens left at that time.
On 9/6/23 at 7:42 spoke with RN Staff A stated she pulled one pen out of the refrigerator and there were two left. She stated they did not normally count insulin, just the narcotics, but since this incident, they have started documenting insulin counts.
On 9/7/23 at 8:55 AM LPN Staff L stated on Monday, the 15th there were 2 pens in cart, it wasn't quite enough for the two doses and she pulled the last pen out of the refrigerator in the medication room.
On 9/6/23 at 6:40 AM Staff D stated she was with Registered Nurse (RN) Staff J on 5/16/23 when she discovered there was missing insulin for Resident #21. She stated they looked through the sharps container and found 5 empty insulin pens for the resident. She stated that it could be weeks before the sharps container would get full enough to be emptied. She took a picture of the pens that showed the labels were dated 5/11/23 with quantity of 15.
On 9/6/23 at 10:39 AM the pharmacist provided a copy of the labels that were generated for that delivery and pointed out that they made two separate labels with 15 qt (meaning 15 ml) per label. She stated a delivery of quantity of 30 would have been 10 pens.
On 9/5/23 at 11:30 AM, the Administrator stated he wasn't sure that 10 pens had actually been delivered and there had been other errors with pharmacy deliveries. He acknowledged that a staff signature indicated verification of accurate delivery.
According to a Proof of Delivery Query form from the pharmacy, LPN Staff K signed for the delivery on 5/11/23 at 6:48 PM, 30 quantity of insulin.
According to the facility Medication Administration Policy dated August 2021, all medication administration services were provided in accordance with regulatory requirements and standings of professional practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
Based on personnel file review, facility policy review and staff interview the facility failed to ensure that the Certified Nurse Aides (CNA) completed the required 12 hours of annual training for 2 o...
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Based on personnel file review, facility policy review and staff interview the facility failed to ensure that the Certified Nurse Aides (CNA) completed the required 12 hours of annual training for 2 of 2 reviewed. The facility reported a census of 46 residents.
Findings include:
A review of personnel files found that CNA Staff G was hired at the facility on 3/16/13, and CNA Staff H was hired on 8/20/19. The files lacked documentation that the two CNA's completed the required 12 hours of annual education.
On 9/7/23 at 2:30 PM, the [NAME] President of Operations and the Administrator acknowledged that the two CNA's did not have annual reviews completed.
According to the Facility Assessment, staff training was necessary to provide the level and types of support and care needed for population. Required in-service training for nurse aides be sufficient to ensure continuing competency of the nurse aides must be no less than 12 hours a year.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy review, resident and staff interview, the facility failed to main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility policy review, resident and staff interview, the facility failed to maintain resident rooms in good repair for 2 of 12 residents reviewed (Residents #5 and #22). The facility reported a census of 24 residents.
Findings include:
1. The Minimum Data Set (MDS) for Resident #5 dated 7/14/23 documented the resident had a Brief Interview for Mental Status (MDS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnosis including bipolar disorder, schizophrenia and post-traumatic stress disorder (PTSD).
The Care Plan initiated 2/1/23 for Resident #5 revealed the resident had episodes of behaviors such as delusions, paranoia and suicidal ideations. The Care Plan directed staff to notify the Medical Director as needed and observe the resident for behaviors and changes in behaviors during care and provide psychiatric consults as needed.
Clinical record review revealed Resident #5 resided in room [ROOM NUMBER].
During an interview 9/6/23 at 12:02 PM, Resident #5 revealed the plaster behind her recliner in her room has needed to be repaired for the past 3 months to 3 years after she accidentally punctured it with her recliner.
During an observation 9/6/23 at 12:17 PM in room [ROOM NUMBER] revealed the wooded window seal and frame below the window air conditioner wood was rotting out.
During an interview 9/6/23 at 12:17 PM in room [ROOM NUMBER], the Administrator acknowledged the walls had not been painted behind the recliner after fixing the repair and the window frame was rotting out. The Administrator further revealed the wall behind the recliner had needed to be repaired since he began working at the facility in April 2023.
Review of facility policy titled, Facility Environmental Policy/Facility Maintenance, dated 2021 revealed for routine/preventive maintenance, the facility will use the TELS program (web-based maintenance software). The policy documented the Administrator will review TELS report routinely to ensure all tasks are completed and the environment is safe for residents and staff. The policy further documented the TELS exception reports are to be reviewed weekly by the Administrator and maintenance for compliance.
2. In an observation on 9/06/23 at 3:03 PM it was discovered that the door frame of Resident #22 disintegrated in the bathroom. Observed that the wood frame appears to be ruined by water damage.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on staff interviews, schedule and timesheet review and facility policy review, the facility failed to ensure there was sufficient staffing and nurse coverage. The facility reported a census of 4...
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Based on staff interviews, schedule and timesheet review and facility policy review, the facility failed to ensure there was sufficient staffing and nurse coverage. The facility reported a census of 46 residents.
Findings include:
On 9/6/23 at 1:55 PM Certified Nurse Aide (CNA) Staff E stated back in December, January and February the facility was very short staffed and there would be only one nurse on for days at a time. She said that one Registered Nurse (RN) would not be rehired because she was found to be sleeping on the job.
On 9/6/23 at 2:59 PM the [NAME] President of Services (VP) for the facility provided a spreadsheet of timesheets for nursing staff. The spreadsheet for January revealed the following:
-On 1/13/23 from 8:00 PM - 5:30 AM no nurse coverage
-On 1/14/23 from 8:30 PM - 5:30 AM no nurse coverage
-On 1/15/23 from 7:00 PM - 5:30 AM no nurse coverage
-On 1/18/23 through 1/20/23 the Director of Nursing (DON) worked from midnight on without another nurse.
-On 1/20/23 from midnight to noon on the 21st no nurse coverage
-On 1/21/23 from 6:00 PM - midnight no nurse coverage
-On 1/22/23 from 5:30 PM - midnight no nurse coverage
-On 1/23 from 4:00 PM - midnight no nurse coverage
-On 1/24/23 through 1/27/23 the DON worked from midnight on without another nurse.
On 9/7/23 at 7:00 AM CNA Staff I stated that in December she often worked with RN Staff M and the nurse would be at the facility for days at a time. She stated Staff M would take naps while on duty and she would have to go wake her up if a resident needed something.
On 9/6/23 at 5:30 PM, RN Staff M, stated she didn't remember how many days in a row she had worked at the facility but she acknowledged that it could have been as many as 4 days. She stated this was her choice because she needed to make some money to support her family. She maintained that she never took naps when she was expected to be on duty. She stated there were times when she was the only nurse in the building for days but she worked through it without sleeping.
On 9/7/23 at 5:55 AM the Dietary Manager (DM) stated that for a period of time around the holidays, there was one RN working without another nurse to relieve her for up to 4 days in a row. The DM stated that RN Staff M was sleeping when she was supposed to be on the floor.
On 9/12/23 at 10:00 AM Housekeeping, Staff M, stated in the months of January and February, it was not unusual for the nurse to say that she was going to take a nap and staff should come and get her if they needed anything. Many times there would only be the 2 CNA's on the floor and she didn't know where the nurse was.
On 9/7/23 at 2:30 PM, the VP and the Administrator stated when the previous administration left they shredded many documents. They were unable to find daily staffing sheets from December, January and February, and the corporation didn't have any other documents related to nurse hours/timesheets. They could not answer the question regarding who the nurses were that were here covering hours.
According to a policy; Clinical Staff Standards. Clinical staff would be consistent, 24/7 and would change only as resident needs change.
According to the Facility Assessment the general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time. An RN or LPN would be on staff for each shift.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, schedule and staff file review, the facility failed to ensure they maintained at least 8 hours of Registere...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, schedule and staff file review, the facility failed to ensure they maintained at least 8 hours of Registered Nurse (RN) coverage. RN Staff J had been working with an expired nursing license and RN Staff M was found to be sleeping when expected to be on the floor. The facility reported a census of 46 residents.
Findings include:
1) On [DATE] at 8:49 AM, RN Staff C stated that in June and [DATE] one of the registered nurses had been pulled from the floor because her license had expired.
A review of the employee file for RN Staff J revealed that her nursing license had an expiration date of [DATE].
On [DATE] at 2:00 PM, RN Staff J acknowledged that her license had expired in May of 2023 and as soon as she discovered it, she was pulled from the floor. She stated that it was the end of July when she found that it had lapsed so she went and got it renewed on [DATE]th and it was verified on [DATE]st 2023.
A review of the daily worksheets found that Staff J was the RN responsible for the nurse coverage 8 days in June and 5 days in [DATE].
2) On [DATE] at 5:55 AM the Dietary Manager (DM) stated that for a period of time around the holidays, there was one RN working without another nurse to relieve her for up to 4 days in a row. The DM said that RN Staff M was sleeping when she was supposed to be on the floor.
On [DATE] at 7:00 AM, Certified Nurse Aide (CNA), Staff I, stated there were days in a row in [DATE] when RN Staff M would stay at the facility and she had witnessed the nurse sleeping when she was expected to be on the floor. It was usually between 2:00 - 4:00 PM. She stated that she did not see any safety issues with residents during that time and if she needed her, she would go wake her up.
