How many inspection deficiencies does CAMBRIDGE PLACE have?

CAMBRIDGE PLACE has 38 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CAMBRIDGE PLACE?

CAMBRIDGE PLACE has a one-star staffing rating from CMS with 0.45 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CAMBRIDGE PLACE located?

CAMBRIDGE PLACE is located in MARYSVILLE, KS. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CAMBRIDGE PLACE have?

CAMBRIDGE PLACE has 91 certified beds.

Who owns CAMBRIDGE PLACE?

CAMBRIDGE PLACE is a for profit - corporation facility and is part of the RECOVER-CARE HEALTHCARE chain.

What questions should families ask when visiting CAMBRIDGE PLACE?

Families visiting CAMBRIDGE PLACE should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does CAMBRIDGE PLACE compare to other nursing homes?

CAMBRIDGE PLACE has a 1-star overall rating, which is below average compared to other nursing homes in KS. Families should carefully review inspection findings and consider alternatives.

CAMBRIDGE PLACE

Name: CAMBRIDGE PLACE
Address: 1100 N 16TH, MARYSVILLE, KS, 66508, US
Telephone: (785) 562-5321
Rating: 1.0

1100 N 16TH, MARYSVILLE, KS 66508 · (785) 562-5321

For profit - Corporation 91 Beds RECOVER-CARE HEALTHCARE Data: November 2025

Trust Grade

40/100

#242 of 295 in KS

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Last Inspection: December 2023

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Cambridge Place in Marysville, Kansas, has received a Trust Grade of D, indicating below-average performance with some concerns about care. It ranks #242 out of 295 facilities in Kansas, placing it in the bottom half, and only one other facility in Marshall County is rated lower. The trend is improving, with issues found decreasing from 19 in 2023 to 4 in 2025. Staffing is a point of concern, rated at 1 out of 5 stars, and the facility has an average turnover rate of 51%. While there have been no fines, which is a positive aspect, the facility has specific issues, such as not having a certified dietary manager overseeing meal preparation and failing to follow proper food safety standards, putting residents at risk for foodborne illnesses.

Trust Score: D
In Kansas: #242/295
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Kansas facilities.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Kansas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 38 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2023: 19 issues

2025: 4 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Kansas average (2.9)

Significant quality concerns identified by CMS

Staff Turnover: 51%

Near Kansas avg (46%)

Higher turnover may affect care consistency

Chain: RECOVER-CARE HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 38 deficiencies on record

Aug 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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The Facility had a census of 77 residents. The sample included 18 residents, with one reviewed for the environment. Based on observation and interview, the facility failed to provide accommodation of needs for one sampled resident, Resident (R) 66, who had a call light on her wall that was unreachable from her bed. This deficient practice placed R66 at risk for preventable accidents and injuries.Findings included:- On 08/24/25 at 10:30 AM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall. The call light was unreachable by R66 when she was in bed.On 08/24/25 at 03:00 PM, observation revealed R66 sat in a wheelchair in her room. R66's call light hung on the wall and was unreachable to R66 when she was in bed. On 08/25/25 at 03:08 PM, Certified Nurse's Aide (CNA) MM stated the resident liked to propel herself up and down the halls in her wheelchair and sit in the hall and dining room area. On 08/24/25 at 02:00 PM, Licensed Nurse (LN) I stated the resident was mobile in her wheelchair and had recently had a total knee replacement and was getting therapy, but could not safely ambulate independently. LN I stated every resident should have an accessible call light.On 08/24/25 at 03:15 PM, Administrative Nurse E stated R66 had moved from a room down the hall about one month ago. Administrative Nurse E had not known R66 did not have a call light bedside her bed. Administrative Nurse E verified that the resident should have a permanent call light to access from their bed, and R66 did not have access to one. On 08/26/25 at 10:30 AM, Administrative Nurse D verified that a resident's call light should be accessible to the resident in bed and should not be across the room from the bed.The facility's Call lights: Accessibility and Timely Response policy, dated 09/09/20, documented the facility would ensure it was adequately equipped with a call light at each resident's bedside and bathing area to allow residents to call for assistance, and the call lights would directly relay to a staff member or centralized location to ensure appropriate response. Staff would be educated on the proper use of the resident call light system, including how the system works, and ensure residents' access to the call light. The policy documented with each staff interaction in the resident's room or bathroom, the staff would ensure the call light was within reach of the resident and 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 13. The facility staff failed to don (put on) gloves when emptying R13's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The facility staff also failed to wear gloves when picking up an uncovered urinary catheter bag from the floor. This deficient practice placed the residents at risk for possible exposure to infection.Findings included:- On 08/24/25 at 09:30 AM, observation revealed no EBP signage outside R13's door, but personal protective equipment (PPE) was on the inside of R13's room door. On 08/24/25 at 02:50 PM, observation revealed R13's room door opened partway; he stood by a recliner with his uncovered urinary catheter bag and tubing on the floor in front of a recliner. Certified Nurse Aide (CNA) P entered the room without donning gloves or a gown and assisted R13 with sitting in a recliner. CNA P left the room with the catheter bag and tubing still on the floor.On 08/24/25 at 03:38 PM, observation revealed R13 sat in a recliner in his room with the door open, and his urinary catheter bag and tubing were on the floor. Licensed Nurse (LN) J entered the room, with an ungloved hand, picked up the catheter bag, placed it on a walker beside the recliner, and left the room. LN J stated she should have placed gloves on before picking up R13's urinary catheter bag.On 08/25/25 at 01:45 PM, observation revealed R13 sat in a recliner in his room with the door open. CNA O entered the room, without a gown, applied gloves, and asked R13 if she could empty his urinary catheter bag, and he replied, Ok. CNA O retrieved a graduated cylinder from R13's bathroom, set it on the floor underneath the uncovered bag on a walker, unhooked the port from the bag, used an alcohol wipe on the port, opened the port, and drained yellow urine into the graduated cylinder. CNA O closed the port, used an alcohol wipe on the port, and placed it back into the holder on the urinary catheter bag. CNA O took the graduated cylinder into the bathroom, poured the urine into the toilet, set the graduated cylinder on top of the toilet, then removed and discarded the gloves and left R13's room.On 08/25/25 at 01:50 PM, when asked how staff could tell if a resident was on EBP, CNA O pointed to the green triangle in the upper corner of R13's entrance door frame and stated there was a green triangle in the corner of the entrance door. When asked if she should have placed a gown on before emptying R13's urinary catheter bag, she stated yes, but had forgotten.On 08/26/25 at 09:00 AM, Administrative Nurse F stated that staff are made aware of a resident being on EBP when they have a green triangle in the corner of the entrance door frame. EBP supplies are hung on the inside of the entrance door. Administrative Nurse F stated that staff could look at tasks on the computer, and the information is available in the care plan. Administrative Nurse F stated staff should keep a resident's urinary catheter bag and tubing off the floor, but if found uncovered on the floor, they should place gloves on to pick it up off the floor.The facility's Catheter Care Policy, revised 10/01/19, documented it was the policy of this facility to provide catheter care to all residents who have an indwelling catheter in an effort to reduce bladder and kidney infections.The facility's Enhanced Barrier Precautions policy, revised 06/11/25, documented it was the policy of this facility to implement EBP precautions for the prevention of transmission of multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics). Implementation of EBP would be performed with high-contact care activities. The policy documented high-contact resident care as follows: dressing, bathing, and transferring. Providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use with central lines (a long, thin tube inserted into a large vein in the neck, chest, or groin that reaches a major vein near the heart) urinary catheters, feeding tubes (tube for introducing high-calorie fluids into the stomach), tracheostomy(opening through the neck into the trachea through which an indwelling tube may be inserted), ventilator tube (a medical device that connects a person's windpipe to a ventilator machine, delivering air, oxygen, and medications directly into their lungs to help them breathe when they cannot do so effectively on their own), hemodialysis catheters (a procedure where impurities or wastes are removed from the blood), Peripherally Inserted Central Catheter (PICC) line (a long, thin tube inserted into a vein in the upper arm that is guided to a large central vein near the heart), midline (a long, thin, flexible tube inserted into a peripheral (outside, surface, or surrounding area of an organ, other structure, or field of vision) vein in the arm, typically for administering medications or fluids) catheters, and wound care: any skin opening requiring a dressing.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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The facility had a census of 72 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff used Styrofoam plates and bowls instead of regular dinnerware for meal service. This placed the residents of the facility at risk for impaired dignity.Findings included:- On 08/24/25 at 12:30 PM, observation during the lunch meal service revealed that staff provided Styrofoam plates for meatloaf, mashed potatoes, and carrots, and used Styrofoam bowls for the strawberry cake. On 08/25/25 at 08:45 AM, observation during the breakfast meal service revealed that staff provided Styrofoam plates for scrambled eggs, toast, and either sausage or bacon, and provided Styrofoam bowls for cereal.On 08/24/25 at 12:55 PM, Dietary Staff (DS) BB stated that the facility used the Styrofoam plates and bowls because the kitchen was short-staffed and did not have enough help to clean the dishes.On 08/26/25 at 10:30 AM, Administrative Nurse D verified that staff should not have used Styrofoam plates and bowls for daily meal service. Administrative Nurse D stated she verified with dietary staff that the reason they use them for the two meals was due to a lack of staff.The facility's Dining Room Standards policy, dated 2020, documented staff would ensure that an attractive, cheerful dining room was maintained with comfortable sound, lighting, furnishings, temperature, and adequate space. The policy documented that single-use disposable dining ware was not permitted except for emergencies.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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The facility identified a census of 77 residents. The sample included 18 residents, with 13 reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of nine cognitively impaired, independently mobile residents. The facility additionally failed to provide adequate supervision and ensure Resident (R) 44's fall prevention interventions were followed, resulting in multiple non-injury falls. This placed the affected residents at risk for preventable accidents.Findings Included: - On 08/24/25 at 09:00 AM, an initial walkthrough of the facility was completed. An inspection of the main nurse's station area revealed a storage closet propped open by a cloth sling rope. An inspection of the storage closet revealed ten containers of purple disinfectant wipes on a shelf in the room. The containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.An inspection of the kitchenette across from the main dining hall revealed a purple disinfectant wipe container in an unlocked cabinet above the sink. The container contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.On 08/24/25 at 09:00 AM, Certified Medication Aide (CMA) R stated that cleaning chemicals were to be stored in a locked closet or drawer. On 08/26/25 at 11:30 AM, Administrative Nurse D stated that staff were expected to ensure chemical products were locked up after use. The facility's Chemical Storage policy, revised 01/2020, indicated the facility would ensure an environment free from potentially hazardous materials, chemicals, and equipment.- R44's Medical Diagnosis section within the Electronic Medical Record (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, unsteadiness on feet, and a history of falls. R44's Significant Change Minimum Data Set (MDS) completed 08/04/25 revealed a Brief Interview for Mental Status (BIMS) score of zero, indicating severe cognitive impairment. The MDS noted no upper or lower extremity impairments. The MDS noted she required assistance from staff for toileting, bathing, personal hygiene, dressing, and transfers. The MDS noted she required partial to moderate assistance from staff while walking. The MDS noted she was at risk for falls and had a history of falls since the last assessment.R44's Falls Care Area Assessment (CAA) completed 08/18/25 indicated she was at risk for a decline in her activities of daily living (ADL) related to her decreased mobility, fatigue, and cognitive impairment. The CAA noted she had a history of falls. The CAA noted that a care plan was implemented to minimize the risks related to her fall history.R44's Care Plan initiated 10/17/20 indicated she was at risk of falls and altered ADLs related to her medical diagnoses. The plan noted she required non-skid footwear (10/17/20). The plan instructed staff to ensure her call light remained within reach (10/17/20). The plan instructed staff to provide appropriate lighting and ensure her room was free from clutter (10/17/20). The plan noted she was dependent on staff assistance for walking, toileting, transfers, bed mobility, personal hygiene, dressing, and bathing (11/15/23). The plan noted she had an unwitnessed fall and instructed staff to place a brightly colored bow on her front wheeled walker (01/30/24). The plan noted R44 had a non-injury fall on the enclosed patio of the secured unit on 09/04/24. The plan noted R44 had a non-injury fall while not wearing the appropriate non-skid footwear on 10/16/24. The plan noted that staff were re-educated on 03/12/25 to use a gait belt after a fall occurred during staff assistance. The plan noted she had a fall on 03/09/25 while wearing regular non-skid black socks. The plan noted that staff were to sign off under R44's medication administration report on each shift to ensure she had non-skid footwear. The plan noted she had a non-injury fall on 03/21/25 while not wearing non-skid socks. The plan noted that a sign was placed above her bed to remind staff to provide her with the appropriate socks. The plan noted R44 had an unwitnessed non-injury fall in front of the nurse's station on 06/03/25. The plan noted that staff were re-educated that R44 required supervision and/or touch assistance while ambulating. R44's EMR under Progress Notes revealed a Communication with Providers note completed on 09/03/24. The note indicated staff were alerted by the secured unit's patio door alarm and found R44 outside on the patio floor of the enclosed patio. The note revealed R44 was assessed by nursing and brought back inside. On 08/26/25 at 07:41 AM, R44 slept in her bed. Her bed was in the lowest position with a fall mat on the floor next to her bed. R44's front-wheeled walker was positioned next to her recliner. R44's walker did not have a bright-colored ribbon tied to it. An inspection of her room revealed the non-skid sock signage was placed above her room's dresser behind a flowerpot. On 08/26/25 at 09:00 AM, Certified Medication Aide (CMA) R stated R44 used both her walker and wheelchair due to her decline in abilities and being placed on hospice care (end-of-life comfort care). She stated R44 was a fall risk due to her weakness and cognitive impairment. She stated staff were expected to ensure her fall interventions were followed and in place. CMA R stated the unit sometimes only had one or two staff members and often had difficulties providing supervision while performing care. On 08/26/25 at 12:24 PM, Administrative Nurse D stated all staff had access to review the care plan and ensure the interventions were in place. She stated new interventions would be discussed by the interdisciplinary team, and staff would be informed by the nurse. The facility's Accidents and Supervision policy (undated) indicated the facility promoted an environment that remains free from accident hazards. The policy indicated the facility appropriately assessed and implemented interventions to prevent falls and minimize complications if falls occurred.

