BETHEL HOME
Non profit - Church related
56 Beds
Independent
Data: November 2025
Trust Grade
85/100
#6 of 295 in KS
Photo by Bethel Home Inc.
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bethel Home in Montezuma, Kansas, has a Trust Grade of B+, which means it is recommended and performs above average compared to other facilities. It ranks #6 out of 295 nursing homes in the state, placing it in the top half, and is the only option in Gray County, indicating it is the best facility available locally. The trend is stable, with the number of issues remaining consistent over the past two years. Staffing is a strong point, rated 5 out of 5 stars with a low turnover of 25%, significantly better than the state average of 48%. However, the facility has some concerning aspects, such as less RN coverage than 80% of Kansas facilities, which might affect resident care. Specific incidents noted include a serious failure to maintain proper tracking of pressure injuries for residents, which could lead to worsening conditions. Additionally, the facility did not ensure that licensed nurses were competent in monitoring skin issues, posing risks to residents with potential skin problems. Furthermore, there were issues with the facility's quality improvement committee not taking timely action to address identified deficiencies, which raises concerns about overall resident safety and care quality. While there are strengths, families should weigh these weaknesses carefully.
- Trust Score
- B+
- In Kansas
- #6/295
- Safety Record
- Moderate
- Inspections
- Holding Steady
- Staff Stability ✓ Good
- 25% annual turnover. Excellent stability, 23 points below Kansas's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Kansas facilities.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Kansas. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
85/100
Top 2%
Needs review
7 → 7 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 7 issues
2025: 7 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (25%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (25%)
23 points below Kansas average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Kansas's 100 nursing homes, only 1% achieve this.
The Ugly 15 deficiencies on record
1 actual harm
Jan 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents. The sample included 14 residents reviewed for person-centered care plan developm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents. The sample included 14 residents reviewed for person-centered care plan development. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three residents, Resident (R) 33 related to psychotropic (any class of medications that alter mood or thought) medication use and dementia (a progressive mental disorder characterized by failing memory, confusion) care. R21's care plan lacked interventions related to as needed (PRN) oxygen use and scheduled nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication use. Additionally, R21's care plan lacked a timely intervention related to the care of pressure ulcer/injury (areas of 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). R3's care plan lacked interventions related to the care of pressure ulcer/injury. These deficient practices had the potential to lead to uncommunicated needs which would negatively impact the physical and psychosocial well-being of the residents.
Findings Included:
- R21's Electronic Health Record (EHR) revealed diagnoses of asthma (a disorder of narrowed airways that caused wheezing and shortness of breath).
The Significant Change Minimum Data Set (MDS) dated 01/18/24, documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R21 was not at risk for pressure ulcer/injury and received oxygen.
The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 10/15/24 documented R21 required extensive assistance with mobility in and out of his recliner, was able to reposition self but had no skin issues or pressure injuries.
The Quarterly MDS, dated 12/05/24 documented a BIMS score of 15, which indicated intact cognition. The assessment documented R21 did not have pressure ulcer/injury, was not at risk for pressure ulcer/injury but had a pressure relieving device on his chair and did not receive oxygen.
Review of the Care Plan updated 12/12/24, on 01/15/25 revealed an intervention dated 12/20/24 that documented R21 had an open sore on the right buttock (first documented on 10/25/24) and instructed staff to provide frequent repositioning.
Review of the Care Plan updated 12/12/24, on 01/15/25 lacked interventions related to oxygen or nebulized medication use or care/maintenance of oxygen or nebulizer equipment.
The Physician Orders revealed the following orders:
Monitor and measure open area on right buttock, every day shift, every Tuesday for open area, initiated on 10/29/24 at 07:00 AM and discontinued on 01/11/25.
Oxygen via nasal cannula at two liters per minute (2LPM) PRN for respiratory distress, initiated on 08/16/24 at 02:02 PM.
Albuterol Sulfate (a short-acting medication to open the lower airways of the lungs) 2.5 milligrams (mg)/three milliliters (mL) 0.083 percent (%) inhale one vial via nebulizer every four hours as needed for wheezing or shortness of breath related to asthma, initiated on 02/21/23 at 02:15 PM.
Ipratropium-Albuterol (a long-acting medication to open the lower airways of the lungs) 0.5-2.5 (3) mg/three mL, inhale one vial via nebulizer two times a day related to asthma, initiated on 10/14/24 at 08:00 PM.
Review of the electronic Medication Administration Record (eMAR) from 11/01/24 to 01/15/25 revealed R21 received appropriate doses of the nebulized medications. The eMAR lacked documentation of PRN oxygen or PRN albuterol. The eMAR documented appropriate changing of oxygen and nebulizer equipment.
Review of Progress Notes revealed the following:
On 10/25/24 at 03:18 AM, R21 had two open areas on his right buttock near the intergluteal cleft and that R21 removed pillows staff had placed behind his back to offload pressure.
On 12/20/24 at 04:02 AM, R21 had an open sore on his right buttock and R21 had pressure-relieving cushions on his recliner and electric scooter.
On 01/11/25 at 02:22 PM, R21 had an open area on his right buttock that had been evaluated as healed on 01/08/25.
During an observation on 01/14/25 at 09:56 AM, R21 rested in his recliner with legs elevated, pressure relieving pad in recliner and wheelchair. Oxygen concentrator observed in R21's room with oxygen cannula coiled under the concentrator handle and nebulizer equipment observed on a table in R21's room.
During an observation on 01/15/24 at 07:00 AM, R21 was seated in his wheelchair with pressure reliving pad in recliner and wheelchair. Oxygen concentrator observed in R21's room with oxygen cannula coiled under the concentrator handle and nebulizer equipment observed on a table in R21's room.
During an observation on 01/16/25 at 10:20 AM or R21's room revealed an oxygen concentrator in R21's room with oxygen cannula coiled under the concentrator handle and nebulizer equipment observed on a table in R21's room.
During an interview on 01/16/25 at 10:28 AM, Certified Nurse Aide (CNA) P revealed if a skin issue was discovered during cares that the nurse would be notified immediately so they could assess the area. CNA P revealed all cares delivered to the residents should be found on the care plan in the care plan book at the nurses' station or in the EHR.
During an interview on 01/16/25 at 10:33 AM, CNA U revealed if any skin abnormalities were discovered during cares that the nurse would be notified so they could assess and treat the area. CNA U revealed that staff carry a pocket [NAME] slip that has each resident's cares listed
During an interview on 10/16/25 at 10:48 AM, Licensed Nurse (LN) X revealed if a new skin abnormality is discovered staff would notify the nurse who would fill out a wound report and initiate orders to monitor and describe the wounds and would also trigger a note on the report sheet that is shared between shifts. LN X revealed that care plan interventions and updates are developed by Administrative Nurse B, Administrative Nurse C, Administrative Nurse D and/or Administrative Nurse E
During an interview on 01/16/25 at 09:33 AM, Administrative Nurse D revealed that all LN staff are responsible to develop or modify care plan interventions as the situations are discovered or change. Administrative Nurse D stated that if a resident has new physician orders, the nurse that noted the orders should add that care and intervention to the care plan. Additionally, Administrative Nurse D stated that if a nurse discovered a new wound or pressure ulcer/injury that the nurse should develop a new care plan intervention as soon as possible.