On [DATE] at 1:55 PM CNA Staff E stated back in December, January, and February 2023, Agency staff were not picking up hours because the corporation hadn't paid the bills. She stated she'd done some finance thought that Staff M status was now do not rehire because she was found to be sleeping on the job. When the other nurse would arrive, they would tag team, one would sleep and the other would be on the floor, but there was a time when it was just Staff M.
On [DATE] at 5:30 PM, RN Staff M, stated she didn't remember how many days in a row she had worked at the facility but she acknowledged that it could have been as many as 4 days. She stated this was her choice because she needed to make some money to support her family. She maintained that she never took naps when she was expected to be on duty. She stated there were times when she was the only nurse in the building for days but she worked through it without sleeping.
According to the Facility Assessment the general staffing plan was to ensure sufficient staff to meet the needs of the residents at any given time. An RN or LPN would be on staff for each shift.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The ...
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Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 24 residents.
Findings include:
During an interview on 9/6/23 at 12:20 p.m. the Dietary Manager reported she is not a Certified Dietary Manager (CDM) but is enrolled to start the class soon.
An interview on 9/6/23 at 1:30 p.m. the Administrator verbalized he thought the facility had a year to get the Dietary Manager certified. He was not aware of the changes to the guidelines.
During an interview on 9/7/23 at 8:09 a.m. the Administrator reported the Dietician come to the facility once a month.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on facility record review, and staff interviews the facility failed to maintain records of quality assurance meetings for 3 of 4 quarters reviewed. The facility reported a census of 24 residents...
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Based on facility record review, and staff interviews the facility failed to maintain records of quality assurance meetings for 3 of 4 quarters reviewed. The facility reported a census of 24 residents.
Findings include:
Review of a facility provided document titled, Quality Assurance Process Improvement (QAPI) Committee dated 7/7/23 revealed all necessary members attended this quarterly meeting. No further quarterly documentation was provided for the previous three quarters.
During an interview 9/6/2023 at 10:56 AM with the Administrator revealed he could not locate any previous documentation prior to his hire date in April at the facility.
During a follow up interview 9/6/23 at 11:24 AM with the Administrator revealed his expectation is to have all required members attend quarterly QAPI meetings.
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, document review, staff interview, and policy review the facility failed to review policies annually and also failed to follow infection control procedures. The facility reported ...
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Based on observation, document review, staff interview, and policy review the facility failed to review policies annually and also failed to follow infection control procedures. The facility reported a census of 24 residents.
Findings include:
1. During review of a facility provided document titled, Infection Control Manual documented an original date of 06/2016 with no revisions or updates.
During an interview 9/6/23 at 11:20 AM with the Administrator revealed his expectation is for the infection control policy to be reviewed annually.
2. In an observation on 9/5/23 at 12:42 PM, Licensed Practical Nurse (LPN) Staff D dropped a tramadol 50 mg tab in the bottom of the drawer in the medication cart. With a gloved hand she retrieved the pill, put it in a cup and then administered it to Resident #10.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on staff interviews, and facility policy review, the facility failed to employ a staff with specialized training in infection prevention and control. The facility reported a census of 24 residen...
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Based on staff interviews, and facility policy review, the facility failed to employ a staff with specialized training in infection prevention and control. The facility reported a census of 24 residents.
Findings include:
During an interview on 9/6/23 at 8:45 AM with the Administrator, requested certification or documentation for any employee who has completed specialized training in infection prevention and control revealed no documentation or certifications of qualifications.
During an interview on 9/6/23 at 8:47 AM with the Administrator revealed that Staff A Registered Nurse (RN)/Interim Director of Nursing (DON) had completed all of her classes for the infection preventionist, but had not yet taken the certification exam. The Administrator further revealed that the current DON Staff B RN does not have her infection preventionist either, but is currently taking the classes. The Administrator stated the last certified infection preventionist was Staff C and she quit in July 2023.
During an interview on 9/6/23 at 8:59 AM with Staff A revealed she was taking her classes for her infection preventionist while working at the facility and was assisting with the infection preventionist position with Staff C. Staff A then revealed she obtained her certification August 29, 2023.
During a follow up interview 9/6/23 at 11:20 AM with the Administrator revealed his expectation is to have a certified infection preventionist monitoring infection control.
Review of a facility provided policy titled, Infection Control Preventionist, dated 2020 documented:
The ICP will be designated in each facility as an RN/LPN (Licensed Practical Nurse) that has completed an accredited training program for infection control.
Feb 2023
8 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on facility record review, staff interviews, and facility policy review, the facility failed to report and provide documentation on an allegations of abuse to the Iowa Department of Inspections ...
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Based on facility record review, staff interviews, and facility policy review, the facility failed to report and provide documentation on an allegations of abuse to the Iowa Department of Inspections & Appeals (DIA) within 5 days when the facility had missing medication from an emergency kit (E-kit) for 2 of 2 incidents. The facility reported a census of 27 residents.
Findings include:
An email sent to Staff N, Director of Nursing (DON), from the pharmacy, dated 8/29/22 at 7:12 PM revealed E-kit A117603 had two hydrocodone 5/325 milligrams (mg), and eight hydrocodone 7.5/325 mg tablets missing. The facility received the E-kit on 8/17/22, and returned to the pharmacy on 8/24/22. No documentation of which resident received the medication or the date the medications were removed from the E-kit.
An email sent to Staff E, Administrator, from the pharmacy dated 8/31/22 at 4:17 PM revealed E-kit A117299 had 30 milliliter (ml) of morphine 20 mg/ml solution missing. The facility received the E-kit on 7/13/22 and returned to the pharmacy on 7/20/22. The Pharmacist noted that she spoke with Staff N but no documentation was found for when the morphine was removed from the E-kit or which staff member removed the medication. Later, Staff N called the pharmacy back and said she found the morphine in the refrigerator. Staff N didn't know why the morphine bottle was left in the refrigerator. Staff N reported no label for resident name on the morphine bottle and she believed the medication came from the E-kit. The initial notification was updated and discrepancy closed.
An email sent to Staff E from the pharmacy dated 9/2/22 at 2:50 PM revealed E-kit A117202 missing four tramadol 50 mg tablets and one morphine 10 mg/ml vial. The facility received the E-kit on 8/24/22 and returned to the pharmacy on 8/31/22. The email documented a report run by the pharmacy that revealed no residents had an order for an morphine injection.
An email 1/24/23 at 6:47 AM from the DIA intake specialist revealed no emails or documentation received from the facility. The facility only wrote in the amendments section of the HFD (Health Facilities Division) submission on 9/2/22. The information included that the pharmacy notified the Administrator about the E-Kit missing 4 tabs of tramadol when picked up on 8/31/22. This falls within the timeline of the initial report. See interventions for initial report. Pharmacy also notified the Administrator the E-kit picked up on 8/31/22 had 1 vial of injectable morphine 10mg/ml missing. The Pharmacy replaced the E-kit last on 8/23/22 and 8/31/22. The responses to DIA intake specialist questions included:
a. E-kit tags reviewed daily by internal staff.
b. Sheets used for every extraction and reviewed by the DON.
c. Pharmacy reviewed and replaced the E-kit every 7 days.
Intervention included for the pharmacies to review and replace the E-kit twice a week with the staff checking the E-kit tags daily. The facility staff indicated they would obtain paperwork for narcotic checks on the E-kit, staff schedule, and who had access to the E-kit on the day the medication likely went missing. The HFD requested the facility submit a 5-day investigation report summary with corrective actions to identify how to prevent a recurrence. The facility responded with their investigation still pending. All information would be provided in a summary at the final investigation report.
The facility failed to report the allegation of abuse to the Iowa DIA within 5 days of receiving a request for additional information.
During an interview 1/18/23 at 11:30 AM, Staff P reported that he provided all information to the surveyor for the self report including emails, a subpoena, two statements from staff, pharmacy's unauthorized drug report, and a drug diversion checklist.
During an interview 1/19/23 at 4:30 PM, Staff F, former Regional Nurse, reported she had just started employment at the facility when the incident of missing medications occurred. Staff F reported on 8/30/22, she reported that she suspected Staff N was high and had disappeared in the bathroom for about an hour, then Staff N told her she needed to go home. An hour later, staff reported Staff N still in the parking lot. A bottle of morphine was reported missing and then found in the refrigerator. The color didn't look right and the Regional Nurse disposed of the medication. While doing the investigation of missing medications, she could not locate any census sheets or E-kit logs. Staff F stated Staff N had changed the schedule so she could not track the staff who worked or had access to keys for the narcotic box and E-kits. Staff F reported that she conducted at least six interviews, and provided typed notes and documentation in a file to the facility. Staff F stated the documentation should be in the investigation file.
During a follow-up interview on 2/1/23 at 3:00 PM, Staff F reported all of the documentation pertaining to the investigation of the incident placed in a manilla folder.
During an interview 2/2/23 at 11:10 AM, Staff P, Administrator, reported facility self reported incidents filed on the DIA website. Allegations of abuse get reported within 2 hours and a fall with major injury gets reported within 24 hours, and anything else gets reported within 24 hours. The facility needed to complete an investigation, and submit a report summary to the DIA within 5 days.