Dec 2023 18 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified and reported allegations of potential abuse to the administrator of the facility immediately. This placed the residents at risk for ongoing abuse and/or mistreatment. Findings included: - R69's Electronic Health Record (EHR) revealed diagnosis of dementia (progressive mental disorder characterized by falling memory, confusion,) major depressive disorder (major mood disorder which causes persistent feelings of sadness,) hypertension (elevated blood pressure.) R69's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R69 had severely impaired cognition. The MDS recorded she required limited assistance of one staff assistance for transfers and activities of daily living (ADL.) The MDS further documented R69 had no falls and no skin issues. R69's Quarterly MDS, dated 10/06/23, recorded R69 had severely impaired cognition. The MDS recorded she required extensive two staff assistance for transfers and ADLs. The MDS further documented R69 had two non- injury and two minor injury falls and lacked any skin issues. R69's Care Plan. dated 09/13/23, recorded R69 requires extensive assistance with most ADL cares. The Care Plan documented the resident had impaired mobility due to wandering, and staff would check on the resident every 15 minutes and had a pressure alarm. The care plan recorded would encourage the resident to sit in a recliner across from the nurse's station window so she could be monitored if she would attempt to get up without staff assistance. The care plan recorded staff would anticipate she would fall due to unsteadiness in her feet, anxiousness and dementia. The Fall Risk Assessments, dated 02/15/23, 04/12/23 11/15/23, noted R69 at high risk for falls. The Nurse's Note, dated 04/12/23 at 01:14 PM, documented staff heard knocking and discovered R69 on the floor, leaned against the door in the bathroom. The note further documented R69 had blood on the right side of her head near the temple area and blood was noted on the floor. The resident stated she did not know what happened. The clinical record lacked documentation a resident centered intervention was put into place to prevent falls and lacked documentation an investigation was completed for the fall. The Nurses Notes, dated 04/21/23 at 05:01 AM, documented staff noted resident rubbing her right hand, evaluation noted bruising to the middle and right of middle knuckle on the right hand. Staff noted a small amount of swelling and the resident complained of tenderness to the right middle knuckle with touch, Staff applied ice and would continue to monitor. The area measured 6.0 centimeters (cm) by 7.5 cm. The EHR lacked any documented skin assessment that included the bruised right hand. On 12/05/23 at 11:30 AM, observation revealed R69 sat in her wheelchair at the dining room table and staff would cue and assist her as needed to eat. On 12/07/23 at 01:00 PM, Administrative Staff A and Nurse Consultant GG stated they had not been informed of R69's fall on 04/12/23 or the bruised hand on 04/23/23 and the staff should report to the administration and an investigation would be completed along with witness statements and reported to the state if indicated. The facility's Resident Right to Freedom from Abuse, Neglect, and Exploitation policy, dated November 6, 2017, documented ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe pursuant to the policy. And have evidence that all alleged violations are thoroughly investigated. The policy recorded the facility must report the results of all investigations to the administrator or his /her designated representative and to other officials in accordance with State laws, within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action must be taken. Residents would be protected from further abuse, neglect, exploitation or mistreatment while the investigation was in process. The facility failed to ensure staff identified and reported an allegation of potential abuse to the facility abuse coordinator or administrative staff immediately to investigate. This placed the residents at risk for ongoing abuse and/or mistreatment.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)69's unwitnessed fall in the bathroom which resulted in swelling and bruising. This deficient practice placed R69 at risk for unidentified and continued abuse, neglect and/or mistreatment. Findings included: - R69's Electronic Health Record (EHR) revealed diagnosis of dementia (progressive mental disorder characterized by falling memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness) and hypertension (elevated blood pressure). R69's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R69 had severely impaired cognition. The MDS recorded she required limited assistance of one staff assistance for transfers and activities of daily living (ADL.) The MDS further documented R69 had no falls and no skin issues. R69's Quarterly MDS, dated 10/06/23, recorded R69 had severely impaired cognition. The MDS recorded she required extensive two staff assistance for transfers and ADLs. The MDS further documented R69 had two non- injury and two minor injury falls; R69did not have any skin issues. R69's Care Plan. dated 09/13/23, recorded R69 required extensive assistance with most ADL cares. R69's Care Plan documented the resident had impaired mobility due to wandering, and staff would check on the resident every 15 minutes; the resident had a pressure alarm. The care plan directed staff would encourage the resident to sit in a recliner across from the nurse's station window so she could be monitored if she attempted to get up without staff assistance. The care plan recorded staff would anticipate R69 would fall due to unsteadiness in her feet, anxiousness and dementia. R69's Fall Risk Assessments, dated 02/15/23, 04/12/23 and 11/15/23 noted R69 was at high risk for falls. The Nurse's Note, dated 04/12/23 at 01:14 PM, documented staff heard knocking and discovered R69 on the floor, leaned against the door in the bathroom. The note further documented R69 had blood on the right side of her head near the temple area and blood was noted on the floor. The resident stated she did not know what happened. R69's clinical record lacked documentation a resident centered intervention was put into place to prevent future incidents and lacked documentation an investigation was completed for the incident. The Nurses Notes, dated 04/21/23 at 05:01 AM, documented staff noted the resident rubbed her right hand. Staff evaluated and noted bruising to the middle and right of middle knuckle on the right hand. Staff noted a small amount of swelling and the resident complained of tenderness to the right middle knuckle with touch, Staff applied ice and continued to monitor. The area measured 6.0 centimeters (cm) by 7.5 cm. R69's EHR lacked any documented skin assessment that included the bruised right hand. On 12/05/23 at 11:30 AM, observation revealed R69 sat in her wheelchair at the dining room table. Staff cued and assisted her as needed to eat. On 12/07/23 at 01:00 PM, Administrative Staff A and Nurse Consultant GG stated they were not informed of R69's fall on 04/12/23 or the bruised hand on 04/21/23. They verified staff should report to those type of incidents to the administration so an investigation could be completed along with witness statements and reported to the state agency if indicated. The facility's Resident Right to Freedom from Abuse, Neglect, and Exploitation policy, dated November 6, 2017, documented ensure that all alleged violations involving abuse, neglect, and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper timeframe pursuant to the policy. And have evidence that all alleged violations are thoroughly investigated. The policy recorded the facility must report the results of all investigations to the administrator or his /her designated representative and to other officials in accordance with State laws, within 5 working days of the incident. If the alleged violation is verified, appropriate corrective action must be taken. Residents would be protected from further abuse, neglect, exploitation or mistreatment while the investigation was in process. The facility failed to investigate an unwitnessed fall and a bruising of unknown origin for R69. The placed the resident at risk for unidentified and ongoing abuse, neglect, and/or mistreatment.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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The facility had a census of 79 residents. The sample included 18 residents with one reviewed for discharge to the hospital. Based on observation, interview, and record review, the facility failed to notify the ombudsman of the facility-initiated discharge of Resident (R) 81, placing R81 at risk for discharges without oversight of the ombudsman office. Findings included: - R81's Electronic Medical Record documented he was admitted to the facility 09/27/23 with diagnoses of atrial fibrillation (rapid irregular heartbeat), hypertension (high blood pressure), left femur (thigh bone) fracture, and anxiety disorder (mental disorder characterized by apprehension, uncertainty and irrational fear). R81's Care Plan, dated 10/02/23, directed staff to ensure the call light was within reach and encourage R81 to use it for assistance as needed. Engage the resident in active conversation. The Progress Note to the physician, dated 10/03/23 at 04:30 PM, stated R81 said he would have better acceptance of being in the nursing home if he could visit home, sit on the porch, and see the dogs. The note asked if R81 was ok to discharge to home with family for short visits during his skilled stay. The Progress Note, dated 10/03/23 at 07:00 PM, documented R81 stated that he intended on committing suicide one way or another and would continue attempts until he was successful. The nurse spent some time providing therapeutic conversation with R81 and he verbalized that he did have a plan in place to commit suicide and intended to follow through with it. One to one staff care was provided to R81 at all times and all items he could harm himself with were removed from his room. His family arrived at the facility to sit with the resident. They agreed that R81 needed to be sent to the hospital for monitoring and the physician gave a verbal order to transfer to the hospital for psychiatric evaluation. The Progress Note, dated 10/05/23 at 02:12 PM, documented R81 was discharged . On 12/07/23 at 10:08 AM, Social Services Staff X verified the facility had not notified the Ombudsman of the discharge. The facility's Transfer and Discharge policy, dated 02/01/20, stated the Social Service Designee would provide notice of transfer to the state ombudsman office. The facility failed to notify the state ombudsman office of the facility-initiated discharge of R81 to a hospital. This placed the resident at risk for decreased oversight and assistance with transfers and discharge.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 25's use of supplemental oxygen. This deficient practice placed R25 at risk for respiratory complications related to uncommunicated care needs. Findings included: - R25's Electronic Medical Record documented diagnoses including chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing)), obstructive sleep apnea (disorder in which a person frequently stops breathing during his or her sleep), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R25 was independent with eating, required moderate staff assistance for dressing, transfers, and maximum staff assistance for wheelchair mobility. The MDS documented R25 used oxygen and a non-invasive ventilator (continuous positive airway pressure-CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). The Functional Abilities Care Area Assessment (CAA), dated 11/21/23, stated R25 was admitted because she was no longer able to meet her own needs. She was alert, oriented, aware of her needs, and able to make them known. She required staff assistance with completion of activity of daily living (ADL) functions, received supplemental oxygen continuously, and was short of breath with exertion. R25's Care Plan dated 11/20/23 lacked documentation of R25's oxygen needs or use. R25's [NAME] (nursing tool that gives a brief overview of the care needs of each resident), dated 11/17/23, lacked mention of her oxygen needs. R25's Care Plan dated 12/05/23 (19 days after admission), included oxygen per order of 3L/M/NC (three liter per minute per nasal cannula), 4.5L/M/NC (four liters per minute per nasal cannula) with activity. The plan directed staff to monitor R25's oxygen saturation and report as indicated. Staff were to provide COPD monitoring every shift for shortness of breath with activity, shortness of breath while lying flat, cyanosis (bluish discoloration of the skin), accessory muscle use, chest wall movement and/or shape abnormalities, presence of cough and/or sputum (mixture of saliva and mucous), peripheral edema (swelling) or a change in level of consciousness. The plan directed staff to check R25's pulse oximetry (measurement of oxygen saturation) with abnormal findings and apply CPAP as per directions on the treatment record. The Physician Order, dated 11/17/23, directed staff to provide supplemental oxygen at 3L/NC to keep saturation level above 90%, and 4.5L with activity. CPAP on at bedtime and off in the morning. On 12/05/23 at 10:48 AM, observation revealed R25 in her recliner with her eyes closed. She received oxygen per nasal cannula at five liters a minute via an oxygen concentrator. On 12/06/23 at 08:42 AM, observation revealed staff brought R25 in a wheelchair from the shower to her room. Certified Nurse Aide (CNA) O and CNA P used gait belt to transfer R25 to her recliner. R25 was short of breath during the transfer. CNA O verified R25 was on five liters of oxygen. On 12/05/23 at 04:31 PM, Administrative Nurse D stated she did not find the baseline care plan and stated it looked as if one had been started then cancelled. Upon request the facility did not provide a baseline care plan policy. The facility failed to develop and implement a baseline care plan for R25's use of supplemental oxygen. This deficient practice placed R25 at risk for respiratory complications related to uncommunicated care needs.