During an interview on 01/16/25 at 10:58 AM, Administrative Nurse B stated the expectation if a change with a resident that the nurse on duty would develop and/or update the care plan with new interventions and to discuss the changes with Administrative Nurse D or Administrative Nurse E to verify appropriateness of the interventions. Administrative Nurse B further revealed the nurses who noted new orders would update the care plan, but she was unsure if the staff were aware of this expectation. Administrative Nurse B further confirmed the care plan lacked oxygen and nebulized medication interventions. Administrative Nurse B confirmed the care plan intervention dated 12/20/24 was for the wound first documented in the EHR on 10/25/24 and stated that the intervention was not addressed in the care plan in a timely manner and failed to meet the expectation for care plan development.
The facility's Comprehensive Person-Centered Care Plans policy, dated 08/15/19 documented each resident would receive nursing care based on individual needs and the care plan was a personalized daily plan that indicated what nursing care is needed, how it was to be accomplished and included resident's preferences. The care plan would be available to each person assigned to a resident and would be reviewed and revised as needed. The care plan could be delegated by the Director of Nursing (DON - Administrative Nurse B) to others but the DON would continue to supervise the process and was involved with evaluation and revision of all care plans. Additionally, the nurse on duty would develop a temporary care plan when new problems developed and included (but not limited to) new medications, skin care and falls. The policy documented that the care plan would be revised to include interventions for pressure ulcer/injury with changes in physician's treatment. Further, the policy documented that all physician's orders, notes and consultant notes would be reviewed and appropriately added to the care plan.
The facility failed to develop and implement a person-centered comprehensive care plan for related to PRN oxygen use and scheduled nebulized medication use. Additionally, R21's care plan lacked a timely intervention related to the care of pressure ulcer/injury. This deficient practice had the potential to lead to uncommunicated needs which had the potential to negatively affect the physical and psychosocial well-being of R21.
- R3's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), history of venous thrombus and embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the blood stream) and acquired absence of left leg below the knee.
The Annual Minimum Data Set (MDS) dated 07/04/24, documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R3 was not at risk for pressure ulcer/injury.
The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 07/04/24 documented R3 required assistance with bathing related to left leg amputation.
The Quarterly MDS, dated 10/03/24 documented a BIMS score of 15, which indicated intact cognition. The assessment documented R3 was not at risk for pressure ulcer/injury.
Review of the Care Plan updated 01/09/25, on 01/15/25 lacked documentation related to a wound on the left leg stump.
The Physician Orders revealed:
Silverlon Island Dressing (a type of dressing intended for use up to seven days) , ensure it is intact and do not remove every evening and night shift for wound care, dated 12/27/24 at 03:00 PM.
Review of the EHR revealed the following:
On 12/02/24 at 04:08 PM, R3 reported an open area on his left leg stump and this was communicated with the physician.
On 12/11/24 at 01:30 PM, R3's wound was evaluated by the physician and new orders were written.
On 12/23/24 at 10:10 AM, R3 was evaluated by the physician and new orders were written for R3 to be evaluated by an off-site wound care clinic.
During an observation on 01/14/25 at 09:00 AM, R3 sat on the edge of his bed with dressing in place on left leg stump.
During an observation on 01/14/25 at 11:24 AM, R3 rested in his recliner.
During an observation on 01/15/25 at 04:00 PM, R3 rested in his recliner.
During an interview on 01/14/25 at 11:24 AM, R3 revealed that he had a wound on the stump of his left leg from something inside his prosthetic limb and was being treated at an off-site wound clinic.
During an interview on 01/15/25 at 04:00 PM, R3 revealed that the wound clinic staff had discovered a protrusion on the plastic liner in his prosthetic limb and that wound clinic staff had corrected the protrusion and that he no longer feels the pressure on the wound that was present before.
During an interview on 01/16/25 at 10:28 AM, Certified Nurse Aide (CNA) P revealed if a skin issue was discovered during cares that the nurse would be notified immediately so they could assess the area. CNA P revealed all cares delivered to the residents should be found on the care plan in the care plan book at the nurses' station or in the EHR.
During an interview on 01/16/25 at 10:33 AM, CNA U revealed if any skin abnormalities were discovered during cares that the nurse would be notified so they could assess and treat the area. CNA U revealed that staff carry a pocket [NAME] slip that has each resident's cares listed
During an interview on 10/16/25 at 10:48 AM, Licensed Nurse (LN) X revealed if a new skin abnormality is discovered staff would notify the nurse who would fill out a wound report and initiate orders to monitor and describe the wounds and would also trigger a note on the report sheet that is shared between shifts. LN X revealed that care plan interventions and updates are developed by Administrative Nurse B, Administrative Nurse C, Administrative Nurse D and/or Administrative Nurse E
During an interview on 01/16/25 at 09:33 AM, Administrative Nurse D revealed that all LN staff are responsible to develop or modify care plan interventions as the situations are discovered or change. Administrative Nurse D stated that if a resident has new physician orders, the nurse that noted the orders should add that care and intervention to the care plan. Additionally, Administrative Nurse D stated that if a nurse discovered a new wound or pressure ulcer/injury that the nurse should develop a new care plan intervention as soon as possible.
During an interview on 01/16/25 at 10:58 AM, Administrative Nurse B stated the expectation if a change with a resident that the nurse on duty would develop and/or update the care plan with new interventions and to discuss the changes with Administrative Nurse D or Administrative Nurse E to verify appropriateness of the interventions. Administrative Nurse B further revealed the nurses who noted new orders would update the care plan, but she was unsure if the staff were aware of this expectation. Administrative Nurse B further confirmed the care plan lacked interventions related to wound care and failed to meet the expectation for care plan development.
The facility's Comprehensive Person-Centered Care Plans policy, dated 08/15/19 documented each resident would receive nursing care based on individual needs and the care plan was a personalized daily plan that indicated what nursing care is needed, how it was to be accomplished and included resident's preferences. The care plan would be available to each person assigned to a resident and would be reviewed and revised as needed. The care plan could be delegated by the Director of Nursing (DON - Administrative Nurse B) to others but the DON would continue to supervise the process and was involved with evaluation and revision of all care plans. Additionally, the nurse on duty would develop a temporary care plan when new problems developed and included (but not limited to) new medications, skin care and falls. The policy documented that the care plan would be revised to include interventions for pressure ulcer/injury with changes in physician's treatment. Further, the policy documented that all physician's orders, notes and consultant notes would be reviewed and appropriately added to the care plan.
The facility failed to develop and implement a person-centered comprehensive care plan for related to wound care. This deficient practice had the potential to lead to uncommunicated needs which had the potential to negatively affect the physical and psychosocial well-being of R3.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 50 residents with 14 residents sampled, which included one resident reviewed for pressure ul...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 50 residents with 14 residents sampled, which included one resident reviewed for 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). Based on observations, interviews, and record review, the facility failed to perform an ongoing assessment of a stage three (full thickness pressure injury extending through the skin into the tissue below) facility acquired pressure ulcer for Resident (R) 2.
Findings included:
- R2's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord).
The Significant Change Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R2 required maximal to total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R2 had a colostomy and urostomy. No pressure ulcers or skin impairments. Preventative mattress and cushion in place.