A Freedom of Abuse, Neglect, and Exploitation Policy revised August 2022 under section Overview, Reporting/Investigation/Response'' revealed any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, must be communicated to the Abuse Coordinator, thoroughly reported, investigated, and documented in a uniform manner. An allegation may be verbal or in writing. The facility must notify the administrator, and other officials in accordance with State law, including the State Survey Agency as soon as the facility is aware of a situation that meets the reporting requirements but not later than 2 hours after the allegation is made. A thorough investigation should be completed by the facility under the direction of the Administrator and in accordance with state and federal law. The investigation into the alleged incident included interviewing staff members and documenting the staff member's knowledge and/or version of the incident in a written narrative that is dated and signed. Supervisory staff interviewed staff and documented the staff's knowledge of the incident in a written narrative, and then signed and dated the document. The Administrator or designee provided written notification to the State Health Department and other required regulatory agencies summarizing the incident, investigation results and facility actions taken to protect the resident(s) and prevent a similar occurrence. The report completed per the guidelines of individual state reporting requirements.
A Freedom of Abuse Standard Addendum dated 10/24/22 revealed all alleged violations reported immediately but not later than 2 hours if alleged violation includes abuse or results in serious bodily injury, and not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury. Results of all investigations of alleged violations submitted within 5 working days of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on facility record review, staff interviews, and policy review, the facility failed to conduct and document a thorough investigation when the facility had missing medication from an emergency ki...
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Based on facility record review, staff interviews, and policy review, the facility failed to conduct and document a thorough investigation when the facility had missing medication from an emergency kit (E-kit) for 2 of 2 incidents. The facility reported a census of 27 residents.
Findings include:
A facility investigation file provided by Staff P, Administrator, to the surveyor on 1/18/23 at 11:30 AM included the following:
a. An online self report to DIA (Department of Inspections and Appeals) on 8/31/22.
b. A drug diversion checklist with staff assignment and completion dates.
c. Emails dated 9/1/22 and 9/2/22 from pharmacy and Staff E, former Administrator, regarding notification of potential undocumented emergency supply withdrawals of controlled substances and unauthorized E-kit withdrawals.
d. Emails to DIA on 8/31 and 9/2/22
e. Written statement by Staff K, Licensed Practical Nurse (LPN) dated 8/30/22.
f. Written note from Staff N, Registered Nurse (RN)/former Director of Nursing (DON), regarding a urine (UA) specimen left on 8/30/22. UA witnessed by Staff O, LPN.
g. Email dated 9/6/22 from pharmacy to Staff E about four tramadol 50 milligrams (mg) tablets, one vial morphine 10 mg / milliliter (ml), two hydrocodone 5/325 mg and eight hydrocodone 7.5 / 325 mg tablets missing. No medications unauthorized by the pharmacy for staff to remove the medications.
h. A summary from the pharmacy dated 9/6/22 pertaining to suspected unauthorized drug use by Staff N.
An email sent to Staff N, Director of Nursing (DON), from the pharmacy, dated 8/29/22 at 7:12 PM revealed E-kit A117603 had two hydrocodone 5/325 milligrams (mg), and eight hydrocodone 7.5/325 mg tablets missing. The facility received the E-kit on 8/17/22, and returned to the pharmacy on 8/24/22. No documentation of which resident received the medication or the date the medications were removed from the E-kit.
An email sent to Staff E, Administrator, from the pharmacy dated 8/31/22 at 4:17 PM revealed E-kit A117299 had 30 milliliter (ml) of morphine 20 mg/ml solution missing. The facility received the E-kit on 7/13/22 and returned to the pharmacy on 7/20/22. The Pharmacist noted that she spoke with Staff N but no documentation was found for when the morphine was removed from the E-kit or which staff member removed the medication. Later, Staff N called the pharmacy back and said she found the morphine in the refrigerator. Staff N didn't know why the morphine bottle was left in the refrigerator. Staff N reported no label for resident name on the morphine bottle and she believed the medication came from the E-kit. The initial notification was updated and discrepancy closed.
An email sent to Staff E from the pharmacy dated 9/2/22 at 2:50 PM revealed E-kit A117202 missing four tramadol 50 mg tablets and one morphine 10 mg/ml vial. The facility received the E-kit on 8/24/22 and returned to the pharmacy on 8/31/22. The email documented a report run by the pharmacy that revealed no residents had an order for an morphine injection.
The E-kit lock verification checklist dated 8/8/22 - 8/18/22 revealed no second staff signature 9 times, and the E-kit only got checked once on 8/12/22 and 8/14/22.
The facility records lacked E-kit lock verification checklists for dates 7/1- 8/7/22, 8/18/22 on the evening and night shifts, and no E-kit lock verification checklists 8/19/22 - 10/31/22.
During an interview 1/18/23 at 11:30 AM, Staff P reported that he provided all information to the surveyor for the self report including emails, a subpoena, two statements from staff, pharmacy's unauthorized drug report, and a drug diversion checklist.
During an interview 1/19/23 at 1:15 PM, the facility's pharmacist stated E-kit A117299 had a 30 ml bottle of morphine 20 mg/ml Staff N told her she found it in the refrigerator. E-kit A117603 had two hydrocodone 5/325 mg tablets and eight hydrocodone 7.5/325 mg tablets missing. She suspected theft, so she reported it to the DEA (Drug Enforcement Administration). The E-kit A117202 had four tramadol 50 mg tablets and a 1 ml vial of morphine 10 mg injectable missing. The pharmacist stated the medications had no documentation and no pharmacy approval provided to dispense the medication. The pharmacist reported whenever medication was removed from the E-kit, staff were supposed to contact the pharmacy for approval, the pharmacy confirmed the prescription, gave approval to remove the medication, and then the facility filled out the information on the form and signed the form.
During an interview 1/19/23 at 4:30 PM, Staff F, former Regional Nurse, reported she had just started employment at the facility when the incident of missing medications occurred. Staff F reported on 8/30/22, she reported that she suspected Staff N was high and had disappeared in the bathroom for about an hour, then Staff N told her she needed to go home. An hour later, staff reported Staff N still in the parking lot. A bottle of morphine was reported missing and then found in the refrigerator. The color didn't look right and the Regional Nurse disposed of the medication. While doing the investigation of missing medications, she could not locate any census sheets or E-kit logs. Staff F stated Staff N had changed the schedule so she could not track the staff who worked or had access to keys for the narcotic box and E-kits. Staff F reported that she conducted at least six interviews, and provided typed notes and documentation in a file to the facility. Staff F stated the documentation should be in the investigation file.
During an interview on 1/23/23 at 1:35 PM, Staff A, DON, reported she worked at the facility since 1/13/23. Staff A reported that she did not find E-kit log verification checklists for the dates of 8/18/22 - 8/31/22, or 9/1/22 -10/31/22. The DON reported that she could not find the facility's investigation file for the incident related to the narcotic discrepancies but continued to look for the documentation. The DON reported that she expected two staff to check the E-kits, the number from each E-kit lock, and document it on the checklist. The DON reported that she planned to change the way the E-kit form looked in order to account and document the lock numbers from all of the E-kits. The E-kits were kept in the medication /supply room by the nurse's station, and the nurse had a key to access the room. The DON reported that staff obtain a physician's order and then get the pharmacy ' s approval in order to obtain medication from the E-kit. Staff are to remove the green numbered lock, obtain the medication needed, write on the E-kit withdrawal form the name of the medication, dose, the amount dispensed, the resident's name, resident's date of birth , the physician who ordered the medication, and then place a red numbered lock on the E-kit whenever they remove medication from the E-kit. The numbered locks (the one removed and the one replaced on the E-kit) written on the E-kit lock verification checklist. The DON received a copy of the form when the pharmacy delivered and replaced the E-kit. The E-kit delivery included contents inside the E-kit. The DON stated when the facility only had one nurse working in the building, they should check the E-kit locks and numbers with another unlicensed staff member.
During an interview on 1/24/23 at 2:30 PM, Staff Q, former Administrator, reported he only worked at the facility a couple of weeks. Staff Q reported that he never reported anything to the DIA during the time he worked at the facility, and did not know of any missing medications.
During an interview on 1/24/23 3:25 PM Staff I, RN, reported that nobody ever went over the process for controlled substances or the E-kit. She always wasted controlled substances with another nurse, and counted the narcotics at shift change. Staff I acknowledged that she didn't know the pharmacy needed to be contacted before removing medication from the E-kit. Staff I reported that Staff N should have arrived at the facility by 9:00 AM on 8/30/22 for a meeting but didn't show up until 10:30 AM. When Staff N arrived, she could tell she was under the influence of something because her eyes looked dilated and glazed, and she had a glazed expression. When she asked Staff N questions, her response was slow and vague. After this, Staff I reported that she got called into a meeting with Staff E. She learned that Staff N went home due to a child's illness. After Staff I met with Staff E, Staff I was told to call Staff N back to the facility. A Certified Medication Aide (CMA) told her Staff N came and asked her for a bottle of morphine from the medication cart. Staff N told the CMA she planned to waste the medication. When Staff I called Staff N back to work, Staff N hadn't left the facility, as she was in the bathroom.