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

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The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 284's Care Plan with effective interventions for staff to follow when R284 had behaviors. This placed R284 at risk for unmet care needs. Findings included: - R284's Electronic Medical Record (EMR) documented R284 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R284's admission Minimum Data Set (MDS) documented it was in progress. R284's Care Plan, revised on 12/06/23, documented R284 had behaviors of yelling out and asking staff to take a gun and shoot me or just kill me or take me outside and let me lay there and die. R284's Care Plan lacked interventions for staff to follow when R284 had these behaviors. The Nurse's Note, dated 12/03/23 at 02:50 PM, documented R284 was calmer that day although she continued to yell out at other residents and staff, as they passed by in the dining room, for someone to shoot her, to throw her in the river, or to throw her away. Attempts to redirect were short lasting. The note documented the resident tended to be calmer when in her room reading or watching television. On 12/07/23 at 11:58 AM, observation revealed R284 sat at the dining room table in a wheelchair. R284 yelled out that she wished she was dead, and she might as well be, nobody knew her. On 12/07/23 at 01:45 PM, Certified Nurse Aide (CNA) O stated R284 had behaviors of yelling out to staff to give her a gun so she could shoot herself. CNA O said she replied to R284 honey, don't talk that way, then R284 would wait ten minutes and repeat the same thing. On 12/11/23 at 09:59 AM, Administrative Nurse D verified R284's Care Plan lacked interventions for staff to follow when R284 had behaviors of yelling out asking people to kill her. Administrative Nurse D stated the care plan nurse, charge nurse, and she were responsible for updating care plans. Administrative Nurse D stated R284's Care Plan should have interventions for staff to follow when R284 had behaviors. The facility's Care Plan Revisions Upon Status Change Policy, revised 02/02/20, documented the comprehensive care plan would be reviewed and revised as necessary, when a resident experienced a status change. The facility failed to update R284's Care Plan with interventions for staff to use when R284 had behaviors of yelling asking people to kill or shoot her. This placed R284 at risk for unmet care needs.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for one of four residents reviewed for activities of daily living (ADLs), when Resident (R) 74 requested staff assistance with repositioning and they told her she would have to wait, then did not return until 41 minutes later to assist her. This placed R74 at risk for impaired mobility and decreased comfort. Findings included: - R74's Electronic Medical Record (EMR) documented R74 had diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), carcinoma (cancer) in right breast, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and chronic pain. R74's admission Minimum Data Set (MDS), dated [DATE], documented R74 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intake cognition. The MDS documented R74 required total staff dependence with most ADLs. The Functional Ability Care Area Assessment (CAA), dated 10/19/23, documented R74 was a new admit to facility with diagnosis of breast cancer with metastasis (spread) to her lungs. The MDS documented R74 required substantial/maximum/dependent staff assistance with ADLs due to her impaired physical mobility and weakness. The Pain CAA, dated 10/19/23, documented the resident utilized a fentanyl (opioid) patch (topical pain medication) and instructed staff to monitor R74 for nonverbal signs or symptoms of pain, and report if she was not relieved by nonpharmacological (management of pain without medications) interventions. The CAA instructed staff to notify the physician if interventions including medications and non-pharmacological were unsuccessful or if R74 complaint of pain was a significant change. The ADL CAA, dated 10/19/23, documented R74 was dependent on staff for most ADLs. R74's Care Plan dated 10/13/23 directed staff to assess for pain, restlessness, agitation, constipation, and other symptoms of discomfort. If present, provide nonpharmacological approaches to aide in decreasing discomfort. On 12/6/23 at 10:30 AM, R74 placed her pendant call light on. Certified Medication Aide (CMA) M entered R74's room and R74 requested to be repositioned in bed, CMA M stated R74 would have to wait until CMA M had help and said she would be back. At 11:01 AM (41 minutes later) CMA M and Certified Nurse Aide (CNA) N entered R74's room and stated they were ready to assist R74 with repositioning. CNA N stated it took so long to get back to assist R74 because staff were busy on the unit, taking care of other residents. She said she had to work with her restorative residents first and had to take her break before she could accommodate R74's request. On 12/11/23 at 09:56 AM, Administrative Nurse D stated she expected staff to provide care to R74 within 15 minutes after she had placed her call light on. The facility's ADLs Policy, revised 08/01/19, documented a resident who is unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility staff failed to provide necessary services in a timely manner when R74 requested staff assistance with repositioning in bed, and staff returned 41 minutes later. This placed R74 at risk for decreased comfort.

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 F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents, The sample included 18 residents with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide neck stretching exercises for Resident (R) 15 to prevent further decline in her neck range of motion as discussed during her quarterly care plan meeting. This placed the resident at risk for decreased or impaired comfort. Findings included: - R15's Electronic Medical Record documented diagnoses of contracture (abnormal permanent fixation of a joint or muscle) of left shoulder muscle, acquired deformity of neck, contracture of left forearm muscle, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, shuffling gait, muscle rigidity and weakness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R15 was independent with eating, required maximal staff assistance with upper body dressing, hygiene, mobility, and was dependent on staff for lower body dressing and toileting. The MDS documented R15 had no ROM issues, had frequent moderate pain, and no therapy in the past five days. The MDS documented the resident received restorative active range of motion exercises three days during the lookback period. R15's Care Plan, dated 11/06/23, stated R15 was receiving restorative care: Bilateral upper extremity (BUE) strengthening in all planes. Pull to stand using grab bar sitting and reaching with left and right upper extremities in all planes. Perform restorative care per order- do not force or rush. Evaluate progress every month. The Progress Note, dated 11/22/23, documented a quarterly care conference was held. The resident received Part B Physical Therapy (PT), Occupational Therapy (OT), and restorative neck stretches/flexes three to five times weekly. R15's EMR documented active ROM and did not specify the neck stretching exercises. On 12/05/23 at 04:27 PM, R15 was in her room in a wheelchair with her head tilted far to the right. A neck pillow sat on her bed. R15 stated she had Parkinson's and that was why her neck was contracted. She stated she used to love to sing but could no longer do that. On 12/06/23 at 08:03 AM, observation revealed R15 ate her breakfast of eggs and raisin bran cereal and though her head was contracted to the right, she was able to eat independently. On 12/07/23 at 09:23 AM, Therapy Staff HH stated therapy did quite a bit of stretching exercises for R15's neck. She stated the therapy staff looked into getting a neck brace, but the resident did not want that. Therapy Staff HH stated R15 had restorative currently with neck stretches. On 12/07/23 at 09:26 AM, Certified Nurse Aide (CNA) M stated, we don't have a scheduled restorative aide [RA]. She stated the regular RA quit several months ago. She stated the RA showed her where the items for restorative were kept and gave a couple of hours of training. CNA M stated usually the CNAs do their work between 06:00 AM and 10:00 AM, then some restorative if they had time in between cares. On 12/07/23 at 09:55 AM, CNA O stated she received no restorative training. On 12/07/23 at 10:32 AM, Licensed Nurse (LN) G stated therapy gave the recommendations for activities or exercises for restorative She stated the facility had no trained restorative aides and she was scheduled to provide restorative on Wednesdays. LN G stated she also worked as a nurse in direct care on Wednesdays. She stated she had never performed neck exercises with R15, just upper body and walking exercises. On 12/11/23 at 10:08 AM, Administrative Nurse D stated the facility had a designated RA every day. She stated the prior RA quit and the facility worked on training staff for restorative services. Administrative Nurse D stated the direct care staff were supposed to provide partial restorative in between their regular work and the activity director sometimes provided restorative activities. She stated one staff took a RA class a month ago. The facility's Restorative Nursing Programs policy, dated October 2018, stated this facility would provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic, or maintenance, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include maintaining proper positioning and body alignment. All residents will receive maintenance restorative nursing services, as needed, by certified nursing assistants. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for such services. The facility failed to provide restorative neck exercises for R15 to prevent further decline in her neck range of motion as discussed during her quarterly care plan meeting. This placed R15 at increased risk for decreased ROM or contractures.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when Resident (R) 67's bedrail exceeded the acceptable safety dimension to prevent entrapment. This placed the resident at risk for accidents and preventable injury. Findings included: - R67's diagnoses from the Electronic Medical Record (EMR) included neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (rapid, irregular heart beat), and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). R67's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact cognition. The MDS documented R67 required extensive assistance of two staff with bed mobility and transfers, had impaired function on one side lower extremity. The MDS further documented R67 used side rails. R67'sCare Plan dated 10/21/23 stated R67 required a quarter side rail for transfers and mobility; staff were to monitor the use of the side rail for entrapment and safety. R67's EMR recorded a Device/Transfer Evaluation dated 10/18/23 which documented a quarter rail to be used for mobility and transfers. On 12/06/23 at 01:15 PM, observation revealed the rail on the right side of R67's bed, with the other side of the bed against the wall. Further observation revealed the rail measured 16 inches wide by 32 inches tall. On 12/06/23 at 01:45 PM, Administrative Nurse E verified the bed rail on R67's bed had too large of an opening. On 12/06/23 at 02:15 PM, Administrative Staff A verified the bed rail on R67's bed had too large of an opening and it needed to be removed from the bed. The facility's Accidents and Supervision policy, dated 02/01/20, stated the resident environment is to remain as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to provide a safe environment free from accident hazards when R67's bedrail exceeded acceptable safety dimensions to prevent entrapment. This placed R67 at risk for accidents and preventable injury.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents, The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide Resident (R) 25's supplemental oxygen at the physician ordered rate through the nasal canula and with the use of a non-invasive ventilator. This deficient practice placed R25 at risk for complications resulting from the incorrect rate of oxygen administered. Findings included: - R25's Electronic Medical Record documented diagnoses including chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing)), obstructive sleep apnea (disorder in which a person frequently stops breathing during his or her sleep), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R25 was independent with eating, required moderate staff assistance for dressing, transfers, and maximum staff assistance for wheelchair mobility. The MDS documented R25 used oxygen and a non-invasive ventilator (continuous positive airway pressure-CPAP- ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep). The Functional Abilities Care Area Assessment (CAA), dated 11/21/23, stated R25 was admitted because she was no longer able to meet her own needs. She was alert, oriented, aware of her needs, and able to make them known. She required staff assistance with completion of activity of daily living (ADL) functions, received supplemental oxygen continuously, and was short of breath with exertion. R25's Care Plan dated 11/20/23 lacked documentation of R25's oxygen needs or use. R25's [NAME] (nursing tool that gives a brief overview of the care needs of each resident), dated 11/17/23, lacked mention of her oxygen needs. R25's Care Plan dated 12/05/23 (19 days after admission), included oxygen per order of 3L/M/NC (three liter per minute per nasal canula), 4.5L/M/NC (four liters per minute per nasal canula) with activity. The plan directed staff to monitorR25's oxygen saturation and report as indicated. Staff were to provide COPD monitoring every shift for shortness of breath with activity, shortness of breath while lying flat, cyanosis (bluish discoloration of the skin), accessory muscle use, chest wall movement and/or shape abnormalities, presence of cough and/or sputum (mixture of saliva and mucous), peripheral edema (swelling) or a change in level of consciousness. The plan directed staff to checkR25's pulse oximetry (measurement of oxygen saturation) with abnormal findings and apply CPAP as per directions on the treatment record. The Physician Order, dated 11/17/23, directed staff to provide supplemental oxygen at 3L/NC to keep saturation level above 90%, and 4.5L with activity. CPAP on at bedtime and off in the morning. The Note to the Physician, dated 11/30/23 at 02:14 PM, stated the resident reported she had not been wearing her CPAP machine at night. The durable medical equipment (DME) company planned to come and add a new pad to her mask. The note did not mention oxygen delivery while using the CPAP. The Note to the Physician, dated 12/04/23, included the 11/29/23 note which stated the resident wore four liters of oxygen, but the CPAP mask did not have an oxygen line. The note asked if the facility needed to implement oxygen at 4four liters into the CPAP mask. On 12/06/23 the physician responded yes; the CPAP does need oxygen during use. The Progress Note, dated 12/07/23 at 01:13 PM, documented R25 was very concerned about her health and continued to be nauseous and dizzy with any movement: R25 stayed in her recliner all day and chose to sleep there. Oxygen was in place, but she became out of breath with just standing up for a very short time. The note recorded R25 constantly wanted to sleep and was still tired when awake. The Physician Oder, dated 12/08/23, stated R25 was to be admitted to the hospital for further evaluation. On 12/05/23 at 10:48 AM, observation revealed R25 in her recliner with her eyes closed. She received oxygen per nasal canula at five liters a minute via an oxygen concentrator. On 12/05/23 at 04:20 PM, observation revealed R25 sat in her recliner and talked on a telephone. She wore oxygen per nasal canula at five liters a minute. On 12/06/23 at 07:37 AM, observation revealed R25 in her recliner in recliner with her eyes closed. Her oxygen per nasal canula at five liters a minute. On 12/06/23 at 08:42 AM, observation revealed staff brought R25 in a wheelchair from the shower to her room. Certified Nurse Aide (CNA) O and CNA P used gait belt to transfer R25 to her recliner. R25 was short of breath during the transfer. CNA O verified R25 was on five liters of oxygen. On 12/07/23 at 07:38 AM, observation revealed R25 sat in her recliner resident asleep. She wore oxygen per nasal canula at five liters a minute. On 12/05/23 at 04:31 PM, Administrative Nurse D stated she did not find the baseline care plan and stated it looked as if one had been started then cancelled. On 12/07/23 at 10:32 AM, Licensed Nurse (LN) G verified R25 received oxygen at five liters a minute. LN G verified R25 should be on three liters a minute usually, and 4.5 liters a minute with activity. LN G verified the resident was not active very often and the oxygen should be at three liters a minute. On 12/11/23 at 10:00 AM, Administrative Nurse D verified staff should have notified the physician of R25's request for oxygen at five liters a minute and obtained an order before increasing the rate. Administrative Nurse D stated the resident preferred to wear her nasal canula under her CPAP mask at night, but staff should ensure R25 received the physician ordered oxygen rate with her CPAP at night. The facility's Oxygen Concentrator policy, dated 10/01/20, stated oxygen was administered under the orders of the physician. The nurse would verify the physician order for the rate and route of administration of the oxygen. The facility failed to provide R25's supplemental oxygen at the physician ordered rate, placing R25 at risk for complications resulting from the incorrect rate of oxygen administered.