The Pressure Ulcer CAA dated 05/08/24, documented CAA triggered secondary to level of assistance required with ADLs while in bed, R2 had a history of pressure ulcers, but currently does not have any skin breakdown.
The Quarterly MDS dated 10/31/24, documented a BIMS of 15. R2 required total assistance of staff with ADLs. R2 required set-up for eating and oral care. R2 had a facility acquired stage three pressure ulcer.
The 01/14/25 Care Plan documented interventions which included:
On 05/23/22, staff were instructed to reposition and turn R2 every two hours and as needed. R2 had personal air mattress applied to bed and personal cushion applied to wheelchair.
Staff educated to encourage R2 to change position every two hours, alternate periods of rest with activity out of bed in order to prevent pressure ulcers.
Staff instructed to educate R2 the causative factors and measures to prevent skin injury. R2 was non-complaint with preventative measures. Staff were instructed to provide good nutrition and hydration.
Staff were instructed to monitor, document location, size, treatment of skin injury.
The Physicians Orders dated 01/14/25 documented:
Arginaid Oral Packet (Nutritional Supplements) give 1 packet orally, one time a day, for supplement date ordered, 09/27/24.
Change outer dressing use alginate (a wound dressing made from seaweed that absorbs fluid and forms a gel to help wounds heal) and put a foam border dressing over. Do not remove the membrane wrap. If contact layer and steri-strips (adhesive wound closures) do not stay in place, try to keep skin substitute on wound bed and replace secondary dressing, date ordered 10-04-24.
Measure and describe wound weekly on Friday for open area on right buttock, date ordered 11/17/24.
Apply skin barrier ointment (A&D ointment or calmoseptine or Vaseline {an over-the-counter ointment that protects and heals skin irritations}) to peri wound (skin surrounding the wound) and cover with gauze, date ordered 12-16-24.
Review of the Progress Notes from 05/22/24 to 01/14/25 documented the following:
The 05/22/24 at 08:30 AM Progress Note revealed R2 assessed with a new open area on right buttock. Measured 1.7 centimeter (cm) with a 0.7 cm by 0.8 cm open are. Physician notified and new order received.
The 05/31/24 at 05:20 PM Progress Note revealed open area on right buttock had worsened, Physician notified, and new orders were received.
The 05/31/24 at 10:01 PM Skin/Wound Note revealed right buttock measured 6cm by 4 cm, the peri wound had skin peeling, some bleeding noted from open area.
Review of the EHR, Wound Clinic notes, and wound book notes from 05/31/24 to 06/25/24, 09/03/24 to 09/17/24 and beyond 11/22/24 lacked documentation of ongoing weekly assessments as per physician orders for R2's stage three pressure ulcer.
Review of Wound Clinic Notes 07/01/24 thru 01/13/25 monthly visits.
On 07/01/24 no measurements noted.
On 07/29/24 no measurements noted.
On 08/26/24 right buttock measured 2.3 cm by 0.7 cm by 0.3 cm stage three pressure ulcer.
On 09/25/24 no measurements.
On 10/23/24 right buttock measured 1.5 cm by 0.4 cm by 0.4 cm.
On 11/19/24 right buttock measured 1 cm by 0.3 cm by 0.6 cm
On 12/16/24 right buttock measured 0.1 cm by 0.1 cm by 0.1 cm.
During an interview on 01/14/25 at 09:32 AM, R2 reported she acquired the pressure ulcer at the facility about six months ago. She reported she thought it was from an allergic reaction but was not sure.
During an observation on 01/15/25 at 07:19 AM, observed a pinpoint open area of right inner buttock during dressing change. Noted a scant amount of yellow drainage on old dressing when removed. Redness surrounding the peri wound noted.
During an interview on 01/15/24 at 07:34 AM, Licensed Nurse (LN) H reported the charge nurse would measure and document on any skin condition weekly. LN H reported that R2 would have her skin notes completed on Friday's.
During an interview on 01/15/25 at 07:50 AM, R2 reported that staff do encourage her to reposition every two hours, and not stay up for long periods. However, R2 reported she would choose to reposition when she wanted to as she liked to keep busy.
During an interview on 01/16/25 at 10:48 AM, LN X reported any new skin concern, the staff would notify the nurse. The nurse would complete a wound report, update the physician and would put an order in EHR to monitor and describe skin concern.
During an interview on 01/16/25 at 11:15 AM, Administrative Nurse B reported that Administrative Nurse C was the wound nurse for the facility. Administrative Nurse B expected pressure ulcers to be monitored weekly.
The facility's policy Skin Protocol - Staging and Care dated 11/19/24 documented residents with high risk for skin breakdown required a pressure reducing device for chair and mattress. Lotion to pressure areas and moisture barrier.
For stage three pressure injury assess location, size, including width, length, depth, and tunnelling, if any, drainage, granulation (a normal part of the wound healing process, where new tissue and blood vessels form in the wound bed) at each dressing change and document in record on wound documentation form. Document all findings in resident's chart.
The facility failed to perform an ongoing assessment of a stage facility acquired pressure ulcer for R2.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents. The sample included 14 residents with five residents reviewed for unnecessary me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R)46's as needed (PRN) psychotropic (any class of medications that alters mood or thought) medication had the required 14 day stop date or clinical rationale for continued use beyond the initial 14 days. This deficient practice had the potential to lead to the resident receiving unnecessary psychotropic medications.
Findings Included:
- R46's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and hypertension (elevated blood pressure).
The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident received antianxiety (a class of medications that calm and relax people) and diuretic (medication to promote the formation and excretion of urine) medication during the look back period.
The Psychotropic Drug Use CAA dated 03/26/24 documented R46 had adverse consequences of prescribed antianxiety medication that had been exhibited such as: sedation, decline in cognitive abilities, slurred speech, short-term memory loss, drowsiness, or little to no activity involvement.
The Physician Orders revealed a telephone order for Xanax (Alprazolam, a benzodiazepine class of medication which works on the neurotransmitters in the brain and is used to treat anxiety) 0.25 milligram (mg), give 0.25 mg every six hours PRN for anxiety, dated 06/22/24. The order lacked a stop date or rationale for the continued use of the medication.
Review of the electronic Medication Administration Record (eMAR) revealed R46 received doses of the PRN Xanax (alprazolam) on 06/22/24 and 09/16/24 and lacked evidence of an ordered stop date.
During an observation on 01/15/25 at 09:34 AM, R46 sat in her wheelchair, working on a puzzle in her room and appeared relaxed and calm.
During an interview on 10/23/24 at 11:22 AM, Administrative Nurse B confirmed the order for PRN Xanax (alprazolam) in R46's EHR had indefinite marked for the end date. Administrative Nurse B revealed she was unaware of the regulatory requirement that PRN psychotropic medications required a 14 day stop date or documented an appropriate clinical rationale for continued use beyond the 14 days.
The facility's Psychotropic Medications policy dated 11/14/17 documented that PRN orders for anti-psychotic (psychoactive or psychotherapeutic) drugs are limited to 14 days and will not renew unless the attending physician evaluates the resident for the appropriateness of the ordered medication.