During an interview on 1/25/23 at 11:40 AM, Staff K, agency LPN, reported she only worked at the facility a few months, and worked the 6 AM - 6 PM shift. Staff K reported that she never checked the E-kits at the facility. Staff K reported that on 8/30/22 Staff N came to her and requested a bottle of morphine from the medication cart for Resident #16. The resident was in hospice. During the day, she didn't give the resident any morphine but the nurse gave the resident morphine during the night. A couple of days prior to this day, Staff O (night nurse) had ordered a new bottle of morphine. On 8/30/22, Staff N came to her and said she needed Resident #16's morphine because it had been in the medication cart for a month. Staff N told her the State wouldn't like that. Staff K reported that she didn't know Staff O ordered the morphine the night before. She found out later that Staff O just ordered the morphine. Staff K stated she gave Staff N the morphine because she didn't know it was new. Staff K stated she was new at the facility and figured the DON would know. Later she was pulled into the office to talk to Staff E and Staff F about hydrocodone missing from the E-kit. A resident had a 5/325 scheduled hydrocodone. Over the weekend of 8/26/22 - 8/27/22, Staff N came into the facility. Staff K reported that she didn't have time to sit and wait for the pharmacy to call back with authorization on the hydrocodone, so she finished the medication administration on other residents. Staff N came and asked her why Resident #17 hadn't gotten hydrocodone yet. She told Staff N she didn't have time to administer the medication. Staff N threw a paper at her and told her to fill it out. It was a form from the E-kit. Staff K asked Staff N for the authorization number from the pharmacy. Staff N said she didn't call the pharmacy. When eight tablets of 7.5 /325 mg hydrocodones and two 5 /325 mg hydrocodones were found missing from the E-kit, she told Staff E about the morphine. Staff K acknowledged narcotics wasted with another nurse, and signed out with another person. Medications are usually wasted in the drug buster. If no nurse witnessed medication wastage, she waited until another nurse came in.
During an interview on 1/25/23 at 10:00 AM, Staff M, LPN, reported that she worked at the facility for six years and left in August 2022. She worked the 6 AM - 2 PM and 2 PM - 10 PM shifts. Staff M reported the nurse and DON had keys to the medication room and medication carts, and the CMA had keys to his/her assigned medication cart. Staff M confirmed that she never got called in about an incident or got requested to write a statement about an incident. Staff M reported that she had concerns about Staff N though because she could never get ahold of her, she wouldn't answer her phone or return messages, and often didn't come in on time. She would come in around 10:30 AM or later. And when she showed up, she would go into the bathroom and stay in the bathroom for over a half hour. Staff M reported that she had to notify the pharmacy whenever medication got removed from the E-kit that contained controlled substances. The pharmacy had to approve the medication order and provide a special code. Then she filled out a ticket with the code provided from the pharmacy, the numbers on the locks, pharmacist name, nurse name, and medication dose removed from the E-kit.
During an interview on 1/25/23 at 11:10 AM, Staff P, Administrator reported that he had worked at the facility since 12/28/22. Staff P reported the information provided to the surveyor related to the facility reported incident on missing medications from the E-kit was all that he could find.
During an interview on 1/25/23 at 12:40 PM, Staff O, LPN, reported that she worked the 2 - 10 PM and 10 PM - 6 AM shifts. Staff O reported whenever there was a discrepancy in narcotics, she corrected the count and told whoever was on-call. Staff O stated she didn't recall any medication discrepancies while she worked at the facility. Staff O reported that nurses and CMAs had keys to the medication room. Staff O recalled an incident that occurred when the facility had missing medication on a resident. Staff O stated that she knew of missing narcotics from an E-kit but reported the pharmacy made mistakes. She thought the hydrocodone tablets missing from the E-kit got administered to Resident #17. Staff O stated she thought someone got the hydrocodone out of the E-kit but didn't make out the paperwork or notify the pharmacy that they took the medication out. Staff O reported that the pharmacy delivered the E-kit to the facility a couple times a week. The E-kit came locked and in a red zipper bag with a lock. She thinks the lock was broken, but doesn't know what's in the bag as you can't see through the red bag to know what contents are inside the E-kit or if anything had been used out of it. Staff O denied knowing anything about morphine for Resident #16.
During a follow up interview on 2/2/23 at 1:35 PM, Staff K, LPN, confirmed she wasted morphine for Resident #16 with another nurse and signed the controlled substance utilization record (total of 29.5 ml documented as wasted). This medication wastage occurred prior to the resident's death, but after the incident with the morphine vial found in the refrigerator that looked cloudy. She doesn't know if the morphine found in the refrigerator was wasted or if it was sent back to the pharmacy. Staff K stated it was left up to Staff F and Staff E on what to do with the morphine.
During an interview 2/2/23 at 1:45 PM, Staff F reported that she did not waste the morphine found in the refrigerator on 8/30/22. She gave the bottle to Staff O, LPN, and she thinks she wasted it with Staff I.
During an interview 2/2/23 at 1:50 PM, Staff I, RN, reported that she never saw the bottle of morphine in the refrigerator. She doesn't know if the morphine got wasted, returned to the pharmacy, or where it went.
Attempts by the surveyor to reach Staff N during the survey timeframe were unsuccessful.
A summary from the pharmacy dated 9/6/22 pertaining to suspected unauthorized drug use by Staff N. The facility summary included an investigation completed with a high degree of suspicion of Staff N. Nurse placed on suspension on 8/30/22 after the completion of the investigation. Any medication removed from the E-kit must be documented and the DON must review the documentation. However, because the nurse was the DON, no documentation was completed. The process was flawed in this situation.
A Freedom of Abuse, Neglect, and Exploitation Policy revised August 2022 under section Overview, Reporting/Investigation/Response revealed any complaint, allegation, observation or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, must be communicated to the Abuse Coordinator, thoroughly investigated and documented in a uniform manner. A thorough investigation should be completed by the facility under the direction of the Administrator and in accordance with state and federal law. The investigation into the alleged incident included:
a.Interviewing staff members and document the staff member's knowledge and/or version of the incident in a written narrative that is dated and signed. Employees are not to write their own statements.
b. Supervisory staff interviewed staff and documented the staff's knowledge of the incident in a written narrative, and then signed and dated the document.
c. The Administrator or designee provided written notification to the State Health Department and other required regulatory agencies summarizing the incident, investigation results and facility actions taken to protect the resident(s) and prevent a similar occurrence.
A Freedom of Abuse Standard Addendum dated 10/24/22 revealed facility staff should exercise caution when handling materials that may be used as evidence such as documentation. Results of all investigations of alleged violations submitted to the State Agency within 5 working days of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observations, record review, policy review, and staff interview the facility failed to provide complete incontinence care for one (Resident #4) of three residents reviewed. The facility repor...
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Based on observations, record review, policy review, and staff interview the facility failed to provide complete incontinence care for one (Resident #4) of three residents reviewed. The facility reported a census of 27 residents.
Findings include:
The Minimum Data Set (MDS) assessment for Resident #4, dated 12/30/22, included diagnoses of Chronic Obstructive Pulmonary Disease (lung disease) and Bipolar. The MDS identified the resident needed extensive assistance of two staff for bed mobility, transfers, and toilet use. The MDS identified the resident as always incontinent of urine. The MDS documented a Brief Interview for Mental Status of 13, indicating mild cognitive impairment.
During an observation on 1/11/23 at 1:00 PM. the resident ambulated with a walker from her wheelchair to the toilet, and Staff B, Certified Nurse's Aide at her side. Staff B removed the resident's wet pull-up brief and pants. With the resident standing and Staff B standing behind the resident, Staff B wiped the resident from mid perineal (peri) area to anal area/lower part of buttocks with 3 different wipes, using 1 wipe for each swipe. Staff B did not cleanse the front peri area, inner thighs, or hips. Staff B removed her gloves, washed her hands, put on gloves, applied a new pull-up and pants on the resident. Staff B confirmed the resident's pull-up, pants, and incontinence pad in the wheelchair were wet.
The review of facility policy, Perineal Care Standard dated August 2021, directed to clean in a downward motion (front to back) and from center to thighs, clean the length of the perineal area, and continue to wash the perineum moving from inside outward to and including thighs.
An interview on 1/25/23 at 2:30, Staff A, Director of Nursing, stated she expected the staff to cleanse the front peri, thighs, and hips with incontinence care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review, the facility failed to store resident medical and business related records in a confidential and secure manner. The facility reported...
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Based on observation, staff interview, and facility policy review, the facility failed to store resident medical and business related records in a confidential and secure manner. The facility reported a census of 27 residents.
Findings include:
On 1/23/23 at 1:15 PM, during a tour of the facility basement with Staff A, Director of Nursing, observed 2 boxes of medical records that contained various forms and resident medical records on a crate, on the floor, in an unlocked basement room. The door to the room was open, with no lock on the door. Staff A confirmed the boxes contained residents' medical records, were not secured, and accessible to all staff.
Review of facility policy titled, Safeguarding & Storage, dated March 2013, documented: The facility has a storage system that is designed and implemented to ensure the safety, security, and accuracy of health records and individually identifiable data. The areas are secure and protect the confidentiality of resident/patient information. File discharge and overflow records in a secure storage area such as a lockable cabinet or a room/office that is not shared with other staff members and can be locked and limit viewing access by unauthorized personnel.
During an interview on 1/23/23 at 1:15 PM, Staff A stated she expected for all medical records to be secured.
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 F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on staff interviews, the facility failed to have quarterly Quality Assessment and Assurance (QAA) committee meetings attended by the required members. The facility reported a census of 27 reside...
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Based on staff interviews, the facility failed to have quarterly Quality Assessment and Assurance (QAA) committee meetings attended by the required members. The facility reported a census of 27 residents.
Findings include:
During an interview on 2/1/23 at 9 AM, the Administrator (ADM) stated he could not provide any documentation of QAA meetings being held quarterly or any attendance sheets for quarterly meetings.