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 F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to assess the actual bedrail prior to use to assure safety for Resident (R) 67. This placed the resident at risk for injury. Findings included: - R67's diagnoses from the Electronic Medical Record (EMR) included neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (rapid, irregular heart beat), and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). R67's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact cognition. The MDS documented R67 required extensive assistance of two staff with bed mobility and transfers, had impaired function on one side lower extremity. The MDS further documented R67 used side rails. R67'sCare Plan dated 10/21/23 stated R67 required a quarter side rail for transfers and mobility; staff were to monitor the use of the side rail for entrapment and safety. R67's EMR recorded a Device/Transfer Evaluation dated 10/18/23 which documented a quarter rail to be used for mobility and transfers. On 12/06/23 at 01:15PM, observation revealed the rail on the right side of R67's bed, with the other side of the bed against the wall. Further observation revealed the rail measured 16 inches wide by 32 inches tall. On 12/06/23 at 01:45PM, Administrative Nurse E verified the bed rail on R67's bed had too large of an opening. On 12/06/23 at 02:15 PM, Administrative Staff A verified the bed rail on R67's bed had too large of an opening and it needed to be removed from the bed. The facility's undated Proper Use of Bed Rails policy, documented the facility shall strive to provide a safe sleeping environment for the residents. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories). Inspection by maintenance staff of all beds and related equipment as part of the regular bed safety program to identify risks and problems including potential entrapment risk. Review that gaps within the bed system are within dimensions established by the FDA. Ensure that bed rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit. The facility failed to assure R67's bed rail/ transfer bar was adequate for use, placing the resident at risk for entrapment or injury.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed provide adequate medically related social services to meet Resident (R) 284's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life. Findings included: - R284's Electronic Medical Record (EMR) documented R284 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R284's admission Minimum Data Set (MDS) documented it was in progress. R284's Care Plan, revised on 12/06/23, documented R284 had behaviors of yelling out and asking staff to take a gun and shoot me or just kill me or take me outside and let me lay there and die. R284's Care Plan lacked interventions for staff to follow when R284 had these behaviors. The Nurse's Note, dated 12/03/23 at 02:50 PM, documented R284 was calmer that day although she continued to yell out at other residents and staff, as they passed by in the dining room, for someone to shoot her, to throw her in the river, or to her away. Attempts to redirect were short lasting. The note documented the resident tended to be calmer when in her room reading or watching television. The admission Patient Health Questionnaire (PHQ-9) Assessment, dated 12/01/23, documented R284 had a history of trauma (a deeply distressing or disturbing experience)/post-traumatic stress disorder (disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). Review of R284's EMR revealed lacked documentation Social Service Designee (SSD) visited with the resident regarding her behaviors of wanting staff to shoot her. On 12/07/23 at 11:58 AM, observation revealed R284 sat at the dining room table in a wheelchair. R284 yelled out that she wished she was dead, and she might as well be, nobody knew her. On 12/07/23 at 01:45 PM, Certified Nurse Aide (CNA) O stated R284 had behaviors of yelling out to staff to give her a gun so she could shoot herself. CNA O said she replied to R284 honey, don't talk that way, then R284 would wait ten minutes and repeat the same thing. On 12/07/23 at 02:05 PM, SSD X stated she was aware of R284's behaviors of yelling out just kill me and she talked to a family member last night and would be putting in a note today regarding this behavior. SSD X stated she had visited with R284 when she had these behaviors. On 12/11/23 at 2:30 PM, Administrative Nurse D stated she was aware of R284's yelling out and wanting staff to shoot her, family had been notified and reported to her R284 had done this for about two years prior to be admitted to facility, and they thought it was just part of her dementia disease. Administrative Nurse D stated SSD should be visiting her regarding this behavior. Upon request the facility failed to provide a policy regarding SSD. The facility's failed to provide adequate medically related social services to meet R284's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)32's outdated insulin (hormone which allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 10:45AM, observation revealed R32's Lantus (long-acting insulin) flex pen had an open date of [DATE] (31 days) and lacked a discard date. On [DATE] at 10:50 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the insulin pen when expired. On [DATE] at 01:30 PM, Administrative Nurse E verified the nurses should label and date the flex pens with the resident's name and discard expired and/or outdated pens. According to www.Medlineplus.gov, Lantus pens can be used within 28 days of opening, but after that time they must be discarded. The facility's Labeling of Medication and Biologicals policy, dated [DATE], documented the facility shall ensure all medication and biologicals used in the facility would be labeled in accordance with current state, federal regulations. All opened or accessed vials should be discarded within 28 days unless the manufacture specifies a different (shorter or longer) date for that opened vial. Labels for individual drug containers must include the date the drug was dispensed and the expiration date when applicable. The facility failed to dispose an outdated insulin flex pen for R32 placing the resident at risk for ineffective medication.

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 F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)46. This placed R46 at risk for inappropriate end of life cares. Findings included: - R46's Electronic Health Record (EHR) revealed diagnosis of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), rheumatoid arthritis (chronic inflammatory disease that affects joints and other organ systems), and atrial fibrillation (rapid, irregular heartbeat). R46's Significant Change Minimum Data Set (MDS), dated [DATE], recorded R46 had severely impaired cognition. The MDS recorded she required extensive two staff assistance with bed mobility and transfers and received hospice services. R46's Care Plan, dated 10/16/23, recorded R46 required extensive assistance with most activities of daily living (ADL) cares. R46's Care Plan documented the resident was admitted to hospice for a terminal prognosis of COPD and Alzheimer's disease. Review of R46's Care Plans revealed the resident was admitted to hospice care on 10/16/23, with no evidence of coordination of care between hospice and the facility, and the facility had not received the hospice care plan from hospice. The hospice care plan was not available to review in the in the EHR. On 12/05/23 at 12:10 PM, observation revealed R46 sat in a wheelchair chair at the dining room table with staff assisting the resident to eat her lunch. On 12/07/23 at 03:00 PM, Administrative Staff A stated she expected the facility to have a hospice care plan for R46 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan for R46 since her admission to hospice 10/16/23. The facility's Providing End of Life Care policy, dated February 1, 2020, documented the facility is committed to providing the needed care and services to those resident's at or approaching end of life care in accordance with the resident's preferences, goals, and professional standards of practice in order to promote their highest practicable physical, mental, and psychosocial well-being. The policy documented end of life and palliative care choices made by the resident/representative would be upheld by the facility. The resident's choice of care would be honored. The family and resident/family would coordinate a plan of care and will implement interventions in accordance with the comprehensive assessment, and the resident's needs, goals, and preferences. The plan of care would identify the care and services that each discipline would provide. If the resident chooses hospice services, the care plan would specify the cares and services to be provided by the facility/hospice. The facility would maintain communication with the resident, representative, and hospice as it relates to the plan of care and services provided. The attending physician would assume responsibility for the overall care and treatment of the resident's medical condition. Care would be supervised to ensure that interventions are implemented as written. The facility would monitor and evaluate the resident's response to the established care plan, including the hospice care plan. The facility failed to coordinate care between themselves and hospice services for R46, who received hospice services, placing her at risk for inappropriate end of life care.

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the residents of one of two buildings who received their meals from that kitchen at risk for foodborne illness. Findings included: - On 12/05/23 at 8:27AM, observation in the kitchen revealed the walk-in freezer door had ice buildup on the frame of the door and would not stay closed. On 12/06/23 at 11:59 AM, Dietary Staff (DS) BB verified the walk-in freezer door had ice buildup on it for about six months, she had notified maintenance, but nothing got done. On 12/6/23 at 12:30PM, Administrative Staff A stated she was aware of the problem with the walk-in freezer door not closing due to ice buildup. The facility's Preventative Maintenance Program Policy, revised 10/25/19, documented the maintenance director was responsible for developing and maintain a schedule of maintenance services to ensure that the buildings, grounds, and equipment were maintained in a safe and operable manner. The facility failed to ensure and maintain one of two kitchens walk-in freezer was in safe operating condition, when the freezer door would build up with ice and would not completely shut. This placed the residents who received their meals from the facility kitchen at risk for foodborne illness.

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 F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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The facility had a census of 79 residents. The sample included two kitchens and 18 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 79 residents who resided in the facility and received their meals from the kitchen. Findings included: - On 12/06/23, review of the noon meal consisted of roast beef, buttered noodles, seasoned squash, dinner roll, and assorted deserts. On 12/06 /23 at 10:56 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/29/23 at 04:25 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had completed the course, failed the test and had to wait six months to repeat the class. On 12/6/23 at 12:30 PM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. On 12/07/23 at 12/05/23 at 8:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 12/07/23 at 09:10 AM, Dietary Staff BB verified she worked at the facility for 24 years and was not a certified Dietary Manager. Dietary Staff BB stated they do not have any pureed or mechanical soft diet. On 12/11/23 at 2:00 PM, Administrative Staff A verified Dietary Staff BB was not certified. The Facility's Director of Food and Nutrition Services dated 2021 documented the director of food and nutrition services is responsible for all aspects of the food and nutrition services department including but not limited to food safety, cost management, and meeting nutritional need of the residents served. The director of food and nutrition services would be qualified according to the position's job description and guidelines put forth by the agency that regulates the facility. A facility that does not have a full-time dietician (registered dietician nutritionist or RDN) or clinically qualified nutritional professional must designate a person to serve as director of food and nutrition services. The director of food and nutrition services would be a certified dietary manager (CDM) or is a certified food service manager or has similar national certification for food service management and safety from an national certifying body or has an associate's or higher degree in food service management or in hospitality, if the course study includes food services or restraint management from an accredited intuition of higher learning and states that have established standards for food service managers or dietary managers, must meet state requirements for food service managers or dietary managers. The director of food and nutrition services would carry out his/her daily activities according to the job description, work schedule, and list of duties. The facility failed to employ a full time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 79 residents and two kitchens in the facility, placing the residents at risk for inadequate nutrition.

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for all the residents who received their meals from the facility's two kitchens. This placed all residents at risk for food borne illness. Findings included: - On 12/05/23 at 08:27AM observation in the first of two kitchens revealed the following: The walk-in refrigerator had a cracked eggshell, an approximately one-half inch(in) by three in. wide piece of plastic wrap on the floor, and numerous different size pieces of paper underneath the bottom shelf. The white chest freezer had approximately one-quarter in. of ice around all the inside and had numerous different sized, dried brown, liquid stains on the bottom. The counter ice machine located at the entrance to the kitchen had numerous different size brown specks of food particle in and around the tray. On 12/06/23 at 10:22 AM, observation revealed in the kitchen the following: The wall behind the ovens located below the oven hood had, approximately six in by eight ft long, had numerous different size dried brown stains. Underneath the three-sink area a five-gallon bucket of concentrated pot and pan detergent had numerous different size food particles with brown dried substance. The pipes, approximately five feet long, located underneath the three-sink area had numerous different size blackish substance on them. The floor ice machine vents located in the dishwashing area had, approximately 12 in by 18 in, gray fuzzy substance throughout them. The four-square ceiling vents, approximately 18 inches in diameter, had gray fuzzy substance around them which flared out approximately 12 in in each corner. The outside of the two oven doors and bottom foot plates had numerous different size brown dried liquid substance and the handles, and the outside had white powdery substance. The two-shelf cart located by the oven had numerous different sized white powdery substance and white dried liquid. The walk-in refrigerator had a cracked egg with the top piece missing, which showed the yellow yoke and clear liquid placed in the pasteurized egg cartons with other eggs. The two fluorescent lights located above the prep table where the spices were had burnt out bulbs. The three fluorescent light frames, located next to the oven hood, had gray fuzzy particles all around them and the third one, located closest to the dishwashing area, had burnt out light bulbs. The counter toaster located next to stove top had numerous different size crumbs and gray greasy substance on the top and sides of it and the tray the toaster sat in had the same. The exchange air vent, approximately three feet (ft) by two ft, located by the dietary manager's office, had gray fuzzy particles throughout. The perimeter of the kitchen floor, approximately four inches wide and the mopboard had numerous different size blackish substance. The metal sharp knife container, fastened to the two-door white lower cabinet located on the wall across from the steam table, had numerous different size brownish black substance. The white bottom cabinet doors located on the wall across from the steam table, had numerous different size dried pink and brown liquid. Four (one gallon) plastic containers full of water, located underneath the steam table had grayish black substance all around the outside of each one. The wall underneath the dishwasher area approximately six ft long by three ft high had numerous different size blackish substance. The shelf and the legs which held up the dishwasher counter, where the dirty dishes were placed were rusted and the bottom shelf, had a hole in the middle approximately eight in long by four in. wide. The Daily Cleaning Duty Sheet, listed task for the morning and evening staff to complete daily. On 12/06/23 at 11:59 AM, Dietary Manager (DM) BB verified all the issues in the kitchen and stated the kitchen staff had a cleaning schedule, but it did not always get done. - On 12/05/23 at 09:00 AM, during initial tour, observation in the second of two facility kitchens revealed the following: One 16-inch oscillating table fan located on the cabinet top blowing air on the food preparation table. The metal fan mesh cover had gray fuzzy substance covering the metal and the three fan blades. Two 4-foot by 3 -foot ceiling mounted heater and air conditioning units, located on each side of the range hood and blowing air directly across the food preparation area. The air vent grills were rusted and covered with a brown greasy/sticky substance and gray fuzzy substance. On 12/06/23 at 12:30 PM, Dietary Staff (DS) CC verified the dirty fan, and the overhead heater/air units with dirty register/vents. The facility's General Sanitation of the Kitchen policy, dated 2021, documented the food and nutrition staff would maintain the sanitization of the kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitization tasks for the kitchen would be outlined in a written cleaning schedule and tasks would be assigned the responsibility of specific positions. The employee would train on how to perform the cleaning task and employees would initial and date tasks when completed. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 79 residents residing in the facility, who received meals from the facility kitchens.