The facility failed to ensure a 14-day stop date or physician evaluation for continued use beyond the 14 days, for R46's PRN psychotropic medication, Xanax. This deficient practice had the potential for R46 to receive an unnecessary psychotropic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
The facility reported a census of 50 residents. Based on observations, interviews, and record review, staff failed to complete proper hand hygiend during wound care for Resident (R)2 and R21, to ensur...
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The facility reported a census of 50 residents. Based on observations, interviews, and record review, staff failed to complete proper hand hygiend during wound care for Resident (R)2 and R21, to ensure best practice regarding infection control and prevention.
Findings included:
- Observation on 01/15/25 at 07:00 AM, Licensed Nurse (LN) J removed a dressing from a skin tear on R21's without hand hygiene, cleaned the wound with normal saline (NS- saline water solution for medical use) and gauze, did not change her gloves or perform hand hygiene, placed new border foam dressing, then transitioned to morning Activities of Daily Living (ADL) assistance with glove change only, no hand hygiene.
Observation on 01/15/25 at 07:03 AM, R2 was assisted back into bed by Certified Nursing Assistant (CNA) O and CNA N. CNA O assisted R2 with dressing then removed gloves, put on new gloves but did not wash her hands, then applied Foley tubing to R2's leg.
Observation on 01/15/25 at 07:19 AM, LN H and CNA N entered a resident's room and applied PPE with no concerns. LN H cleansed wound to right buttock, removed another 4x4 from package with her dirty glove to dry the area, then removed gloves. LN H did not wash her hands, applied gloves and applied calcium alginate (highly absorbent dressing) to the center of the wound, then applied a dressing. LN H then applied A&D ointment to the area around the wound and removed her gloves. LN H put the remaining calcium alginate in the packet and back into the box, and cleaned up the area.
During an interview on 01/15/25 at 07:08 AM, LN J confirmed she did not perform appropriate glove changes. She stated she should have changed her gloves and performed hand hygiene between dirty and clean phases.
During an interview on 01/15/25 at 07:34 AM, LN H acknowledged that she should have washed her hands when she removed her gloves before she applied new gloves. She was aware that every time a person removes gloves their hands should be washed.
During an interview on 01/15/25 at 07:43 AM, CNA O verified that she did not wash her hands when she had removed her gloves and applied new gloves and continued cares. CNA O reported she should have washed her hands prior to applying new gloves.
During an interview on 01/16/25 at 08:15 AM, Administrative Nurse C revealed she routinely educated staff on infection control and expected them to follow infection control practices including hand washing and wound.
During an interview on 01/16/25 at 10:30 AM, Administrative Nurse B revealed she expected staff to follow good infection control procedures.
The facility failed to ensure staff followed appropriate hand hygiene during wound care for R2 and R21. These deficient practices had the potential to spread possible infections to the residents in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
The facility reported a census of 50 residents. Based on interview and record review the facility failed to ensure an effective and ongoing antibiotic stewardship for appropriate antibiotic use for th...
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The facility reported a census of 50 residents. Based on interview and record review the facility failed to ensure an effective and ongoing antibiotic stewardship for appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi-drug resistant organisms
Findings included:
- During an interview on 01/16/24 at 08:15 AM, Administrative Nurse C reported she is the Infection Preventionist (IP- a trained healthcare professional who works to prevent the spread of infections in healthcare facilities) for the facility. Administrative Nurse C revealed she tracked when an antibiotic started, she reported the nurses on the units were to follow McGeer's Criteria (a set of guidelines for identifying infections in long-term care facilities) and notify her when a new antibiotic was started. Administrative Nurse C reported this did not happen. Administrative Nurse C reported she was not notified that R30 was being tested for clostridium difficile (C-diff: contagious bacteria characterized by foul smelling frequent loose bowel movements) on 01/13/24 and revealed that is a problem. She said it is the policy that precautions should have been started. She reported that she had not heard of any signs or symptoms of C-diff, but the surveyor informed her that the EHR documented 56 loose stools out of 75 in the past 30 days. The surveyor also informed Administrative Nurse C that she had another antibiotic scheduled to start on that day. She agreed that it needed to be investigated. Surveyor and Administrative Nurse C looked at previously ordered antibiotics for R30:
Cephalexin Oral Capsule 500 MG (Cephalexin) one capsule by mouth two times a day for UTI until 08/29/2024 ordered on 08/22/24. It did not have the culture and sensitivity completed and it was not on the tracking form.
Levaquin Oral Tablet 250 MG (Levofloxacin) one tablet by mouth one time a day for UTI for seven days ordered on 12/23/2024 was not on the tracking record.
Azithromycin Oral Tablet 250 MG (Azithromycin) four tablets by mouth one time only for bacterial pneumonia and UTI ordered on 1/5/2025 was not on the surveillance tracking record and was an unusual dose that she agreed should have been investigated at that time. Amoxicillin-Pot Clavulanate Oral Tablet 500-125 MG (Amoxicillin & Pot Clavulanate) one tablet by mouth two times a day for bacterial pneumonia for seven days ordered on 1/5/2025 was not on the tracking record.
Administrative Nurse C confirmed that there was not a culture and sensitivity for R12 for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) one tablet by mouth two times a day for Bacteriuria for seven days order on 11/28/2024.
Administrative Nurse C confirmed R12 had an order for Cefdinir Oral Capsule 300 MG (Cefdinir) one capsule by mouth two times a day for cough for 10 Days started on 1/7/2025 lacked an appropriate diagnosis for an antibiotic and it was not on the tracking form.
During an interview on 01/16/25 at 10:30 AM, Administrative Nurse B revealed that she was not aware that R30 had loose stools, and that communication was a problem. Administrative Nurse B confirmed the lack of completion of the computerized infection monitoring system. She reported the infection control nurse was working to improve the infection control surveillance and antibiotic stewardship issues with communication and documentation.
The facility's Antibiotic Stewardship policy, reviewed 05/01/24, instructed staff to monitor antibiotic use with support from teh Medical Director, Pharmacist, and Director of Nursing/designee. Staff were to monitor antibiotic use and infections. All practitioners would be encouraged to follow standard of practice for ordering antibiotic treatment for symptoms including but not limited to McGeer Criteria.
The facility failed to ensure an effective and ongoing antibiotic stewardship for appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi-drug resistant organisms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the fall care plan with an appropriate...
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The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the fall care plan with an appropriate intervention for two residents. Resident (R) R33 and R36. Additionally, the facility failed to update care plan with facility acquired pressure ulcer (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) for R2, and R23's care plan was not updated with psychotropic (alters mood or thought) medications changes. These deficient practices had the potential to have a negative effect on the overall physical and psychosocial well-being of the residents in the facility.
Findings included:
- During the onsite survey, the surveyors identified a concern regarding the revision of care plans for four of the sampled residents.
R36's Electronic Health Record (EHR) revealed the care plan lacked fall intervention. The fall that occurred on 12/12/24 had no intervention placed to prevent further falls.
R33's EHR revealed the care plan lacked fall interventions. The falls that occurred on 01/16/24, 06/06/24, 06/15/24, 07/07/24, and 10/23/24.
R2's EHR revealed the care plan lacked a revision for an open area noted on the right buttock that was facility acquired on 05/22/24.