During an interview on 2/1/23 at 9:15 AM, the ADM stated he expected QAA meetings to be held quarterly and attended by the required members.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on facility document review, staff interview, and facility policy review, the facility staff failed to accurately sign out controlled substance medications whenever medication removed from an em...
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Based on facility document review, staff interview, and facility policy review, the facility staff failed to accurately sign out controlled substance medications whenever medication removed from an emergency kit (E-kit) for 3 of 3 E-kits reviewed, and failed to verify, track, and document the E-kit lock numbers after each shift and whenever an E-kit accessed. The facility reported a census of 27 residents.
Findings include:
An email sent to Staff N, Director of Nursing (DON), from the pharmacy, dated 8/29/22 at 7:12 PM revealed E-kit A117603 had two hydrocodone 5/325 milligrams (mg), and eight hydrocodone 7.5/325 mg tablets missing. The facility received the E-kit on 8/17/22, and returned to the pharmacy on 8/24/22. No documentation of which resident received the medication or the date the medications were removed from the E-kit.
An email sent to Staff E, Administrator, from the pharmacy dated 8/31/22 at 4:17 PM revealed E-kit A117299 had 30 milliliter (ml) of morphine 20 mg/ml solution missing. The facility received the E-kit on 7/13/22 and returned to the pharmacy on 7/20/22. The Pharmacist noted that she spoke with Staff N but no documentation was found for when the morphine was removed from the E-kit or which staff member removed the medication. Later, Staff N called the pharmacy back and said she found the morphine in the refrigerator. Staff N didn't know why the morphine bottle was left in the refrigerator. Staff N reported no label for resident name on the morphine bottle and she believed the medication came from the E-kit. The initial notification was updated and discrepancy closed.
An email sent to Staff E from the pharmacy dated 9/2/22 at 2:50 PM revealed E-kit A117202 missing four tramadol 50 mg tablets and one morphine 10 mg/ml vial. The facility received the E-kit on 8/24/22 and returned to the pharmacy on 8/31/22. The email documented a report run by the pharmacy that revealed no residents had an order for an morphine injection.
The E-kit lock verification checklist dated 8/8/22 - 8/18/22 revealed no second staff signature 9 times, and the E-kit only got checked once on 8/12/22 and 8/14/22.
The facility records lacked E-kit lock verification checklists for dates 7/1- 8/7/22, 8/18/22 on the evening and night shifts, and no E-kit lock verification checklists 8/19/22 - 10/31/22.
On 1/24/23 at 3:25 PM, Staff I, Registered Nurse (RN), reported that she worked at the facility from August 2022 - October 2022. Staff I reported that nobody ever went over the process for controlled substances or E-kit at the facility. Staff I reported that she didn't know that she needed to call the pharmacy prior to the removal of medication from the E-kit. She just filled out the form and took the medication needed for a resident. Staff I reported if the E-kit lock had a red lock, it meant the kit came from the pharmacy. A green lock on the E-kit meant someone had opened the kit. The E-kit lock got checked every shift but Staff I didn't think the facility had a log book to document the E-kit lock numbers. Staff I reported anyone who had keys had access to the medication room, including the nurse and medication aide. Staff I reported that she attended a virtual training about E-kits when the facility had an incident that occurred with missing medications.
During an interview on 1/24/23 at 5:25 PM, Staff H, RN, reported that she worked as an agency nurse. Staff H reported she didn't know the process for the E-kit.
During an interview on 1/23/23 at 1:35 PM, Staff A, DON, reported she worked at the facility since 1/13/23. Staff A reported that she did not find E-kit log verification checklists for the dates of 8/18/22 - 8/31/22, or 9/1/22 -10/31/22. The DON reported that she could not find the facility's investigation file for the incident related to the narcotic discrepancies but continued to look for the documentation. The DON reported that she expected two staff to check the E-kits, the number from each E-kit lock, and document it on the checklist. The DON reported that she planned to change the way the E-kit form looked in order to account and document the lock numbers from all of the E-kits. The E-kits were kept in the medication /supply room by the nurse's station, and the nurse had a key to access the room. The DON reported that staff obtain a physician's order and then get the pharmacy ' s approval in order to obtain medication from the E-kit. Staff are to remove the green numbered lock, obtain the medication needed, write on the E-kit withdrawal form the name of the medication, dose, the amount dispensed, the resident's name, resident's date of birth , the physician who ordered the medication, and then place a red numbered lock on the E-kit whenever they remove medication from the E-kit. The numbered locks (the one removed and the one replaced on the E-kit) written on the E-kit lock verification checklist. The DON received a copy of the form when the pharmacy delivered and replaced the E-kit. The E-kit delivery included contents inside the E-kit. The DON stated when the facility only had one nurse working in the building, they should check the E-kit locks and numbers with another unlicensed staff member.
During an interview on 1/25/23 at 11:10 AM, Staff P, Administrator, reported the information provided to the surveyor for the incident related to the E-kit was all that he could find.
During an interview on 1/25/23 at 11:40 AM, Staff K, Licensed Practical Nurse (LPN) reported that they never checked E-kits at this facility. Staff K reported that some facilities where she previously worked checked the E-kit and ensured the lock numbers matched.
An undated facility policy and procedure titled Controlled Substances revealed controlled substances (Class II) secured and counted by the nurse at the beginning of each shift. These scheduled drugs had a high abuse potential with severe psychic or physical dependence liability. The charge nurse notified whenever there was a discrepancy or incorrect count.
A Medication Administration Guidelines revised August 2021 revealed: whenever a narcotic was removed from the E-kit, two licensed nurses needed to obtain an authorization from the pharmacy to open the E-kit, and then the pharmacy gave out an authorization code. With two licensed nurses in attendance, one nurse pulled the sticker for the narcotic E-kit replacement order, placed the sticker on the refill order form, and faxed the form to the pharmacy. Another nurse completed the triplicate medication form found inside the E-kit. One copy of the form left in the E-kit, one copy of the form given to the Director of Nursing, and one copy faxed to the pharmacy. Medication needs to be removed with two licensed nurses validating, then the E-kit needs to be re-locked with a red lock, and the new lock number logged into the E-kit log sheet. Medication destruction is per policy.
A document titled E-kits: What you Need to Know dated 2020 provided by the facility's pharmacy revealed an E-kit is a physical set of emergency medications in a protected container sent to the facility for use in emergency situations. Pharmacy exchanges the E-kit out weekly. Once a withdrawal is submitted to the pharmacy, it is processed and exchanged within 48 hours. The E-kit withdrawal of controlled medications require authorization from the pharmacy and include the following steps:
a. A valid prescription provided to the pharmacy prior to withdrawal. The pharmacist reviewed the prescription prior to provision of an authorization code.
b. Contact pharmacist for authorization.
c. Complete the E-kit withdrawal authorization log and place the form back in the E-kit.
d. Withdraw the authorized quantity of medication
e. Replace the security seals.
f. If a withdrawal discrepancy is found upon a used E-kit replenishment at the pharmacy, a withdrawal discrepancy form is completed with patient utilization information promptly.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure there was a sufficient number of staff ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure there was a sufficient number of staff capable of rendering nursing services, awake and on duty at all times as the facility had 1 Certified Nurse's Aide (CNA) on duty and the scheduled nurse was sleeping. The facility reported a census of 27 residents.
Findings include:
During an observation on 1/26/23 at 4:20 AM, upon entering the facility, observed no staff in the three resident halls, with one resident sitting at a dining room table, and heard voices in a resident's room.
On 1/26/23 at 4:30 AM, witnessed Staff C, Certified Nurse's Aide (CNA), exit a resident's room. Staff C reported being the only CNA working the night shift and the Director of Nursing (DON) was in room [ROOM NUMBER] sleeping. Staff C confirmed the facility only had two staff total in the building. Staff C stated Staff D, CNA, from the previous shift, reported to Staff C that the DON worked 24 hour shifts, and was in room [ROOM NUMBER], as the facility had said it was okay for the DON to sleep. Staff D said to just wake the DON if Staff C needed anything. Staff C stated she had not seen the DON during Staff C's shift so far, but did hear the DON talking with a resident in the hall during the night. Staff C stated she did not need to wake the DON during her shift.
On 1/26/23 from 4:30 AM to 5:30 AM, watched Staff C answer call lights, talk with a resident at a table, and went in and out of resident rooms with no other staff visible in the facility.
On 1/26/23 at 5:30 AM, Staff C stated she was going to wake the DON for a resident's scheduled pain medication. Staff C knocked on the door to room [ROOM NUMBER] and entered the room.
During an observation on 1/26/23 at 5:45 AM, the DON came out of room [ROOM NUMBER].
On 1/26/23 at 6 AM, Staff C stated the DON was sleeping when she knocked and entered room [ROOM NUMBER] at 5:30 AM.
On 1/26/23 at 9:15 AM, the DON reported being the only nurse scheduled to work since 1/22/23 at 6 PM and has worked continuously since 1/22/23. The DON confirmed she was sleeping when Staff C woke her at 5:30 AM, as she is sleeping at the facility during the night and staff wake her if needed. The DON confirmed that her and Staff C were the only two staff working on the night shift of 1/25/23 - 1/26/23 from 10 PM - 6AM.
The facility's daily staffing sheet for 1/25/23 10 PM - 6 AM shift, documented scheduled staff of one Nurse, the DON, and one CNA, Staff C.