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

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

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The facility had a census of 79 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) 2023 Quarter 1 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (5) dates. Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 12/06/23 at 08:30AM, observation revealed a registered nurse on duty in the facility. On 12/07/23 at 01:00PM, Administrative Staff (AS) A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Reporting Payroll Based Data Journal policy, dated 12/01/2019, states complete, and accurate direct care staffing information is to be reported electronically and, in the uniform, specified by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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The facility had a census of 79 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide infection control measures for residents' oxygen tubing when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections. Findings included: - Upon request, the facility was unable to provide evidence the facility assessed risks and implemented a surveillance plan to identify and prevent Legionella (prevent Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other opportunistic waterborne pathogens. On 12/05/23 at 08:45 AM, observation in R32's room revealed her uncovered oxygen tubing coiled up on the oxygen canister with the nasal canula touching the back of the tubing. On 12/05/23 at 10:48 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/06/23 at 07:37 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/07/23 at 07:38 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/07/23 at 12:55 PM, observation in R32's room revealed her uncovered oxygen tubing coiled up on the oxygen canister with the nasal canula touching the back of the tubing. On 12/07/23 at 01:01 PM, Administrative Nurse D verified the above finding at 12:55 PM and stated she was just in there and had not noticed it being uncovered. Administrative Nurse D stated staff should place R32's oxygen tubing and nasal canula in the bag on the front of the oxygen canister, with the breathing treatment mask. Administrative Nurse D started to place the oxygen tubing into the bag. When asked by the surveyor, Administrative Nurse D stated she probably should get a new one and placed the tubing into the trash can. On 12/11/23 at 10:00 AM, Administrative Nurse D stated nasal cannulas should be bagged when not in use. On 12/11/23 at 10:59 AM, Administrative Staff A stated the facility had nothing in place prior to now to prevent Legionella or other water borne illnesses in the water system. The Infection Prevention and Control policy, dated 08/15/22, stated a water management program had been established and control measures and testing protocols were in place to address potential hazards associated with the facility's water system. The maintenance Director would serve as the leader of the water management program. The policy stated the facility would conduct an annual review of the infection control program including policies and procedures. The facility's Oxygen Concentrator policy, dated 10/01/20, stated oxygen was administered under the orders of the physician. The policy stated staff would keep delivery devices covered in plastic bag when not in use. The facility failed to provide infection control measures for residents' oxygen nasal cannulas when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections.

Sept 2023 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 F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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The facility identified a census of 42 residents with seven residents reviewed for restorative therapy. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1, R2, R3, and R4. with the restorative therapy services to maintain or improve mobility with the maximum practicable independence. The deficient practice placed R1, R2, R3, and R4 at risk for an avoidable decline in range of motion and mobility. Findings included: - R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle wasting and atrophy (wasting or decrease in size of a part of the body), and unsteadiness of feet. R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R1 required supervision with set up help only for bed mobility, transfer, ambulation, locomotion, eating and personal hygiene. R1 require one staff limited assistance for dressing, toileting, and bathing. Staff were directed to provide R1 with restorative nursing services: active range of motion (AROM), bilateral upper extremity strengthening in a sitting position moving in all planes with one pound dumbbells or red t-band, balance task of tossing bean bags or ball in a standing position with front wheeled walker at contact guard assist, and retrieve items from the floor with front wheeled walker at contact guard assist three to six times a week. R1's Electronic Medical Record (EMR) documented R1 had zero minutes of restorative therapy from 08/20/23 thru 09/18/23. R2 had diagnoses of dementia, muscle wasting and atrophy, and unsteadiness of feet. R2 had a BIMS score of seven which indicated severe cognitive impairment. R2 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. Staff were directed to provide R2 with restorative nursing services: AROM and Walk to Dine. R2's EMR documented R2 had zero minutes of restorative therapy from 08/20/23 thru 09/18/23. R3 had diagnoses of dementia, muscle wasting and atrophy, and unsteadiness of feet. R3 had a BIMS score of fourteen which indicated intact cognition. R3 required limited to extensive assistance for all activities of daily living with the exception of eating. Staff were directed to provide R3 with restorative nursing services: ambulate R3 with front wheeled walker as far as she can go, therapeutic exercise for bilateral lower extremities strengthening with resistance, and NuStep (exercise equipment) for five to ten minutes three to six times a week. R3's EMR documented R3 had zero minutes of restorative therapy from 08/20/23 thru 09/18/23. R4 had diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), weakness, and hypertension (high blood pressure). R4 had a BIMS score of fifteen which indicated intact cognition. R4 was independent with all activities of daily living. Staff were directed to provide R4 with restorative nursing services: bilateral upper extremity AROM with over the door pulley, bilateral upper extremity strengthening times ten to fifteen reps with red t-band or one pound dumbbells moving in all planes, ambulate outside on uneven surfaces with four wheeled walker, resisted ambulation with two to five pound cuff weights with four wheeled walker indoors, lower extremity strengthening times ten to fifteen reps with three to four pounds, and NuStep at level three to five for ten to twenty minutes. R4's EMR documented R4 has zero minutes of restorative therapy from 08/20/23 thru 09/18/23. On 09/18/23 at 10:00 AM, Certified Nurse's Aide (CNA) M stated that there was not enough time and staff in the day to perform restorative nursing services. CNA M stated all of the CNAs were rotated through to perform restorative nursing but since the schedule had changed all of the CNAs had to be working on the floor and there was no time for restorative. On 09/18/23 at 10:15 AM, Certified Medication Aide (CMA) R stated the residents were not getting restorative therapy like they had previously been when the staff was different. CMA R stated she could see a difference in the residents physical well-being. On 09/18/23 at 10:30 AM, Administrative Nurse D stated that there was always a restorative nurse working on the floor and from 06:00 AM to 09:00 AM the restorative aide would assist getting residents up and then would provide restorative nursing services unless they got re-assigned to work on the floor due to call ins. On 09/18/23 at 01:00 PM, Therapy GG stated that the facility did not have any kind of restorative program or restorative nursing. Therapy GG stated when a resident came off of therapy it did no good to write a restorative program for the resident to maintain their progress from therapy because restorative nursing services were not being done. On 09/18/23 at 01:30 PM, Administrative Staff A stated she felt that the restorative aides were not charting the services they provided. The Restorative Nursing Program Policy, dated 02/01/20, documented it is the policy of the facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic or maintenance restorative nursing care that does not required the use of a qualified therapist or licensed nurse for oversight. This training may include, but is not limited to: maintaining proper positioning and body alignment, encouraging and assisting residents, as needed in turning and position changes, encouraging residents to remain active and assisting with exercises according to the plan of care, and assisting resident with range of motion exercises, performing passive range of motion for residents unable to actively participate. Residents will receive maintenance restorative nursing services as described above as deemed necessary by certified nurse's aides or designated restorative aide. A resident's Restorative Nursing plan will include: the type of activities to be performed and the frequency of activities. The discharging therapist, Restorative Coordinator, or designated licensed nurse will communicate to the appropriate restorative aide, the provisions of the resident's restorative plan, providing any necessary training to carry out the plan. Restorative aides will implement the plan for a designated period of time, performing the activities and documenting the activities in the EMR. The facility failed to provide R1, R2, R3, and R4. with the restorative therapy services to maintain or improve mobility with the maximum practicable independence. The deficient practice placed R1, R2, R3, and R4 at risk for an avoidable decline in range of motion and mobility.