R23's EHR revealed the care plan lacked revisions to reflect the changes in psychotropic medication as follows:
R23's Buspirone HCl tablet (is used to treat certain anxiety disorders or to relieve the symptoms of anxiety) 15 milligrams, give one tablet by mouth, two times a day related to anxiety disorder, ordered on 3/28/2023 was not on R23's care plan in EHR or noted on the paper update care plan sheet in care plan book.
During an interview on 01/16/25 at 08:40 AM, CMA K reported if a care plan had changed recently, the nurse would update the staff during report at beginning of the shift. CMA K also reported she would look at the care plan in the book or on the computer to check for any change of care.
During an interview on 01/16/25 at 10:30 AM, Administrative Nurse B expected care plans to be correct and revised, she verified that R23's care plan did not have Buspirone or anxiety concern on care plan.
During an interview on 01/16/25 at 10:45 AM, Administrative Nurse E reported the nurse on duty would update the care plan sheet in the care plan book.
During an interview on 01/16/25 at 10:48 AM, Licensed Nurse (LN) X reported that the care plan update sheet in care plan book is updated. Administrative Nurse B, Administrative Nurse D or Administrative Nurse E would update the care plan in the EHR.
During an interview on 01/16/25 at 10:58 AM, Administrative Nurse B stated the expectation if a change with a resident that the nurse on duty would develop and/or update the care plan with new interventions and to discuss the changes with Administrative Nurse D or Administrative Nurse E to verify appropriateness of the interventions. Administrative Nurse B further revealed the nurses who noted new orders would update the care plan, but she was unsure if the staff were aware of this expectation.
The facility's Comprehensive Person-Centered Care Plans policy dated 08/15/19 documented each resident would receive nursing care based on individual needs and the care plan was a personalized daily plan that indicated what nursing care is needed, how it was to be accomplished and included resident's preferences. The care plan would be available to each person assigned to a resident and would be reviewed and revised as needed. The care plan could be delegated by the Director of Nursing (DON - Administrative Nurse B) to others but the DON would continue to supervise the process and was involved with evaluation and revision of all care plans. Additionally, the nurse on duty would develop a temporary care plan when new problems developed and included (but not limited to) new medications, skin care and falls. The policy documented that the care plan would be revised to include interventions for pressure ulcer/injury with changes in physician's treatment. Further, the policy documented that all physician's orders, notes and consultant notes would be reviewed and appropriately added to the care plan.
The facility failed to revise four residents' care plans after pressure ulcer injuries occurred for R2. The facility failed to revise the care plan for R23 regarding psychotropic medication changes. The facility failed to revise the care plan after falls occurred for R33 and R36.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident ...
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The facility had a census of 50 residents and the sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for four residents. Resident (R) 37 who had medications located in her room that was not secured. Additionally, three residents R21, R33, and R36 had repeated falls with inappropriate or lacked a care plan revision after falls. These failures placed the affected residents at risk for preventable accidents and related injuries.
Findings included:
- During the onsite survey, the surveyors identified a concern regarding the unsecured medications observed in one resident's room during interview. Additionally, three residents noted to have repeated falls, when care plans were reviewed, falls that had occurred either lacked an intervention, or an appropriate intervention was completed.
During an observation on 01/14/25 at 01:36 PM, R37 had three over the counter medications on her over the bed table. A jar of Amish Origins Deep Penetrating Pain Relief Cream (used for arthritis, sore muscles, and joints), a tube of Hydrocortisone one percent cream (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions), and a bottle of Anti-Itch cream lotion (used on the skin) to help relieve pain and itching from minor burns, cuts, scrapes, insect bites, and rashes). All three medications had a warning label Keep out of reach of children.
During an interview on 01/15/25 at 05:10 PM, R37 reported she always kept her medications on her over the bed table and had never been educated to secure medications in her room.
During an interview on 01/15/25 at 05:15 PM, Certified Medication Aide (CMA) M reported that residents should have medications that are allowed to be in their room in a drawer. CMA M reported she did not believe that residents had a place in their room to lock and secure medications.
During an interview on 01/16/25 at 10:18 AM, License Nurse (LN) J reported she was not aware of an assessment for self-medication she had to complete on the electronic health record (EHR). LN J reported the physician would order may keep at bedside and self-administer medications. LN J reported that there was no area in a resident's room to secure medications.
During an interview on 01/16/25 at 11:01 AM, Administrative Nurse E reported the EHR had a self-administration assessment that the nurse should complete when a resident has an order to self-medicate and may keep at bedside and verified that R37 did not have an assessment completed. Additionally, Administrative Nurse E reported that medications in a resident's room should be in a drawer.
During review of R36's EHR, noted that R36 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition dated 10/25/24, had several falls noted.
The Progress Note on 03/14/24 at 08:30 AM, staff found R36 on the floor, seated upright by bed. R36 reported she lost her balance and fell. R36 had a small laceration by her left eye, and a skin tear noted on left elbow.
The Progress Note on 05/21/24 at 08:20 AM, R36 had a witnessed fall in the bathroom after she stepped on her toe and lost her balance, staff attempted to prevent fall. R36 had minor injuries noted, bruise on left knee, left wrist, and third finger of left hand.
The Progress Note on 12/12/24 at 06:45 AM, staff found R36 on the floor in bathroom next to the toilet. R36 reported her foot gave out and she fell. No injuries noted.
During review of the Care Plan the falls that occurred on 03/14/24 and 05/21/24 had no immediate intervention to prevent further falls. The intervention used after fall was reviewed was an order for Physical and Occupational therapy. The fall that occurred on 12/12/24 had no intervention placed to prevent further falls.
During review of R21's EHR, noted that R21 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition dated 12/05/24, had falls noted.
The Progress Note on 07/24/24 at 09:11 PM, R21 was found on floor in his room, noted that he had three head injuries and injured left shoulder. R21 was transferred to the hospital.
The Root Cause Analysis unknown date revealed, impaired mobility related to dizziness, that was related to diuretic use. No immediate intervention noted. The Care Plan intervention was PT/OT evaluation, dated 07/24/24.
The Progress Note on 11/11/24 at 06:30 PM, R21 was found on his knees on the floor, with his upper body in the wheelchair seat. R21 reported his feet tangled under him and cased his to fall. Noted a bruise on left hand, left knee had an abrasion and right ear had a small cut noted.
The Root Cause Analysis unknown date revealed R21 had overestimated his ability and did not use call light for assistance. No immediate intervention noted. The Care Plan intervention was PT evaluation, dated 11/11/24.
During review of R33's EHR, noted that R33 had a BIMS score of three, which indicated severely impaired cognition dated 01/02/25, R33 had several falls noted.
The Progress Note on 01/16/24 at 04:03 PM, Witnessed fall by staff, R33 hit his shoulder on the wall in hallway and fell backwards. Noted a bruise on left wrist. No fall intervention noted on care plan.
The Progress Note on 04/11/24 at 11:50 AM, R33 reported he fell backwards when he had reached into his closet to pick something up. No injuries noted. R33 was reminded to ask staff for assistance on the Care Plan dated 04/11/24. R33 had a BIMS of eight dated on 02/01/24.
The Progress Note on 05/30/24 at 10:45 AM, R33 was found on the floor in his room next to wheelchair. R33 reported he had to fix the wheelchair. The Care Plan intervention dated 05/03/24, maintenance to check brakes.