Review of an untitled facility timesheet form documented Staff C started her shift on 1/25/23 at 10 PM and ended her shift on 1/26/23 at 6 AM, for a total of 8 hours.
Review of an untitled facility timesheet form, dated 1/12/23 - 2/1/23, documented the DON worked the following shifts:
a. 1/22/23 5:30 PM - 1/23/23 12 AM
b. 1/23/23 12 AM - 1/23/23 8 AM
c. 1/23/23 8 AM - 1/23/23 4 PM
d. 1/23/23 4 PM - 1/24/23 12 AM
e. 1/24/23 12 AM - 1/24/23 8 AM
f. 1/24/23 8 AM - 1/24/23 4 PM
g. 1/24/23 4 PM - 1/25/23 12 AM
h. 1/25/23 8 AM - 1/25/23 8 AM
i. 1/25/23 4 PM - 1/26/23 12 AM
j. 1/26/23 12 AM - 1/26/23 8 AM
During an interview on 2/1/23 at 1 PM, the DON stated she expected at least two staff to be on duty and awake at all times.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on record review and staff interview the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 12 of 69 days reviewed. The facility re...
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Based on record review and staff interview the facility failed to have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week for 12 of 69 days reviewed. The facility reported a census of 27 residents.
Findings include:
Review of facility daily assignment staffing sheets for 8/3/22 - 8/31/22, 9/1/22 - 9/11/22, and 12/3/22 - 1/3/23 lacked documentation of a RN scheduled to work on the following days:
a.
8/20/22
b.
8/21/22
c.
9/3/22
d.
9/4/22
e.
9/11/22
f.
12/17/22
g.
12/22/22
h.
12/23/22
i.
12/24/22
j.
12/25/22
k.
12/31/22
l.
1/1/23
During an interview on 1/19/23 at 10:20 AM, Staff A, Director of Nursing, confirmed the facility did not have any RN coverage on the above dates and expected to have RN coverage scheduled 8 hours a day, 7 days a week.
Jun 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, and staff interviews, the facility failed to provide a resident with a door or a curtain for th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, and staff interviews, the facility failed to provide a resident with a door or a curtain for the bathroom to ensure privacy for one of twenty-six residents reviewed (Resident #15). The facility reported a census of 26 residents.
Findings include:
Resident #15's Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status score of 15, indicating intact cognition. Resident #15 required limited assistance of one person with toilet use.
On 6/13/22 at 4:20 PM, observed that Resident #15's bathroom lacked a door or curtain to provide privacy. While interviewing Resident #15 in her room, observed two dietary staff entered the adjoining room that was visible from her room. As Resident #15 sat in her room, two dietary staff were present in the adjoining room that contained the stored food items. The adjoining rooms had no curtain pulled to divide the rooms. Resident #15 stated she didn't like not having a door or curtain on her bathroom, as it invaded her privacy because different staff came in and out of the adjoining room where they stored the food items. Resident #15 stated she would like a curtain or door.
On 6/16/22 at 8:42 AM, the Administrator commented that they expected Resident #15 to have a door or a curtain on her bathroom entrance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the confidential group interview on 6/20/22 at 1:49 PM, three residents agreed that the limited time restriction of Mo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the confidential group interview on 6/20/22 at 1:49 PM, three residents agreed that the limited time restriction of Monday, Wednesday, and Friday from 10:00 to 11:00 AM made it difficult for them to access their personal trust funds. The residents explained they couldn't get their requested funds outside of the restricted times including after hours and weekends.
On 6/21/22 at 9:09 AM, Staff B, Licensed Practical Nurse (LPN), reported that the residents could request money on Monday, Wednesday, and Friday from 10 AM until 11 AM. Staff B then pointed to a sign on the Administrator's door that read, Resident Trust Hours Monday, Wednesday and Friday from 10 AM - 11 AM. Staff B added that the nurses didn't have access to petty cash for the residents to use.
The Resident Trust Fund policy revised 8/11/21 did not list a restricted time frame in which the residents could request their funds.
On 6/21/22 at 2:26 PM, the Administrator acknowledged that she set a time restriction for residents that wanted to request funds. The Administrator explained that no one had access to cash except her. The Administrator explained that she wouldn't get anything done if she allowed the population of residents to request money at any time.
The Iowa Administrative Code dated 6/16/21 documented Rule #58.42(3) that recorded that the facility shall keep on deposit personal funds over which the resident has control in accordance with Iowa Code section 135C.24(2). Should the resident request these funds, they shall be given to the resident on request with receipts maintained by the facility and a copy to the resident.
Based on observations, the confidential group interview, staff interviews, and clinical record reviews, the facility failed to make resident funds accessible when requested for 3 out of 3 residents reviewed (Resident #15). The facility reported a census of 27.
Findings:
1. Resident #15's Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status score of 15, indicating intact cognition.
On 6/13/22 at 4:16 PM, Resident #15 said that the residents could only get their personal money from facility on Monday, Wednesday and Friday from 10 AM - 11 AM. Resident #15 explained that when she asked for money that day (Monday), she got told she couldn't get money that day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interview, the facility failed to properly fill out the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) of Non Coverage, Centers of ...
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Based on clinical record reviews and staff interview, the facility failed to properly fill out the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) of Non Coverage, Centers of Medicare & Medicaid (CMS) form #100555 for 3 of 3 sampled residents. (Residents #12, #13 and #20). The facility reported a census of 26 residents.
Findings Include:
1. Resident #12's SNF ABN, CMS form #10055 dated 4/27/22 lacked the estimated cost of therapy or provide an explanation that the estimated cost of therapy could not be obtained.
2. Resident #13's SNF ABN, CMS form #10055 dated 4/29/22 lacked the estimated cost of therapy or provide an explanation that the estimated cost of therapy could not be obtained.
3. Resident #20's SNF ABN, CMS form #10055 dated 5/23/22 lacked the estimated cost of therapy or provide an explanation that the estimated cost of therapy could not be obtained.
The facility lacked a policy for Medicare and Medicaid Beneficiary Notices.
The Centers for Medicare and Medicaid Beneficiary Notices website (https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN), last modified on 12/1/2021 at 8:00 PM, provided a link to an undated document titled Form Instructions Advance Beneficiary Notice of Non-coverage that provided instructions related to the section on the SNF ABN form regaring the estimated cost. The form instructed that notifiers must complete the column under Blank (F) to ensure the beneficiary has all available information to make an informed decision about whether or not to obtain potentially non-covered services. Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed under Blank (D). In general, we would expect that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially would generally still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted. Multiple items or services that are routinely grouped can be bundled into a single cost estimate. For example, a single cost estimate can be given for a group of laboratory tests, such as a basic metabolic panel (BMP). An average daily cost estimate is also permissible for long term or complex projections. As noted above, providers may also pre-print a menu of items or services in the column under Blank (D) and include a cost estimate alongside each item or service. If a situation involves the possibility of additional tests or procedures (such as in laboratory reflex testing), and the costs associated with such tests cannot be reasonably estimated by the notifier at the time of ABN delivery, the notifier may enter the initial cost estimate and indicate the possibility of further testing. Finally, if for some reason the notifier is unable to provide a good faith estimate of projected costs at the time of ABN delivery, the notifier may indicate in the cost estimate area that no cost estimate is available. We would not expect either of these last two scenarios to be routine or frequent practices, but the beneficiary would have the option of signing the ABN and accepting liability in these situations.
On 6/21/22 at 8:11 AM, the Administrator acknowledged that the estimated cost of services would be vital for residents to make an informed decision to pay out of pocket for continued services. The Administrator stated, that she would tell the staff that they need to figure out the estimated cost of services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review, and staff interviews, the facility failed to notify the resident and/o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy review, and staff interviews, the facility failed to notify the resident and/or their responsible party of the bed hold policy for 1 of 1 residents reviewed (Resident #16) for hospital discharge. The facility reported a census of 26 residents.
Findings include:
Resident #16's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented diagnoses of anxiety and history of urinary tract infection.
The Progress Notes for Resident #16 revealed:
a.
On 4/8/22 at 1:30 PM, the health status note (HSN) revealed Resident #16 complained of nausea and vomiting. Resident #16 had no fever and had stable vital signs. The provider saw Resident #16 for her complaints of nausea, emesis, and abdominal pain from the previous evening. The provider felt Resident #16 needed to be seen in the emergency room for evaluation. Resident #16 transferred to the hospital and the nurse notified her Power of Attorney.
b.
On 4/10/22 at 9:19 PM, the HSN documented that Resident #16 remained in the hospital due to an esophageal abrasion (a distinct break in the margin of the esophageal mucosa) and ulcer.
c.
On 4/13/22 at 2:25 PM, the admission Note recorded that Resident #16 returned to the facility after her hospitalization. Resident #16 noted to be alert and able to make her needs known.
The clinical record lacked documentation that Resident #16 and/or her responsible party received education regarding the bed hold when she transferred to the hospital on 4/8/22.
The facility document titled Bed Hold dated, 3/3/20, identified the following:
All residents are given the option of reserving their bed when leaving the facility with the intent to return. The temporary absence may be for hospitalization or therapeutic leave. All residents and/or their responsible party should be informed in writing about the facilities bed hold policy at the time of admission. A copy of the bed hold agreement provided to the resident and/or responsible party prior to the resident being transferred to a hospital or the start of a therapeutic leave. The bed hold authorization form should be completed and signed by the resident and/or their responsible party each time a resident leaves the facility. The section labeled Bed Hold Policy and Bed Hold Authorization Form: in case of emergency transfer, the resident and/or their responsible party should be provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice sent with the other papers accompanying the resident to the hospital. The bed hold authorization form must be completed and signed by the resident and/or the responsible party to be valid.