Mar 2022 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic (medication to promote the formation and excretion of urine) daily. The Pressure Ulcer/Injury Care Area Assessments (CAA), dated 12/12/21, documented the resident was at risk for the potential development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), related to impaired mobility, presence of bilateral lower extremity edema (swelling resulting from an excessive accumulation of fluid in the body tissues), secondary to her multiple health diagnosis and comorbidities (presence of two or more diseases or medical conditions) as listed in her medical record. The record lacked a comprehensive care plan. The Physician Order, dated 02/24/22, directed staff to administer Coumadin (an anticoagulation medication) 4 milligrams (mg) by mouth in the evening every Tuesday, Thursday, and Saturday, and Coumadin 3 mg in the evening every Monday, Wednesday, Friday, and Sunday. The Progress Note, dated 03/11/22 at 04:50 PM, documented R22 reported pain in her right inner shin and was noted to have a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). The Progress Note, dated 03/11/22 at 11:03 PM, documented a certified nurse aid (CNA) called the nurse into R22's room at bedtime to look at the resident's right leg. The nurse had previously reported a hematoma and reassured R22 that staff did know about the hematoma and encouraged the resident to elevate her legs to offset swelling. The Progress Note, dated 03/15/22 at 11:42 AM, documented R22 had a fluid filled blister to her right inner leg and the resident reported pain. The note further documented the blister looked as if would pop within the week and had applied a pad to protect the area. The Weekly Skin Assessment, dated 03/08/22, documented the upper extremities had generalized bruising and her feet had been purple. No documented skin assessment completed as of 03/16/22. R22's medical record lacked physician notification of the fluid filled blister to her right shin. On 03/15/22 at 08:12 AM, observation revealed R22 seated in her recliner. R22 had an area approximately four inches long and two inches wide of clear to yellowish fluid filled blister to her right shin. On 03/15/22 at 08:12 AM, R22 stated she had a blister on her right leg and she had occasional pain to the area. On 03/16/22 at 03:06 PM, Administrative Nurse D reported the nursing staff should do weekly assessments on all the residents. The staff should have reported the skin issue to the residents' physician on 03/11/21 at the onset of the blister/hematoma. The facility's Skin Assessments policy, dated January 2022, documents all residents will have a skin assessment completed at least once a week by the charge nurse. All assessments will be completed and documented by a licensed nurse. Upon request the facility failed to provide a physician notification policy. The facility failed to notify the physician upon onset of a blister to the right lower extremity of R22, placing the resident at risk of further complications to skin. The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review and interview, the facility failed to notify the physician of low blood pressures for Resident (R) 121, and a large fluid filled blister on the right lower leg of R22. This placed the residents at risk for worsening conditions and inadequate cares and treatments. Findings included: - The Physician Order Sheet, dated 03/01/22, recorded R121 had diagnoses of coronary artery disease (abnormal condition characterized by dysfunction of the heart and blood vessels), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and hypotension (low blood pressure). R121's Quarterly Minimum Data Set (MDS), dated 01/17/22, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and no behaviors. The MDS documented R121 required extensive staff assistance with dressing, personal hygiene, limited staff assistance with transfers, walking, and received oxygen therapy. The Medication Care Plan, dated 02/03/22, recorded R121 had diagnoses of coronary artery disease, congestive heart failure, hypotension, and directed staff to administer cardiac medications as ordered by the physician. The Medication Care Plan, directed staff to monitor R121's blood pressure daily and report abnormal readings to the physician. The Physician's Order, dated 02/06/22, directed staff to check R121's blood pressure every day, and notify the physician if the diastolic blood pressure (DBP-bottom number: force of blood flow against artery walls) less than 60. The February 2022 Medication Administration Record (MAR) recorded R121 had four diastolic blood pressures less than 60. The March 2022 Medication Administration Record (MAR) recorded R121 had three diastolic blood pressures less than 60. Review of R121's medical record lacked documentation staff notified the physician about the seven occurrences R121's blood pressure was below physician ordered parameters. On 03/16/22 at 07:40 AM, observation revealed R121 sat in her wheelchair with oxygen in place per a portable tank and staff propelled the resident to the shower room. On 03/16/22 at 10:17 AM, Licensed Nurse (LN) H stated R121 was on continuous oxygen and had a fluid restriction related to her congestive heart failure. LN H stated staff checked R121's blood pressure every day and should report abnormal findings to the physician. On 03/16/22 at 10:07 AM, Administrative Nurse D stated staff should check R121's blood pressure daily and report the resident's blood pressures below the parameters as ordered by the physician. Upon request the facility was unable to provide a policy for physician notification. The facility failed to notify the physician of R121's low blood pressures, placing the resident at risk for continued low blood pressures and adverse medication side effects.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 77 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 22 placing the resident at risk for improper care and continued skin injury. Findings included: - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic (medication to promote the formation and excretion of urine) daily. The Pressure Ulcer/Injury Care Area Assessments (CAA), dated 12/12/21, documented the resident was at risk for the potential development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), related to impaired mobility, presence of bilateral lower extremity edema (swelling resulting from an excessive accumulation of fluid in the body tissues), secondary to her multiple health diagnosis and comorbidities (presence of two or more diseases or medical conditions) as listed in her medical record. The Baseline Care Plan lacked focus, goals, and intervention for skin care. The record lacked a comprehensive care plan. The Physician Order, dated 02/24/22, directed staff to administer Coumadin (an anticoagulation medication) 4 milligrams (mg) by mouth in the evening every Tuesday, Thursday, and Saturday, and Coumadin 3 mg in the evening every Monday, Wednesday, Friday, and Sunday. The Progress Note, dated 03/11/22 at 04:50 PM, documented R22 reported pain in her right inner shin and was noted to have a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). On 03/15/22 at 08:12 AM, observation revealed R22 seated in her recliner. R22 had an area approximately four inches long and two inches wide of clear to yellowish fluid filled blister to her right shin. On 03/16/22 at 03:06 PM, Administrative Nurse D verified a comprehensive care plan had not been completed directing staff how to care for R22. The facility's Care Plan Development and Revision policy dated February 2022, recorded a comprehensive plan of care will be developed by the interdisciplinary team and the resident in order to meet the resident's medical, nursing, mental, and psychosocial needs. Using the results of the comprehensive admission assessment, the interdisciplinary team together with the resident will develop a comprehensive plan of care which will outline the services the facility is to furnish to meet the residents medical, nursing, mental, and psychosocial needs. Such care plan will be developed within seven days after the completion of the comprehensive assessment. The facility failed to develop a comprehensive care plan for R22, placing the resident at risk for further skin issues and improper care.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 77 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to complete the weekly skin assessment to document Resident (R) 22's skin condition which developed on 03/11/22. This placed the resident at risk for further skin issues. Findings included: - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic (medication to promote the formation and excretion of urine) daily. The Pressure Ulcer/Injury Care Area Assessments (CAA), dated 12/12/21, documented the resident was at risk for the potential development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), related to impaired mobility, presence of bilateral lower extremity edema (swelling resulting from an excessive accumulation of fluid in the body tissues), secondary to her multiple health diagnosis and comorbidities (presence of two or more diseases or medical conditions) as listed in her medical record. The record lacked a comprehensive care plan. The Physician Order, dated 02/24/22, directed staff to administer Coumadin (an anticoagulation medication) 4 milligrams (mg) by mouth in the evening every Tuesday, Thursday, and Saturday, and Coumadin 3 mg in the evening every Monday, Wednesday, Friday, and Sunday. The Weekly Skin Assessment, dated 03/08/22, documented R22's upper extremities had generalized bruising and her feet had been purple. No documented skin assessment completed as of 03/16/22. The Progress Note, dated 03/11/22 at 04:50 PM, documented R22 reported pain in her right inner shin and was noted to have a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma). The Progress Note, dated 03/11/22 at 11:03 PM, documented a certified nurse aide (CNA) called the nurse into R22's room at bedtime to look at the resident's right leg. The nurse had previously reported a hematoma, reassured R22 that staff did know about the hematoma, and encouraged the resident to elevate her legs to offset swelling. The Progress Note, dated 03/15/22 at 11:42 AM, documented R22 had a fluid filled blister to her right inner leg and the resident reported pain. The note further documented the blister looked as if it would pop within the week and had applied a pad to protect the area. R22's medical record lacked physician notification of the fluid filled blister to her right shin. On 03/15/22 at 08:12 AM, observation revealed R22 seated in her recliner. R22 had an area approximately four inches long and two inches wide of clear to yellowish fluid filled blister to her right shin. On 03/16/22 at 03:06 PM, Administrative Nurse D reported the nursing staff should do weekly assessments on all residents. The staff should have reported the skin issue to the residents' physician on 03/11/21 at the onset of the blister/hematoma. The facility's Skin Assessments policy, dated January 2022, documents all residents will have a skin assessment completed at least once a week by the charge nurse. All assessments will be completed and documented by a licensed nurse. Upon request the facility failed to provide physician notification policy. The facility failed to complete the weekly skin assessment to document Resident (R) 22's skin condition which developed on 03/11/22.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R4's Physician Order Sheet (POS), dated 03/11/22, documented diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement), major depressive disorder, single episode (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (group of thinking and social symptoms that interferes with daily functioning). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and a mood score of one. The MDS documented R4 was independent with eating and required extensive staff assistance for all other activities of daily living (ADLs). The MDS documented R4 received antipsychotic medications (medication used to treat major emotional conditions and mental illness) seven days of the lookback period. The MDS documented the physician stated a gradual dose reduction (GDR) of the antipsychotic was contraindicated. The Medication Care Plan, dated 12/03/21, documented R4 used Seroquel (antipsychotic medication) related to depression. The Care Plan directed staff to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness, consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) documented antipsychotic drugs increased the risk of death in elderly patients with dementia-related psychosis (mental disorder characterized by a disconnection from reality). Seroquel was not approved for the treatment of patients with dementia-related psychosis. The Physician's Order, dated 08/21/20, directed staff to administer Seroquel 25 milligrams (mg), at bedtime, for depression. The Pharmacist Drug Regimen Review, dated 09/11/20, requested an appropriate diagnosis for the use of Seroquel and documented only extended release Seroquel to be used with resistant depression. The physician responded with depression as the diagnosis. The Pharmacist Drug Regimen Review, dated 02/05/21, recommended a GDR of Seroquel 25 mg at bedtime. The physician declined the recommendation and wrote well controlled on this dose. The Pharmacist Drug Regimen Review, dated 03/20/21, documented R4 received Seroquel at bedtime for depression without an accompanying antidepressant and in the absence of an appropriate diagnosis. The report stated Seroquel was approved as adjunct (in addition) therapy of depression, but no antipsychotic was approved as monotherapy (main therapy) in major depressive disorder. Consider adding an antidepressant and in four weeks reduce the dose of Seroquel. The physician declined and wrote This works well for him; nurses report no adjustment needed. Review of the Pharmacist Drug Regiment Reviews revealed no further recommendations regarding the inappropriate use of Seroquel. On 03/15/22 at 12:11 PM, observation revealed Certified Medication Aide (CMA) R administered Parkinson's medication to R4, who took the medications whole, with water and without problems. On 03/17/22 at 10:15 AM, Administrative Nurse E verified the physician had not followed the pharmacist's recommendation for an appropriate diagnosis for the continued use of Seroquel. The facility's Psychotropic Medication Use policy, dated January 2022, documented the physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors which the staff will monitor. The attending physician must certify that a psychotropic medication is necessary to treat a specific condition/behavior. The facility failed to follow the consultant pharmacist recommendations regarding the use of Seroquel without an appropriate diagnosis. The facility had a census of 77 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist's recommendations were addressed by the facility and physician for a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for Resident (R) 21 and provide an appropriate diagnosis for an antipsychotic medication (medication used to treat major emotional conditions and mental illness) for R4. This placed the residents at risk to receive unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 03/03/22, recorded R21 had diagnoses of depression (mental health disorder characterized by a persistent depressed mood, causing impairment of daily life), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R21 had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) and no behaviors. The MDS recorded R21 required limited staff assistance with most activities of daily living (ADLs), received antidepressant medication (medications used to treat mood disorders and relieve symptoms of depression), opioids (narcotic medication used to treat moderate to severe pain), and antianxiety medication (medication used to calm and relax people with excessive anxiety, nervousness and tension). The Medication Care Plan, dated 01/16/22, directed staff to administer R21's medications as ordered by the physician, and monitor the medications for effectiveness, and/or adverse side effects. The Medication Care Plan recorded the consultant pharmacist reviewed R21's medication regimen monthly and made recommendations to ensure appropriate use of the resident's medications. The Physician's Order, dated 02/16/22, directed staff to administer Ativan (antianxiety medication) 0.5 milligrams (mg) every six hours PRN to R21 for anxiety. The Pharmacist Medication Review, dated 02/22/22, recorded Ativan 0.5 mg every six hours PRN required a 14 day stop date or a physician's rationale for extended use. Review of R21's medical record lacked documentation the PRN Ativan had a 14 day stop date or a physician's rationale for extended use. On 03/15/22 at 08:21 AM, observation revealed R21 sat in her wheelchair in the hall and visited with another resident and staff. On 03/17/22 at 10:40 AM, Administrative Nurse D stated the consultant pharmacist completed a recommendation for a 14 day stop date or physician's rationale for continued use on 02/22/22 for R21's PRN Ativan. Administrative Nurse D stated the facility lacked documentation staff sent the pharmacist recommendation to the physician and/or the physician responded. The facility's Pharmacist Medication Review policy, dated 12/01/07, recorded the pharmacist would ensure appropriate 14 day stop dates or rationales for extended use for PRN psychotropic medications, make recommendations to monitor medication effectiveness, and report irregularities to the physician, medical director and DON. The facility failed to ensure a 14 day stop date or a physician's rationale for extended use for R21's PRN psychotropic medication, placing the resident at risk to receive unnecessary psychotropic medications and adverse medication side effects.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R4's Physician Order Sheet (POS), dated 03/11/22, documented diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement), major depressive disorder, single episode (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (group of thinking and social symptoms that interferes with daily functioning). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and a mood score of one. The MDS documented R4 was independent with eating and required extensive staff assistance for all other activities of daily living (ADLs). The MDS documented R4 received antipsychotic medications (medication used to treat major emotional conditions and mental illness) seven days of the lookback period. The MDS documented the physician stated a gradual dose reduction (GDR) of the antipsychotic was contraindicated. The Medication Care Plan, dated 12/03/21, documented R4 used Seroquel (antipsychotic) related to depression. The Care Plan directed staff to administer psychotropic medications as ordered by the physician, monitor for side effects and effectiveness, consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) documented antipsychotic drugs increased the risk of death in elderly patients with dementia-related psychosis (mental disorder characterized by a disconnection from reality). Seroquel was not approved for the treatment of patients with dementia-related psychosis. The Physician's Order, dated 08/21/20, directed staff to administer Seroquel 25 milligrams (mg), at bedtime, for depression. The Pharmacist Drug Regimen Review, dated 03/20/21, documented R4 received Seroquel at bedtime for depression without an accompanying antidepressant and in the absence of an appropriate diagnosis. The report stated Seroquel was approved as adjunct (in addition) therapy of depression, but no antipsychotic was approved as monotherapy (main therapy) in major depressive disorder. Consider adding an antidepressant and in four weeks reduce the dose of Seroquel. The physician declined and wrote This works well for him; nurses report no adjustment needed. On 03/15/22 at 12:11 PM, observation revealed Certified Medication Aide (CMA) R administered Parkinson's medication to R4, who took the medications whole, with water and without problems. On 03/17/22 at 10:15 AM, Administrative Nurse E verified the physician had not followed the pharmacist's recommendation for an appropriate diagnosis for the continued use of Seroquel. The facility's Psychotropic Medication Use policy, dated January 2022, documented the physician's order for a psychotropic drug will include both a qualifying diagnosis for the drug and a list of specific target behaviors which the staff will monitor. The attending physician must certify that a psychotropic medication is necessary to treat a specific condition/behavior. The facility failed to ensure R4 did not receive unnecessary antipsychotic drugs when the physician ordered an antipsychotic drug without an appropriate diagnosis, placing R4 at risk for adverse side effects of the drug. The facility had a census of 77 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for Resident (R) 21 and provide an appropriate diagnosis for an antipsychotic medication (medication used to treat major emotional conditions and mental illness) for R4. This placed the residents at risk to receive unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 03/03/22, recorded R21 had diagnoses of depression (mental health disorder characterized by a persistent depressed mood, causing impairment of daily life), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R21 had a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact) and no behaviors. The MDS recorded R21 required limited staff assistance with most activities of daily living (ADLs) and received antidepressant medication (medications used to treat mood disorders and relieve symptoms of depression), opioids (narcotic medication used to treat moderate to severe pain), and antianxiety medication (medication used to calm and relax people with excessive anxiety, nervousness and tension). The Medication Care Plan, dated 01/16/22, recorded R21 had a recent increase in anxiety behaviors related to more confusion, trouble sleeping and concerns about her health status. The Medication Care Plan directed staff to administer R6's medications as ordered by the physician, and monitor the medications for effectiveness, and/or adverse side effects. The Physician's Order, dated 02/16/22, directed staff to administer Ativan (antianxiety medication) 0.5 milligrams (mg) every six hours PRN to R21 for anxiety. The Pharmacist Medication Review, dated 02/22/22, recorded Ativan 0.5 mg every six hours PRN required a 14 day stop date or physician's rationale for extended use. Review of R21's medical record lacked documentation the PRN Ativan had a 14 day stop date or physician's rationale for extended use. On 03/15/22 at 08:21 AM, observation revealed R21 sat in her wheelchair in the hall and visited with another resident and staff. On 03/16/22 at 09:17 AM, Licensed Nurse (LN) H stated R21 had recent increased confusion, anxiety, behaviors, and staff administered PRN Ativan and assessed the effectiveness of the medication. On 03/17/22 at 10:40 AM, Administrative Nurse D stated the facility had not addressed R21's PRN psychotropic medications without a 14 day stop date or physician's rationale for extended use. The facility's Psychotropic Medication policy, dated January 2022, directed staff to ensure PRN psychotropic medications had a 14 day stop date, or a physician's rationale for extended use. The facility failed to ensure a 14 day stop date or physician's rationale for extended use for R21's PRN psychotropic medication, placing the resident at risk to receive unnecessary psychotropic medications and adverse medication side effects.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 77 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 40 and R25. This placed R40 and R25 at risk for inappropriate end of life cares. Findings included: - R40's Physician Order Sheet, dated 02/10/22, revealed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion.) R40's Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R40 had severely impaired cognition. The MDS recorded she required extensive two staff assistance with bed mobility and transfers and received hospice services. The Activities of Daily Living (ADL) Care Plan, dated 01/22/22, recorded R40 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, hygiene and limited assistance with eating. The Care Plan documented the resident was admitted to hospice for a terminal prognosis of senile dementia (progressive mental deterioration characterized by confusion and memory failure) and received hospice services. Review of R40's Care Plans revealed the resident was admitted to hospice care on 06/24/21, with no evidence of coordination of care between hospice and the facility. On 03/15/22 at 08:45 AM, observation revealed R40 sat in a wheelchair chair at the dining room table with staff assisting the resident to eat her breakfast. On 03/15/22 at 01:45 PM, Administrative Nurse D stated she expected the facility to have a hospice care plan for R40 to be able to coordinate care with hospice services. Administrative Nurse D verified the facility lacked a hospice care plan for R40 since her admission to hospice 06/24/21. The facility's Hospice Care Plan policy, dated April 17, 2018, documented hospice is palliative care and provides services to Medicare and Medicaid eligible residents of the agency. The policy documented hospice would provide services to the resident in accordance with the hospice care plan as developed and amended from time to time by hospice. The policy documented Hospice retains professional management responsibilities for all hospice services including the hospice care plan shall be develop, at the time an eligible resident is admitted into the Hospice program, and a hospice care plan for the management and palliation of the resident's terminal illness. The hospice care plan would be developed in cooperation with the interdisciplinary care team of the agency. The hospice care plan is a written document which includes a written and detailed description of the services and supplies necessary to provide palliative care for the resident, and hospice would furnish a copy of this plan for each resident at the time of hospice admission. The hospice care plan would be updated at least every 15 days and a copy of the updated plan shall be furnished to the facility. The policy documented hospice agrees to provide all drugs and pharmaceuticals related to the management of the terminal illness and which are specified in the hospice care plan for an eligible resident. The policy documented if an eligible residents' hospice care plan specifies the need for medical equipment and medical supplies which are not ordinarily provided by the facility to its residents nor included in the base room and board charge, then Hospice shall assist the patient in securing such medical equipment and supplies. The facility failed to coordinate care between themselves and hospice services for R40, who received hospice services, placing her at risk for inappropriate end of life care. - R25's Physician Order Sheet (POS), dated 02/10/22, documented diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement), chronic pain, recurrent major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and adult failure to thrive (a state of decline that may be caused by chronic ongoing diseases). The Significant Change Minimum Data Set (MDS), dated [DATE], was in process and documented R25 received hospice services. The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R25 was independent for eating, required extensive assistance of two staff for all other activities of daily living, no range of movement impairment, and used a wheelchair. The MDS documented R25 received scheduled and as needed (PRN) pain medication and reported almost constant pain at a level of nine. The facility care plan, dated 12/28/21 lacked any mention of hospice services. The Physician's Order, dated 02/25/22, directed staff to obtain a hospice consult. The Physician's Order, dated 02/28/22, documented admit to hospice services with a diagnosis of Parkinson's Disease. On 03/16/22 at 01:05 PM, Certified Medication Aide (CMA) S and CMA T assisted R25 from his wheelchair to his bed using the total lift. Staff gently transferred him and his expression did not change. As he laid on the bed, he frowned, but did not speak. On 03/15/22 at 01:35 PM, Consultant GG stated the hospice care plan was in the chart under miscellaneous. She stated the facility care plan should include hospice services as it is important to coordinate between the two. On 03/17/22 at 09:45 AM, Administrative Nurse E verified the facility's care plan had not included hospice services and should so staff would be aware of what hospice would provide for R25. The facility's Hospice Care Plan policy, dated April 17, 2018, documented hospice is palliative care and provides services to Medicare and Medicaid eligible residents of the agency. The policy documented hospice would provide services to the resident in accordance with the hospice care plan as developed and amended from time to time by hospice. The hospice care plan would be developed in cooperation with the interdisciplinary care team of the agency. The hospice care plan is a written document which includes a written and detailed description of the services and supplies necessary to provide palliative care for the resident, and hospice would furnish a copy of this plan for each resident at the time of hospice admission. The hospice care plan would be updated at least every 15 days and a copy of the updated plan shall be furnished to the facility. The policy documented if an eligible residents' hospice care plan specifies the need for medical equipment and medical supplies which are not ordinarily provided by the facility to its residents nor included in the base room and board charge, then hospice shall assist the patient in securing such medical equipment and supplies. The facility failed to coordinate care between themselves and hospice services for R25 who received hospice services, placing him at risk for inappropriate end of life care.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for three residents. This placed the residents at risk for not receiving adequate nutrition and choking. Findings included: - On 03/15/22 at 11:40 AM, observation revealed Dietary Staff (DS) BB (Dietary Manager) prepared a pureed diet. DS BB placed three slices, approximately three ounces (oz) of pork loin into a blender. DS BB blended the pork loin, added some of the meat broth (not measured), and emptied the pork into a storage bowl in the warming well. Further observation revealed DS BB placed three, 1/2 cup servings of spinach into a blender with some spinach juice (not measured), blended the spinach to the correct texture, emptied the spinach into the storage bowl, and placed into the warming well. Continued observation revealed DS BB place three 2 by 2-inch slices of butterscotch cookie bars and some milk (not measured) into a blender, blended the dessert, placed into three separate bowls, and stored in the refrigerator. On 03/15/22 at 02:30 PM, DS BB stated she did not follow a pureed recipe and stated she just blended it and added broth or milk to make it pureed. On 03/17/22 at 10:30 AM, Administrative Nurse E verified dietary staff are expected to use a pureed recipe when preparing a pureed diet. The facility's undated Pureed Diet Order policy, documented all resident's requiring a pureed/blended diet have a physician order for pureed foods. The policy documented the Dietary Manager would prepare a care plan to reflect the modification in consistency. The pureed policy documented the staff would follow the facilities policies/procedures, such as puree volume method procedures, to ensure a correct portion is served and pureed foods with appropriate sauces or gravies, as needed to ensure adequate moisture for safe consumption and enhanced flavor. The facility failed to prepare a pureed diet using professional standards to maintain nutritive value for the three residents who had a physician order for pureed texture, placing the residents at risk for not receiving adequate nutrition, and potential for choking.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 77 residents in the facility, who received their meals from one of the two facility kitchens. This placed the residents at risk for foodborne illness. Findings included: - On 03/14/22 at 9:00 AM, during initial tour, observation revealed the following: One - 16-inch Oscillating table fan located on the cabinet top blowing air on the food preparation table. The metal fan mesh cover had gray fuzzy substance covering the metal and the three fan blades. Six - 12 inches x 3 foot fluorescent lights, located above the food preparation area, with the plastic light covers covered with a brownish gray fuzzy substance. Two - 4 foot x 3 foot ceiling mounted heater and air conditioning units, located on each side of the range hood and blowing air directly across the food preparation area. The air vent grills covered with a brown greasy/sticky substance and gray fuzzy substance. On 03/15/22 at 02:30 PM, Dietary Staff (DS) BB verified the dirty fan, the overhead fluorescent light fixture covered with lint, and the overhead heater/air units with dirty register/vents. The facility's Kitchen Preventative Maintenance policy, dated March 2022, documented the facility would conduct preventative maintenance on kitchen equipment, structures, and finished routinely, and as needed. All routine preventative maintenance would be documented, signed by maintenance and such records would be retained. The facility failed to prepare, store, distribute and serve food under sanitary conditions for the 77 residents residing in the facility, who received meals from one of the two facility kitchens.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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The facility had a census of 77 residents. The sample included 18 residents. Based on observation, interview and record review, the facility failed to use a proper disinfection agent on the facility's multi use glucometer (an instrument which measures the amount of glucose (sugar) in your blood). This placed the residents in one of two facility buildings at risk for blood borne pathogens (any organism that can produce disease) when staff obtained blood sugar tests of residents. Findings included: - On 03/16/22 at 11:41 AM, observation revealed Licensed Nurse (LN) I obtained a blood sugar test from Resident (R) 173. After checking the blood sugar, she laid the glucometer on top of the medication cart and went on to do other things. Further observation revealed LN I used Clorox wipes with ammonium chloride, not bleach, to disinfect the glucometer. On 03/16/22 at 11:45 AM, LN I stated the two facility Evencare G2 glucometers were used for any resident needing accuchecks and stated if she needed to use the glucometer for another person she would clean it with Clorox wipes. The facility could not locate the manufacturer's instruction booklet. Clorox Disinfecting Wipes are proven to kill COVID 19 Virus* in 15 seconds; cleans and kills 99.9% of viruses and bacteria with powerful, 5x cleaning power* wipe; ALL PURPOSE WIPE: These all-purpose disposable wipes remove common allergens, germs and messes on surfaces like kitchen counters bathroom surfaces and more. The Evencare G2 glucose meter website documented the following products are validated for disinfecting the EVENCARE G2 meter and lancing device: Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8), Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10), Clorox Trademark) Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12), Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 69687-1) On 03/17/22 at 09:47 AM, Administrative Nurse E verified staff had not used the correct disinfecting wipe per the manufacturer's instructions. The facility's Cleaning of Multi-Use Glucometer policy, dated February 2022, directed staff to clean the entire glucometer with Medline's Micro Kill (alcohol wipes are not sufficient). The policy stated the following products are validated for disinfecting the EvenCare G2 meter: o Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) o Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) o Clorox Healthcare® Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) o Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 69687-1). The facility failed to disinfect the multi-use glucometer in one of two facility buildings with the correct disinfectant per manufacturer's instructions, placing residents at risk for blood borne pathogens.