The Progress Note on 06/06/24 at 01:52 PM, R33 was found on the floor in his room next to the recliner, no injuries noted. No intervention noted on the care plan.
The Progress Note on 06/09/24 at 01:30 PM, R33 was found on the floor in his room next to recliner. No injuries noted. The Care Plan update sheet dated 06/09/24 revealed fall bed/chair alarm.
This intervention was noted on the Care Plan already dated 05/26/23.
The Progress Note on 06/15/24 at 10:45 AM, R33 was found on the floor near his room-mates bed. R33 reported he attempted to close the door to the room and lost his balance. The Care Plan intervention dated 06/15/24, continue plan of care.
The Progress Note on 07/07/24 at 08:00 AM, R33 was found on the floor near his bed, bed alarm had alerted staff. No injuries noted. The Care Plan intervention dated 07/07/24, continue plan of care.
The Progress Note on 10/23/24 at 08:28 PM, R33 was found on floor on his left knee in front of his wheelchair. R33 reported he did not know how he fell. Intervention is to not put R33 in his recliner after supper. The Care Plan intervention dated 10/23/24, maintenance to check chair alarm.
The intervention noted in the Progress note was not on he care plan.
During an interview on 01/16/25 at 08:40 AM, CMA K reported if a care plan had changed recently, the nurse would update the staff during report at beginning of the shift. CMA K also reported she would look at the care plan in the book or on the computer to check for any change of care.
During an interview on 01/16/25 at 10:28 AM, Certified Nurse Aide (CNA) P reported if a resident is found on the floor, the staff call the nurse on the walkie talkie, the nurse would investigate, the team would discuss an intervention, then reported to incoming shift.
During an interview on 01/16/25 at 10:45 AM, Administrative Nurse E reported the staff would discuss after the fall/incident and develop an intervention. The nurse on duty would update the care plan. Administrative Nurse E reported that during a care plan meeting the incidents would be looked at that time for the intervention completed.
During an interview on 01/16/25 at 10:48 AM, Licensed Nurse (LN) X reported the staff are notified on duty of the new intervention after a fall, and it is communicated in shift report. The Administrative Nurse B, Administrative Nurse D or Administrative Nurse E would update the care plan.
During an interview on 01/16/25 at 10:58 AM, Administrative Nurse B reported that Administrative Nurse D and or Administrative Nurse E are expected to check the intervention for appropriateness. CNAs would suggest interventions and the nurse on duty is expected to update the care plan.
The facility's policy Self-Administration of Medications dated 01/13/2020 documented each resident who wishes to self-administer medications may do so if the interdisciplinary team has determined that self-administration is clinically appropriate. The nurse would complete the Medication Self-Administration assessment in EHR and reviewed quarterly.
The facility lacked a policy of storage of medications in a resident's room.
The facility's policy Falls and Prevention dated 01/17/2017 documented all staff from all departments are part of the Fall Prevention Program and are to be stewards to fall safety. Every fall will be investigated and discussed with all available staff on the scene, using a root cause approach. One new intervention will be put in place.
The facility failed to ensure a safe environment free from accident hazards for R21, R33, R36, and R37. This placed the resident at risk for injury and preventable accidents.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with one resident reviewed for accident hazards. Based on interview, observation,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 55 residents with one resident reviewed for accident hazards. Based on interview, observation, and record review, the facility failed to ensure a safe environment for one resident with the failure to remove the keys from a facility owned vehicle/golf cart, which allowed Resident (R1) to leave the facility in the golf cart, without the knowledge of staff, and operate the vehicle on public roadways.
Findings include:
- Review of R1's Electronic Health Record (EHR) documented R1 had the diagnoses that included weakness, unspecified pain and dorsalgia (a chronic [lasting more than three months] symptom of generalized back pain which may be a result of many different conditions).
The 05/18/23 Quarterly Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The resident had no exit seeking behaviors. The resident required assistance of one staff for walking in his room, but was able to walk independently in the corridor/locomotion on/off unit/transfers. His balance during transition was not steady, but he was able to stabilize without staff assistance when moving from seated to standing position and surface to surface transfers. His balance during transition where resident was not steady and only able to stabilize with staff assistance when walking and turning around and facing the opposite direction. The resident utilized a walker or wheelchair for mobility. The resident had one non-injury fall since the previous assessment.
The Care Plan documented the following:
1. On 02/16/22, the resident was able to transfer independently but required a four-wheeled walker and staff assistance of one for ambulation and was able to self-propel independently throughout the building without staff assistance. The resident was a high risk for falls related to his fall history but lacked interventions specific to being outside the facility related to falls.
2. On 08/11/23 (after the resident had an elopement [an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff]), staff identified the resident as an elopement risk and instructed staff to assess for fall risk and have a wander guard bracelet in place (a bracelet that sets off an audible alarm with residents who are wearing one attempt to exit the building without an escort). Staff were to check the device every shift and as needed (PRN).
3. The Care Plan lacked interventions related to resident going outside the facility, unassisted and unattended.
The physician's orders lacked directions specific to the resident being allowed to go outside without staff escort or supervision.
Review of the EHR Progress Notes revealed that on 08/10/23 at approximately 04:11 PM, Physical Therapy Staff C telephoned the facility and stated that she was following R1 driving down the road in a facility owned golf cart. Further documented that R1 often goes outside independently and that R1 had not notified staff of his intention to take a golf cart off the property. R1 had not been evaluated for golf cart safety as he had never expressed an interest in driving it. Administrative Staff E and Certified Nurse Aide (CNA) F left the facility in Administrative Staff E's personal vehicle and found R1 driving and followed him until he pulled the gold cart over. CNA F then got into the golf cart and R1 drove back to the facility where he was assessed for injury. Staff educated the resident related to asking permission to leave the property and having staff assistance to get in/on the golf cart.
Review of the facility's provided witness statements revealed that CNA D documented that on 08/10/23 at approximately 04:00 PM, CNA D was leaving the facility for her break and observed R1 sitting in his wheelchair right next to the unattended golf cart. R1 did not attempt to get in the golf cart, so she continued to her vehicle without incident. CNA D reported after driving away from the facility, she noticed a golf cart driving but couldn't make out who the driver was but didn't think anything of it as others in town frequently drive golf carts on the roadway. Upon her return to the facility after her break, facility staff advised her that R1 had eloped.
Review of the facility's provided witness statements revealed on 08/10/23 at approximately 04:06 PM, Physical Therapy Staff C observed R1 sitting in his wheelchair outside as she was preparing to leave the facility at the end of her shift. When she walked to her vehicle, she noticed an empty wheelchair sitting where she had previously seen R1 seated. After leaving the facility grounds, she observed a facility owned golf cart being driven by R1. She called the facility to notify them that R1 had eloped and followed R1 to the intersection of that road and the highway. She further documented that R1 turned around and headed the opposite direction of the highway, so she stopped following the resident.
Review of the facility's provided witness statements revealed CNA F documented on 08/10/23 at approximately 04:11 PM, she left the facility with Administrative Staff E to find R1. After finding R1 and getting his attention, CNA F got in the golf cart with him and accompanied him back to the facility. CNA F reported that R1 was aware of place and direction, and was able to drive back to the facility without cuing.