On 6/16/22 at 7:59 AM, the Administrator reported that Resident #16 didn't have a bed hold completed when she transferred to the hospital on 4/8/22. The Administrator explained that they expected the bed hold to be completed and documented in the resident's progress notes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interviews, the facility failed to develop and implement a baseline ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interviews, the facility failed to develop and implement a baseline care plan within 48 hours for one (Resident #24) of six residents reviewed. The facility reported a census of 26 residents.
Findings include:
Resident #24's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date to the facility on 3/25/22. The MDS included diagnoses of Schizophrenia, Chronic Obstructive Pulmonary Disease, and tobacco use. A Brief Interview for Mental Status score of 12, indicated moderately cognitive impairment.
Review of Resident#24's health record lacked documentation of a Baseline Care Plan (BCP) completed.
The RAI/Care Planning Management policy revised 8/17, documented that the Interdisciplinary Team would review the interim care plan (BCP) on the first business day after admission to assure care areas are addressed and family, responsible party, and/or the resident involvement occurred.
On 6/16/22 at 2:10 PM, the Administrator confirmed that a BCP did not get completed for Resident #24. The Administrator explained that they expected the B for completion within 48 hours after admission.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, policy review, and staff interviews, the facility failed to revise care plans to include the r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, policy review, and staff interviews, the facility failed to revise care plans to include the required assistance a resident needed related to their activities of daily living (ADL's) for 1 out of 4 residents reviewed (Residents #19). The facility reported a census of 26.
Findings include:
Resident #19's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The MDS recorded that Resident #19 required total dependance of one person for toilet use and extensive assistance of one person for bed mobility, dressing, transfers, and personal hygiene. Resident #19's diagnoses included progressive neurological conditions, ataxia, and dementia.
The Care Plan Problem dated 3/14/17 reviewed on 6/22/22 documented Resident #19 as a risk for ADL decline related to cognitive impairment. The Care Plan included the following Approaches dated 3/14/17
a. Resident #19 ambulated independently with a walker.
b. Resident #19 could dress and groom himself with set-up and verbal cues, assist as needed.
The same Care Plan Problem dated 3/14/17 reviewed on 6/26/22 documented Resident #19 as a risk for ADL decline related to cognitive impairment. The Care Plan included a undated hand written Approach that documented Resident #19 as an assist of one with transfers and ADLs. The section related to dressing and grooming remained the same.
The RAI-Care Planning policy revised August 2017 documented goals would be resident specific, measurable, and realistic. Interventions will be action verb directed and specific to each resident. The comprehensive care plan will be completed by the assessment coordinator before the 21st day for an initial, annual, or significant change assessment. For a quarterly review, the team will complete the MDS quarterly and review the care plan on a 92 day schedule. This review information is added to the resident's electronic medical record within 24 hours following the review conference.
On 6/15/22 at 11:14 AM, the Administrator acknowledged the Care Plan for Resident #19 lacked an update or revision since 2020. The Administrator stated, the Care Plans needed to be updated and that they knew the facility had issues with that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clincial record reviews, and staff interviews, the facility failed to ensure a resident took their medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clincial record reviews, and staff interviews, the facility failed to ensure a resident took their medications before leaving the resident for one of five residents reviewed (Resident #2) for Medication Administration. The facility reported a census of 26 residents.
Findings include:
Resident #2's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of coronary artery disease (heart disease), non-Alzheimer's dementia, and paroxysmal tachycardia (fast heart rate). The MDS documented a Brief Interview for Mental Status score of 13, indicating intact cognition.
On 6/14/22 at 10:16 AM, observed Resident #2 in his room with three pills, one round white tablet, one yellow tablet, and a half of a white oblong tablet, in a medication cup on his stand. Resident #2 reported those were his morning medications and that he would take them when he was ready.
On 6/15/22 at 9:51 AM, observed Resident #2 in his room with a medication cup on his bed with one oblong white tablet and one yellow tablet. Staff B, Licensed Practical Nurse (LPN), went to Resident #2's room, per request. Staff B removed the pills from Resident #2's room. Staff B added that she gave him the medications that morning by putting his medications in his hand. Staff B reported that it appeared Resident #2 placed the pills in his mouth and took a drink of water. Staff B confirmed the medication as Digoxin tablet 125 micrograms (MCG) and atorvastatin calcium tablet 40 milligrams (MG). Staff B acknowledged that the pills did not appear moist like they would if Resident #2 put into his mouth.
Resident #2's Medication Administration Record, dated 6/1/22 - 6/30/22, documented the following physician's orders
a. atorvastatin calcium tablet 40 MG, give 1 tablet by mouth in the morning for hyperlipidemia (high cholesterol)
b. Digoxin tablet 125 MCG, give 1 tablet by mouth in the morning related to Paroxysmal Tachycardia.
On 6/15/22 at 10:15 AM, the Administrator explained that they expected the nurse to observe the resident take their medications. The Administrator reported that if the resident refused to take their medication, the nurse should dispose of the medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews the facility failed to complete a recapitulation of stay (a final summary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews the facility failed to complete a recapitulation of stay (a final summary of the resident's status), for 1 of 1 residents reviewed (Residents #26) that discharged from the facility. The facility reported a census of 26 residents.
Findings include:
Resident #26's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive impairment. The MDS included diagnoses of diabetes, hypertension, bipolar, and schizophrenia.
The Health Status Note dated 3/15/22 at 10:26 AM, documented that Resident #26's ride arrived. Resident #26's discharge instructions got faxed previously to the receiving facility. Resident #26's belongings were sent with her, her medications got returned to the pharmacy, and the Interdisciplinary Team received notification that Resident #26 discharged . Resident #26 left the facility by car with her friend.
The Physician Order dated 3/14/22 documented an order that Resident #26 could transfer to another long term care facility with the same medications and treatments.
The clinical record lacked documentation of Resident #26's recapitulation of stay, or the summary of the resident's status upon discharge from the facility on 3/15/22.
The Transfer/Discharge Summary - Outside the Facility form, dated 2/15 instructed the following:
1. Review the facility process for managing transfers out of the facility with the resident and the responsible party
2. Verify that a physician order for transfer or discharge obtained
3. Coordinate with the Interdisciplinary Team to provide information and education to prepare the resident to be discharged
The facility document titled Transfer/Discharge Documentation Recommendations dated 2/15 included:
The type of discharge labeled as planned discharge, documentation to be included:
1.
Physician order
2.
Interdisciplinary Discharge Summary, Discharge Information
3.
Resident/Family education
4.
Inventory list
5.
Nursing Progress note
6.
Copy of Advanced Directives
On 6/21/22 at 9:26 AM, the Administrator reported that no recapitulation of stay got completed when Resident #26 transferred to another long term care facility on 3/15/22. The Administrator explained they expected a recapitulation of stay to be completed upon transfer and/or discharge. The Administrator said the facility did not have an option under the assessment tab in the resident's electronic health record to complete a recapitulation of stay. The Administrator reported they notified the Corporate Nurse Consultant of the need for the assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, family, and staff interviews, the facility failed to complete a smoking assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, family, and staff interviews, the facility failed to complete a smoking assessment for 1 (Resident #13) of 2 residents reviewed. The facility reported a census of 26 residents.
Findings include:
Resident #13's Minimum Data Set (MDS) assessment dated [DATE], included diagnoses of non-Alzheimer's dementia and unspecified injury of head, subsequent encounter. A Brief Interview for Mental Status score of 7, indicated moderate cognitive impairment for decision making.
On 6/15/22 at 4:10 PM, observed Resident #13 wearing a smoking apron, sitting with staff, and smoking in the designated smoking area outside the facility.
Resident #13's health record lacked documentation of a smoking assessment completed.
The Safe Smoking Program Policy revised 8/20/21, documented that an initial safe smoking evaluation will be completed on admission. The care plan will be developed and revised as indicated.
On 6/15/22 at 2:32 PM, the Administrator confirmed no smoking assessment got completed. The Care Plan lacked smoking precautions. The Administrator reported that they expected a smoking assessment to be completed and smoking included in care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on staff interview and record review the facility failed to provide documentation of a Quality Assessment and Assurance Committee that met at least quarterly to identify issues with respect to w...
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Based on staff interview and record review the facility failed to provide documentation of a Quality Assessment and Assurance Committee that met at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary. The facility reported a census of 26 residents.
Findings included:
The Quality Assurance Process Improvement (QAPI) Committee form dated 1/7/22 and 5/20/22 revealed the facility lacked documentation to show that the facility had quarterly QAPI meetings since the last recertification.
The untitled and updated QAPI Policy documented the Administrator represents the governing body of the facility. The Administrator may delegate the necessary authority for actions and processes inherent to the QAPI performance improvement program.The program shall comply with all applicable federal, state, and local Regulatory agency requirements.
On 6/15/22 at 12:27 PM, the Administrator stated that she could not provide documentation of quarterly QAPI meetings held before the start of her employment in February 2022. The Administrator explained that when she got hired she discovered the facility lacked an assigned Medical Director to attend quarterly QAPI meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on the facility menu, observations, and staff interviews, the facility failed to ensure residents on a pureed texture diet received the proper portion size based on the planned menu for 2 of 2 r...