Aug 2020 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 73 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise one of 18 care plans, Resident (R) 56's care plan for urinary catheter (tube placed in the bladder to drain urine into a collection bag). Findings included: - R56's Physicians Order Sheet, dated 08/01/20, documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), benign prostatic hyperplasia/hypertrophy (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and bladder neck obstruction with retention of urine. R56's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS recorded the resident required limited assistance with bed mobility, independent with transfers, and required supervision with toilet use and personal hygiene. The MDS recorded the resident had an indwelling urinary catheter. The Urinary Incontinence/Catheter Care Area Assessment (CAA), dated 07/24/20, documented the resident required a suprapubic (urinary bladder catheter inserted through the skin) urinary catheter, but lacked additional information. The Self-Care Deficit Care Plan, dated 07/30/20, directed staff to empty the suprapubic catheter every shift and as needed. The care plan lacked additional care for R56's catheter. The Physician Order, dated 07/02/19, documented the resident had a suprapubic catheter due to urinary retention. The Physician Order,dated 08/06/20, directed staff to change the suprapubic catheter every four weeks, as needed, provide routine cares at the insertion site, and change the sponge daily, and as needed. On 08/24/20 at 02:30 PM, observation revealed the resident ambulated with a walker from the living room to the therapy room and the urinary drainage tubing drug on the floor. Continued observation revealed the tubing attached to the urinary drainage bag clipped on the resident's walker. On 08/25/20 at 08:30 AM, observation revealed the resident sat at the dining room table and ate breakfast with the urinary drainage tubing lying on the floor. Observation revealed the tubing attached to the catheter bag on the resident's walker. On 08/26/20 at 10:30 AM, observation revealed the resident sat in a recliner with the urinary drainage tubing lying on the floor, hooked on the side of his walker, with cloudy yellow urine in the tubing. On 08/26/2020 at 02:10 PM, Administrative Nurse E verified R56's care plan should be updated with interventions for care of the residents suprapubic catheter. The facility's Care Plan Development and Revision policy, dated February 2020, documented a comprehensive plan of care would be developed by the interdisciplinary team and the resident in order to meet the resident's medical, nursing, mental, and psychosocial needs. Periodically, when the resident and their care needs change, the interdisciplinary team, using the results of periodic assessments, will further develop, review, and revise the comprehensive plan of care. The facility failed to update and revise R56's care plan to include appropriate suprapubic catheter care and treatment, placing the resident at risk for inadequate catheter care and potential urinary infections.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 73 residents. The sample included 18 residents with one reviewed for urinary catheter (tube placed in the bladder to drain urine into a collection bag) use. Based on observation, record review, and interview, the facility failed to provide appropriate urinary catheter care for Resident (R) 56, who's urinary drainage tubing was on the floor three of four days during the survey. Findings included: - R56's Physicians Order Sheet, dated 08/01/20, documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), benign prostatic hyperplasia/hypertrophy (BPH-non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and bladder neck obstruction with retention of urine. R56's Annual Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS recorded the resident required limited assistance with bed mobility, independent with transfers, and required supervision with toilet use and personal hygiene. The MDS recorded the resident had an indwelling urinary catheter. The Urinary Incontinence/Catheter Care Area Assessment (CAA), dated 07/24/20, documented the resident required a suprapubic (urinary bladder catheter inserted through the skin) urinary catheter but lacked additional information. The Self- Care Deficit Care Plan, dated 07/30/20, directed staff to empty the suprapubic catheter every shift and as needed. The care plan lacked additional care for R56's catheter. The Physician Order, dated 07/02/19, documented the resident had a suprapubic catheter due to urinary retention. The Physician Order, dated 08/06/20, directed staff to change the suprapubic catheter every four weeks, as needed, provide routine cares at the insertion site, and change the sponge daily, and as needed. On 08/24/20 at 02:30 PM, observation revealed the resident ambulated with a walker from the living room to the therapy room and the urinary drainage tubing drug on the floor. Continued observation revealed the tubing attached to the urinary drainage bag clipped on the resident's walker. On 08/25/20 at 08:30 AM, observation revealed the resident sat at the dining room table and ate breakfast with the urinary drainage tubing lying on the floor. Observation revealed the tubing attached to the catheter bag on the resident's walker. On 08/26/20 at 10:30 AM, observation revealed the resident sat in a recliner with the urinary drainage tubing lying on the floor, hooked on the side of his walker, with cloudy yellow urine in the tubing. On 08/26/20 at 01:10 PM, Administrative Nurse E verified the urinary catheter tubing lying on the floor and stated the tubing should be be kept off the floor. The facility's Catheter Care, Urinary policy, dated September 2014, documented the purpose is to prevent catheter associated urinary tract infections. Maintaining unobstructed urine flow, check the resident frequently to be sure he/she is not lying on the catheter, and to keep the catheter and tubing free of kinks. The policy documented the urinary drainage bag must always be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy documented to be sure to the tubing and drainage bag are kept off the floor, and ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. The facility failed to provide R56 adequate urinary catheter care, placing the resident at risk for urinary infections.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 73 residents. The sample included 18 residents with one reviewed for dialysis. Based on observation, interview, and record review, the facility failed to assess Resident (R) 9's dialysis access site twice daily as care planned. Findings included: - R9's Physician Order Sheet (POS), dated 07/21/20, documented a diagnosis of end stage renal disease (ESRD) requiring dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented the resident required supervision with all activities of daily living (ADLs), reported rare, moderate pain, and received dialysis. The Dialysis Care Plan, dated 08/20/20, documented the resident received dialysis three times per week, and directed staff to monitor the resident's Arteriovenous (AV) shunt (abnormal connection between an artery and a vein, and is sometimes surgically created to help with dialysis treatment) for positive thrill (rumbling sensation that you can feel), and if no thrill noted, notify physician. The care plan directed staff to palpate (feel) the access site every shift, monitor for fluid overload (increased blood pressure, tachycardia, edema), monitor labs as ordered, and report abnormal lab values to the physician. The Progress Note, dated 08/17/20 at 12:03 PM, documented a nurse at the hospital called the facility stating the resident was in the emergency room (ER) due to her dialysis access site bleeding uncontrollably from dialysis. The hospital nurse stated the bleeding stopped, the site dressing was to stay in place today, and the facility nurse was to call for increased bleeding issues not improved with gentle pressure up to 20 minutes or brisk bleeding. The note documented the resident returned to the facility with a dressing in place and no noted bleeding at that time. Review of R9's Medical Administration Record and Treatment Administration Record (MAR/TAR) lacked documentation of dialysis access checks. On 08/26/20 at 11:15 AM, observation revealed R9 in her room with a clean bandage over her dialysis access site. On 08/25/20 at 10:54 AM, R9 stated she received dialysis three days per week- Monday, Wednesday, and Friday. R9 stated the nurse checked her dialysis access when she returned from her appointment. On 08/26/20 at 04:02 PM, Licensed Nurse (LN) G stated the resident left the facility about 06:30 AM for dialysis on Monday, Wednesday, and Friday. LN G stated staff weighed the resident before dialysis and assessed the access site's thrill daily, but did not document any assessments. On 08/26/20 at 11:15 AM, Administrative Nurse D verified nurses were to check for thrill and bleeding each shift per the care plan and the facility had no documentation of the assessments. The facility's Hemodialysis Access Care policy, dated September 2010, directed staff to check the patency of the site at regular intervals, palpate the site to feel the thrill, and check for signs of infection at the access site when performing routine care and at regular intervals. The facility failed to assess R9's dialysis access site routinely at regular intervals, placing the resident at risk for dialysis access problems.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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The facility had a census of 73 residents. Based on record review and interview, the facility failed to ensure every Certified Nurse Aide (CNA) employed at the facility for at least one year completed the minimum 12 hours of in-services per year and lacked a system for accurately tracking nurse aide education. Findings included: - The facility's employment records documented 18 nurse aides were employed at the facility for at least one year. The facility's in-service records lacked documentation that all 18 nurse aides completed the required 12 hours of in-service training in the past year and lacked a tracking system. On 08/27/20 at 09:30 AM, Administrative Staff A stated the facility lacked a system in place to monitor completion of in-service hours and acknowledged the 18 aides lacked the 12 hours of yearly in-service. The Staff Education and In-Services policy, dated August 2020, documented the facility would provide regular, planned education for all staff. The purpose of such on-going education is to ensure that facility services and procedures assist residents to attain and maintain their highest practicable level of physical, mental, and psychosocial functioning. The direct care staff shall participate in at least 12 hours of in-service education each year. The in-service program shall provide all employees with training in at least the following areas; fire prevention and safety, disaster preparedness, accident prevention; resident rights, psychosocial needs of residents, dementia care; infection prevention and control; prevention of abuse, neglect, exploitation , crime and reporting of suspicion of such; and suicide prevention. The policy documented the facility shall maintain documentation of in-services; content outline, presenter, and individual staff attendance record. The facility failed to ensure every CNA employed at the facility for at least one year completed a minimum 12 hours of in-services per year and lacked an accurate tracking system, placing the residents at risk for inappropriate care.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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The facility had a census of 73 residents. The sample include 18 residents with 10 reviewed for immunizations. Based on record review and interview, the facility failed to provide five of 10 sampled residents, Resident (R) 21, R23, R30, R43, R51, in one of two facilities, with the current Centers for Disease Control and Prevention (CDC) pneumococcal and influenza vaccine information to make an informed decision. Findings included: - On 08/26/20 at 10:38 AM, review of R21, R23, R30, R43, and R51's immunization records documented the use of the CDC's Inactive Influenza Vaccine, What You Need to Know Vaccine Information Statement, dated 06/03/06, but lacked the current fact sheet dated 08/15/19, and the Pneumococcal Polysaccharide Vaccine Information statement, dated 07/29/97, but lacked the current fact sheet dated 10/30/2019. On 08/26/20 at 10:38 AM, Administrative Staff A verified the facility did not provide the residents or their representatives, in one of two facilities, with the current CDC information for the administration of influenza and pneumococcal immunizations. The facility's Influenza Vaccination policy and Pneumococcal Vaccination policy, dated March 2020, lacked direction to ensure the resident or their representative were given the current CDC information. The facility failed to provide R21, R23, R30, R43, R51, or their representatives, with current CDC influenza and pneumococcal immunization information, placing the residents at risk for making uninformed decisions.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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The facility had a census of 73 residents. Based on observation, interview, and record review, the facility failed to implement infection control procedures to disinfect the glucometer (instrument used to calculate blood glucose [sugar]), disinfect contaminated laundry, and to dispose of potentially infectious face masks inside the droplet isolation room, in one of two facility buildings. (Resident (R) 9, R44, R66) Findings include: - On 08/25/20 at 03:14 PM, Social Services (SS) X donned gown, gloves, and wore a cloth face mask. SS X entered the droplet precaution room to see R66 who was in quarantine due to his new admission to the facility. Later SS X came out of the room wearing the face mask, removed her gloves, and used hand gel. Observation revealed SS X kept the cloth face mask on while standing by the isolation room and a staff person brought her a disposable face mask. On 08/25/20 at 03:14 PM, SS X verified she should have removed the gloves and face mask prior to leaving the isolation room. The facility's Isolation Precautions policy, dated October 2018, documented gloves and disposable gowns will be removed before leaving the room. The facility failed to follow infection control guidelines when staff failed to remove a soiled mask after leaving R66's room (while in quarantine), placing the residents at risk for infection. - On 08/26/20 at 07:11 AM, observation revealed Licensed Nurse (LN) G used a glucometer to obtain R44's blood sugar, then used Lysol spray (a brand name of cleaning and disinfecting spray not effective on blood borne pathogens) to disinfect the glucometer and let it lie on a clean paper towel. Further observation revealed LN G, using the same glucometer, obtained R66's blood sugar sample and used Lysol spray to disinfect the glucometer. On 08/26/20 at 07:13 AM, LN G stated the facility ran out of Micro-Kill (disinfectant) wipes, so they used Lysol and changed the facility policy to Lysol for cleaning the glucometer. She verified staff used the glucometer to test nine residents' blood sugar. On 08/27/20 at 11:28 AM, Administrative Nurse D stated the facility could not obtain bleach wipes and started using the Lysol spray to disinfect the glucometer. Administrative Nurse D verified Lysol did not kill blood borne pathogens (microorganisms such as viruses or bacteria that are carried in blood and can cause disease in people). The glucometer's manufacturer's Instructions for Disinfection instructed staff to use Environmental Protection Agency (EPA) approved bleach wipes or Micro-Kill alcohol wipes and leave the disinfectant wet on the glucometer for a specific time. The facility failed to properly disinfect a multiuse glucometer between resident uses, placing the residents at risk for infection. - On 08/26/20 at 08:56 AM, observation of the laundry process revealed staff used Prestige laundry products and Pure Build detergent which was hooked up to the facility washing machines. The June, July, and August 2020 Water Temperature Logs documented daily temperatures between 128-138 degrees Fahrenheit (F). On 08/26/20 at 09:02 AM, Laundry Staff (LS) V stated she only used bleach on whites and linens, no clothing. LS V stated she had been told to wash quarantined resident laundry together with regular laundry. LS V stated if the resident was positive for COVID 19, she would wash their laundry separately. She stated the gowns staff wore in the quarantine room were washed separately. LS V stated she had not been trained to wear gowns during laundry and just wore a cloth face mask and gloves. LS V stated she should wash quarantine laundry separately. On 08/26/20 at 09:10 AM, Housekeeping/Laundry Staff U stated the facility used Pure Build products since last fall, used bleach for certain cycles - linens, whites, and washed resident's clothing all together. On 08/27/20 at 02:33 PM, Housekeeping/Laundry Staff U verified the Pure Build detergent lacked disinfectant qualities. On 08/27/20 at 11:26 AM, Administrative Nurse D verified staff did not disinfect residents' laundry properly due to no regular use of disinfectant and no record of disinfectant use. The facility undated Laundry Temperatures policy posted in laundry, documented water temperatures to be 120-170 F, and if below 160 F, 125 ppm (parts per million) disinfectant added. The facility failed to properly disinfect residents' laundry when staff washed all residents' laundry together, placing the residents in one of two facility buildings at risk for potential infections when staff did not separate and properly disinfect laundry.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Kansas facilities.