Review of the facility's provided witness statements revealed that Administrative Staff E documented that on 08/10/23 at approximately 04:11 PM, he was in another staff member's office when the telephone call came in from Physical Therapy Staff C that R1 was driving a golf cart off the facility property. Administrative Staff E documented that he found R1 driving approximately three blocks from the facility. CNA F joined R1 in the golf cart and Administrative Staff E returned to the facility followed by CNA F and R1 in the golf cart.
According to www.wundergound.com for 08/10/23 at approximately 04:00 PM, the weather was sunny, 89 degrees Fahrenheit, and a [NAME] wind of 16 miles per hour (mph).
Review of the topographical elements of the facility revealed that approximately ½ mile to the north was a highway with heavy traffic.
Observation of the physical environment of the front door on 08/16/23 at 10:00 AM, revealed the main entrance was a set of electrically controlled sliding glass doors, electronically locked with a keypad on the wall that required a four-digit code entered for the doors to actuate. There was a small vestibule with a second set of electronically controlled sliding glass doors. A cul-de-sac style driveway with an awning protuberance from the building large enough to protect vehicles/residents from the weather. Right outside the main entrance, there were four chairs, two on either side of the main entrance for residents/visitors to use. The facility lacked signage on the outside of the doors to remind visitors to remove their keys from their own vehicles. Further the facility lacked signage on the inside of the doors to remind visitors to not allow residents to leave the facility without staff notification/permission.
On 08/16/23, CNA D was unavailable for interview by surveyor.
On 08/16/23 at 03:05 PM, CNA G stated that she was on duty at the time of the incident, but was not notified of an elopement until after R1 had returned to the building. CNA G stated that the training that staff had before the elopement was to go and find the resident and call for help if they found the resident.
On 08/16/23 at 03:19 PM, CNA H stated if a resident were to leave the facility, staff were to exit the building and attempt to find the missing resident, stay with them, and call for help if they found the missing resident.
On 08/16/23 at 04:00 PM, Administrative Nurse B stated that the expectation in the event of a resident who eloped was for all available personnel (not just clinical staff) to exit the building and look for the resident, stay with the resident, and call for help if found. When R1 returned to the facility, he was laughing and thought the situation was funny, and reported that the resident lacked the ability to appreciate the seriousness of the situation. Stated that the immediate intervention for re-education of the staff related to an elopement was a mass text, and that an in-person in-service training had been planned but had not happened yet, and planned on doing an inservice the following day. Additionally stated that she was able to see which staff members had opened the message and verified that it was not considered an in-service training as she was unable to verify that any staff had actually read the information. Further stated that the facility no longer kept any keys in any of the facility owned vehicles, after R1 eloped.
Review of the Course Completion History, dated 08/21/23, revealed the Understanding wandering and Elopement started on 08/16/23 at 1:06 PM, a total of three hours after the surveyor entered the facility.
The facility's Elopement Plan policy, dated 10/23/19 documented that an elopement is defined as an incident in which a resident who has impaired decision-making ability and is oblivious to his/her own safety needs leaves the facility without the knowledge or supervision of staff. Further documented that all staff would participate in a mandatory in-service regarding elopement procedures at any time that an elopement occurred.
The facility failed to ensure a safe environment for this resident, documented with moderately impaired cognition, with the failure to remove the keys from a facility owned vehicle which allowed R1 to elope from the facility and operate the vehicle on public roadways. This deficient practiced placed R1 at risk for significant injury due to accidents.
Feb 2023
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to establish and maintain a system to identify, track, and measure wounds when Residents (R) 51 admitted to the facility with two pressure injuries (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) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record. The facility further failed to identify, document, and track a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) on R54's heel, which included measurements, description, and/or follow up regarding the wound. As a result of the deep tissue injury the resident reported she experienced significant pain at the site of the injury. The facility also failed to have a system in place for the consistent tracking, monitoring, measuring, and assessing of R9's right great toe injury (initially identified as a skin issue in August of 2022, then a spider bite, then a pressure injury, later a stage II pressure injury, then a chronic ulcer) and required treatment and debridement of the ulcer in January of 2023. This deficient practice placed her at risk of worsening and further development of skin related injuries. The facility failed to establish and maintain a system to ensure the identification, tracking, monitoring, and measuring of R41's stage II pressure ulcers on his buttocks. This deficient practice placed the resident at risk of worsening and further development of skin related injuries.
Findings included:
- Review of R54's Electronic Health Record revealed the resident had a diagnosis of fracture of the right lower leg.
Review of the 01/17/23 admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and limited assistance of one-person personal hygiene. The resident required formal and clinical assessments for pressure injury risk. The resident had a risk of pressure injury development and had one or more unhealed pressure injuries. The resident had 1 unstageable pressure injury, which presented as a deep tissue injury and was present upon admission. The facility provided pressure injury care to the resident.
Review of the Pressure Injury Care Area Assessment dated 01/17/23 revealed the pressure injury CAA triggered secondary to level of assistance the resident needed with bed mobility, and the presence of a deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister). The resident was non-weight bearing on her right ankle and required extensive assistance for all activities of daily living. The note documented the resident also admitted with a deep tissue injury on her left heel, that she stated was from her fall before entering the facility. The resident's care plan would address the need for staff to monitor her injury and float her heels when she was not up in the wheelchair. She also had a risk for pressure injury development related to the level of assistance needed with activities of daily living.
Review of the Baseline Care Plan, utilized from R54's admission on [DATE] through 01/26/23 revealed the resident required limited assistance of one staff for bed mobility and extensive assistance one staff for transfers and toileting. The resident had intact skin and no skin breakdown. The care plan lacked any documentation of the resident's deep tissue injury and/or any direction to staff to care for the area or interventions to prevent further injury to the heel.
Review of the Care Plan in the Electronic Health Record dated 01/26/23 revealed the following interventions.
The resident had an activity of daily living self-care performance deficit related to non-weight bearing status of the right ankle.
The resident had potential impairment to her skin integrity.
Staff wound encourage good nutrition and hydration to promote healthier skin.
Staff were to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface.
Both care plans lacked any indication the resident had a deep tissue injury to the left heel and/or any direction to staff regarding care of the wound and/or interventions in place to prevent worsening of the wound.
Review of the 01/12/23 Braden Scale for Predicting Pressure Score Risk revealed the resident was at risk for pressure injury development.
Review of the Skin Integrity section of the admission Assessment dated 01/12/23 and signed 01/17/23, lacked any indication the resident had wound on her left heel.
Review of the Skin Observation Tool opened on 01/12/23, but not locked until 1/19/23 revealed the resident had bruising to the left heel. The tool lacked any further documentation related to the wound on the resident's heel.
The resident's Nurse's Notes lacked any documentation regarding the wound on the resident's left heel until 01/14/23, 2 days after admission.
Review of the 01/14/23 Nurse's Note revealed staff called the nurse into the resident's room do observe a darkish reddish black area on her left heel the note further documented the area had red around it. The resident reported the area was very sore to touch and measured 5 centimeters (cm). The note lacked any further measurements of the wound or description to note what part of the wound measured 5 cm.
Review of the Skin Observation Tool on 01/14/23 and locked 01/14/23 lacked any documentation regarding the wound on the resident's heel.