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Based on the facility menu, observations, and staff interviews, the facility failed to ensure residents on a pureed texture diet received the proper portion size based on the planned menu for 2 of 2 residents and failed to follow the menu for 22 of 26 residents. The facility reported a census of 26 residents.
Findings include:
The facility's Week 2 Menu dated 4/15/21 identified one serving of pureed cheeseburger on a bun, six fluid (fl) ounces (oz) of tomato juice, one serving of pureed potato wedges (no skin), #8 (3 oz) scoop (SCP) of pudding with topping, and 8 fl oz milk.
The facility's diet type report dated 6/15/22 documented two residents on a pureed diet.
During an observation on 6/16/22, beginning at 11:43 AM, Staff A, Cook, reported that he planned to puree two portions. Staff A placed 8 oz of potato wedges in the food processor, added milk, processed until smooth, and placed the product into a pan. Staff A placed 6 oz of ground hamburger in the food processor, added brown gravy, processed until smooth, and placed the product into a pan. Staff A, Cook, provided each of the two residents, on a pureed diet, with approximately one and a half 3 oz scoops of each, pureed meat and pureed potatoes, leaving four and a half oz of meat and 2 oz of potatoes remaining. The remaining pureed portions got discarded. Staff A used no reference to measure or calculate the portion size for the puree. Staff A's failure to determine the proper portion size resulted in the residents not receiving the appropriate portion size.
2. The facility's Week 2 Menu dated 4/15/21, documented the noon meal as a cheeseburger on bun, lettuce, tomato, onion, potato wedges, pudding with topping, and milk.
During an observation on 6/16/22 beginning at 12:00 PM, two residents with a pureed diet order did not receive buns and 22 residents did not receive cheese as the menu directed.
3. During an observation of meal service on 6/16/22, at 12:00 PM, a pan of ground meat got placed on a gas stove, with the flame on, and at 12:45 PM the ground meat got served to a resident. The ground meat appeared very hard and dry. `
On 6/16/22 at 12:53 PM, the Dietary Manager (DM) stated the facility did not have current menus and was still using the fall/winter menus approved by the Dietician on 4/15/21. The DM stated she expected the staff to use the pureed portion chart to calculate the proper pureed portion size for each resident on a pureed diet and to follow the scheduled menus.
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 observations, policy review, 2013 Food Code, and staff interviews, the facility failed to serve and store food under sanitary conditions, in order to reduce the risk of contamination and food...
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Based on observations, policy review, 2013 Food Code, and staff interviews, the facility failed to serve and store food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 26 residents.
Findings include:
1. On 6/13/22 at 12:20 PM, observed with the Dietary Manager (DM) during the initial tour, the following:
a. In the refrigerator marked for residents:
i. partial turkey wrap sandwich in plastic container- no name and no date.
ii. biscuits and gravy in in plastic container - no name and no date.
iii. slice of pizza in zip lock bag - no name and no date.
iv. glass of milk - not covered, no name and no date.
v. bottle of ranch dressing, 1/4 full - no name and no date.
vi. freezer section - 2 large bags of pretzels - not dated and DM stated those are for activities.
b. In the small chest freezer:
i. An undated open pack of nine danishes and an undated 10 pack of danishes.
c. The microwave covered in dried food on all sides, on the tray, and on the top of inside of the microwave.
Review of facility policy titled, Foods brought by family/visitors reviewed 10/29/18 documented:
a. Perishable foods must be stored in resealable containers with tight fitting lids in the refigerator.
b. Containers are to be labeled with resident's name, the item, and the date brought in.
c. These items are to be stored in the residents refrigerator in the dining room for no more than 3 days.
2. On 6/16/22 starting at 12:00 PM, observed Staff A, Cook, not his wash hands and then donned (put on) gloves. Staff A started the lunch service, he touched the buns with his gloved hands. Then Staff A touched the lids to the pans, cleansed the thermometer with an alcohol swab, touched the garbage can lid and side, touched inside of bowls, and then proceeded, while wearing same gloves, to touch more hamburger buns, potato wedges, and hamburger patties. Staff A used tongs to remove the pan lids, then placed tongs on the counter, and proceeded to use same tongs to serve hamburger patties and potato wedges. Staff A removed his gloves, applied new gloves, and without doing hand hygiene, he placed his gloved hand inside an oven mitt to pull a pan out of the oven, with his same used gloved hand he touched the buns, and proceeded to touch the diet cards, the microwave, the cart handles and then touch more buns with the same gloves.
The Proper Hand Washing and Glove Use policy dated 2020 documented the following:
a. Employees will wash hands before after handling foods.
b. Hands are washed before donning gloves and after removing gloves.
c. Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment.
The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.
On 6/16/22 at 12:53 PM, the DM confirmed she observed Staff A touching multiple items before touching food with the same gloves. The DM reported that they expected the staff to wash their hands before gloves, gloves should be used only one time, all stored food to be dated, and labeled.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and policy reviews, the facility failed to provide proper hand...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, staff interviews, and policy reviews, the facility failed to provide proper hand hygiene and glove usage during medication administration for 2 out of 5 residents reviewed (Resident #20 and #24). The facility also failed to provide documentation that oxygen tubing got changed for 2 of 2 residents reviewed (Resident #20 and #25 ). The facility reported a census of 26 residents.
Findings include:
1. Resident #24's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of schizophrenia and chronic obstructive pulmonary disease.
On 6/16/22 at 8:09 AM, observed Staff C, Certified Medication Aide (CMA), handed Resident #24 a medication cup containing their morning medications. Resident #12 lifted the cup to her lips and ingested the medication. Staff C discarded the medication cup then proceeded to touch the cart and computer without performing hand hygiene.
The June 2022 Medication Administration Recorded (MAR) revealed Resident #24 received her medications for the morning of 6/16/22.
2. Resident #20's MDS dated [DATE] identified a BIMS score of 6, indicating severe cognitive impairment. The MDS inlcuded diagnoses of renal insufficiency and coronary artery disease.
On 6/14/22 at 10:11 AM, noted Resident #20's oxygen tubing lacked a dated label.
Resident #20's Clinical Physician Orders revealed the facility lacked an order to change oxygen tubing.
In an interview on 6/15/22 at 02:29 PM, Staff B, Licensed Practical Nurse (LPN), acknowledged that she did not know where to locate documentation related to the changing of oxygen tubing since the facility no longer used paper Medication Administration Records (MARS).
On 6/16/22 at 10:06 AM, observed Staff C fail to perform hand hygiene before she put on gloves in preparation for eye drop administration for Resident #20. After Staff C administered the eye drops, she then placed the eye drops back in the box, opened the medication cart, and placed the box of eye drops into the drawer of the medication cart without performing hand hygiene.
The June 2022 MAR revealed Resident #20 received Artificial Tears Solution eye drops on the morning of 6/16/22.
The undated policy titled Handwashing Policy and Procedure directed staff to wash hands after gloves are removed.
On 6/16/22 at 2:56 PM, the Administrator acknowledged that the CMA should have completed hand hygiene before applying gloves, after removing gloves, and after the medication administration.
3. Resident #25's MDS dated [DATE] identified a BIMS score of 7, indicating severe cognitive impairment. The MDS documented diagnoses that included chronic lung disease, heart failure, and anemia.
On 6/14/22 at 8:23 AM, observed Resident #25's oxygen tubing lacked a dated label.
Resident #25's Clinical Physician Orders revealed the facility lacked an order to change oxygen tubing.
The policy titled Respiratory System Management date August 2021 lacked documentation of how often the oxygen tubing needed to be changed or labeling requirements.
On 6/15/22 at 3:02 PM, the Administrator explained the oxygen tubing change date used to be written on the paper (MAR), but since the facility started using an electronic record the process needed to be fixed.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $140,738 in fines, Payment denial on record. Review inspection reports carefully.
- • 95 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $140,738 in fines. Extremely high, among the most fined facilities in Iowa. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Aspire Of Perry's CMS Rating?
CMS assigns Aspire of Perry an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Aspire Of Perry Staffed?
CMS rates Aspire of Perry's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 79%, which is 33 percentage points above the Iowa average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 88%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Aspire Of Perry?
State health inspectors documented 95 deficiencies at Aspire of Perry during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 89 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Aspire Of Perry?
Aspire of Perry is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BEACON HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 46 certified beds and approximately 29 residents (about 63% occupancy), it is a smaller facility located in Perry, Iowa.
How Does Aspire Of Perry Compare to Other Iowa Nursing Homes?
Compared to the 100 nursing homes in Iowa, Aspire of Perry's overall rating (2 stars) is below the state average of 3.0, staff turnover (79%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Aspire Of Perry?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Aspire Of Perry Safe?
Based on CMS inspection data, Aspire of Perry has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Iowa. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Aspire Of Perry Stick Around?
Staff turnover at Aspire of Perry is high. At 79%, the facility is 33 percentage points above the Iowa average of 46%. Registered Nurse turnover is particularly concerning at 88%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Aspire Of Perry Ever Fined?
Aspire of Perry has been fined $140,738 across 3 penalty actions. This is 4.1x the Iowa average of $34,486. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Aspire Of Perry on Any Federal Watch List?
Aspire of Perry is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.