Concerns

• 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade D (40/100). Below average facility with significant concerns.

Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Cambridge Place's CMS Rating?

CMS assigns CAMBRIDGE PLACE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Kansas, 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 Cambridge Place Staffed?

CMS rates CAMBRIDGE PLACE's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 51%, compared to the Kansas average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Cambridge Place?

State health inspectors documented 38 deficiencies at CAMBRIDGE PLACE during 2020 to 2025. These included: 38 with potential for harm.

Who Owns and Operates Cambridge Place?

CAMBRIDGE PLACE 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 RECOVER-CARE HEALTHCARE, a chain that manages multiple nursing homes. With 91 certified beds and approximately 78 residents (about 86% occupancy), it is a smaller facility located in MARYSVILLE, Kansas.

How Does Cambridge Place Compare to Other Kansas Nursing Homes?

Compared to the 100 nursing homes in Kansas, CAMBRIDGE PLACE's overall rating (1 stars) is below the state average of 2.9, staff turnover (51%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Cambridge Place?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Cambridge Place Safe?

Based on CMS inspection data, CAMBRIDGE PLACE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Kansas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Cambridge Place Stick Around?

CAMBRIDGE PLACE has a staff turnover rate of 51%, which is about average for Kansas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Cambridge Place Ever Fined?

CAMBRIDGE PLACE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Cambridge Place on Any Federal Watch List?

CAMBRIDGE PLACE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 91
Avg. Residents: 78
Occupancy: 86.4%
Ownership: For profit - Corporation
Chain: RECOVER-CARE HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
38 Deficiencies: -10
Final Score: 40/100

Nearby Alternatives

FRANKFORT COMMUNITY CARE HOME 4-star

View all in MARYSVILLE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 175350