Review of the Licensed Nurse Administration Documentation revealed staff checked the bottom of the resident's left heel each shift and noted the resident had a deep tissue injury. Staff were to make sure it was not getting worse every shift. Staff signed the record from 01/18/22 (6 days after the area was noted in the resident's record) through 1/24/23. The administration record lacked evidence the resident had a deep tissue injury on the left heel upon admission on [DATE].
Review of the 01/19/23 Nurse's Note revealed the resident reported the resident's left heel was tender to touch and looked bruised.
Review of the 01/19/23 Nurse's Note revealed the resident had a bruise on the left heel that was not painful unless you put pressure on it.
Review of the Skin Observation Tool dated 1/21/23 and locked 1/21/23 lacked any documentation of the wound to the resident's left heel.
Review of the 01/24/23 Nurse's Note revealed the resident had a full cast from knee to toes on the right lower leg. Staff were to put Iodine on the blister on the resident's left heel.
Review of the Licensed Nurse Administration Documentation revealed an order for iodine to the blister on the resident's left heel every evening shift for wound care, which stared 01/24/23. The administration record lacked evidence the facility treated the resident's deep tissue injury prior to 01/24/23.
Review of the Skin Observation Tool dated 01/28/23 revealed the resident had a blister to the left heel. The observation lacked any measurements or further description of the wound on the resident's left heel.
Review of the 01/26/23 Nurse's Note revealed the resident wore a blue boot on the left foot for her deep tissue injury. The note lacked any further description of the resident's deep tissue injury.
Review of the 01/28/23 Nurse's Note revealed the dark area where blister was on the resident's left heel was intact with no fluid present. The note lacked any further description of the injury to the resident's left heel.
Review of the 01/29/23 Nurse's Note revealed the bottom of the resident's left heel was looking better where the blood blister was.
Observation on 01/31/23 at 05:03 PM revealed License Nurse (LN) G entered the resident's room, washed hands, and approached the resident who gave permission to remove her shoe and sock and for the surveyor to observe the wound to her left heel. The resident sat in her recliner with her shoes on and a thick sock in place on the left foot. The LN commented that the resident had a heavy sock on with her shoe. The wound to the left heel presented as a deep purple, irregular circular shape, which was approximately the size of a quarter. The LN did not measure the wound at this time and stated she would measure the wound later this shift. The LN commented the wound looked better. The wound also presented with a hardened peri-wound, which extended out around the entire border of the deep purple area and the LN identified as hard. The resident had pressure relieving boots laying on her bed, in her room. The resident reported the wound was not as painful at this time as it was in the past and at one point it hurt worse than the broken bones she had on the other leg.
An interview with the resident on 01/31/23 at 11:15 AM revealed the area to her left foot was healing up. She reported she had not really had any pain to the heel this day. The resident stated they were trying to put her shoe back on so that she could transfer with it. She reported staff were applying iodine to dry up the area on the left heel. She stated staff had not talked to her about what caused the wound to develop, so she thought if it was a bruise, it was probably from the fall. The resident reported she wore a soft boot on her foot at nighttime when she slept. The resident denied being provided education related to the rationale for the use of the boot. The resident reported she had had little pain in the left broken foot, but the right heel was very painful at times. The resident reported she was not aware she had the wound to the left heel until she moved to the facility, she stated it was far underneath the foot, so took a while for anyone to see it. The resident further reported when staff did notice it, it looked bad and was black, blue, and purple.
An interview on 01/31/23 at 03:14 PM with Certified Nurse Aide (CNA) M revealed the resident had a shoe on the left foot and she liked to have her feet up in the recliner. The resident admitted to the facility when she broke her ankle. She reported she has not seen the wound to the left heel, but thought she got it when she broke her ankle. She stated the facility was putting iodine on the resident's heel and the resident had boots for when she was in bed to remove the pressure.
An interview on 01/31/23 at 04:50 PM with LN G revealed Physician KK called the wound a blood blister (review of documentation revealed the physician identified the area as a blister) and ordered iodine as a treatment. The LN reported she thought the wound was from the fall when she fell and broke the ankle. She reported she saw the wound every night to know how the wound was progressing, when she put the iodine on it. The LN reported she was not routinely measuring the wound, but did measure it the first time she saw it. She stated she documented information regarding the wounds some in the nurse's notes. They used a boot in bed to float the resident's heels. When the wound was first identified, she looked at it then the MDS nurse said it was a deep tissue injury. The LN reported the soft boots were added when the MDS nurse thought it was a deep tissue injury and not a bruise. The LN reported there should be a care plan for the resident regarding her wound and the boots she wore at night. The LN reported she would measure the wound and put a note in later this day and would add interventions to the resident's care plan.
An interview on 02/01/23 at 11:18 AM with Administrative Nurse D revealed the facility really did not have a specific system for tracking wounds. If a someone found a wound, they would go get one of the two RNs to look at it and confirm it and they also decided what caused the wound. Administrative Nurse D would expect measurements and documentation on a deep tissue injury. She further would expect to see a deep tissue injury and interventions such as a pressure relieving (soft) boot on the resident's care plan.
Review of the policy Skin Protocol - Staging and Care updated 08/12/22 revealed for deep tissue injuries would be defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, [NAME], purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain will often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The policy directed staff to utilize the following equipment for residents at risk for skin breakdown: pressure reducing devices, lotion for pressure areas and moisture barrier, temporary care plans, and Braden pressure ulcer risk assessments. Staff were directed to review residents for immobility, use Braden scaled to determine risk on admission, utilize individualized repositioning schedules with pressure reducing devices, and document date, time and describe skin conditions in resident records.
The facility failed to identify, document, and track a deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) on R54's heel, which included measurements, description, and/or follow up regarding the wound. As a result of the deep tissue injury the resident reported she experienced significant pain
- Review of the R51's Electronic Health Record revealed the resident had diagnoses of fracture of the right femur (thigh bone) and Parkinson's Disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness).
Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. The resident required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and extensive assistance of one staff for personal hygiene.
Review of the 12/05/22 Pressure Injury Care Area Assessment revealed the assessment triggered secondary to level of assistance needed and pressure injuries prior to admission. R51 admitted to the facility with two pressure injuries identified as a stage I (characterized by superficial reddening of the skin (or red, blue, or purple hues in darkly pigmented skin) that when pressed does not turn white (non-blanchable erythema) and a stage II (redness with the loss of partial thickness of the skin including epidermis and part of the superficial dermis). The assessment noted the pressure injuries worsened during a recent hospital stay.
Review of the 12/12/22 (admission) Braden Scale for Predicting Pressure Sore Risk revealed the resident had a moderate risk of pressure injury development.
Review of the 01/01/22 (most recent) Braden Scale for Predicting Pressure Sore Risk revealed the resident was at risk for pressure injury development.
Review of the Care Plan initiated 10/26/22 revealed the following interventions:
Staff would know the resident had an Activity of Daily Living (ADL) self-care performance deficit related to weakness.
Staff would know the resident had limited physical mobility related to weakness, Parkinson's disease, and a recent hip fracture/surgery.
The resident had pressure ulcers on his right and left inner buttocks.
Staff would administer treatments as ordered and monitor for effectiveness.
Staff would assess, record, and monitor wound healing.
Staff would assess and document the status of wound perimeter, wound bed and healing progress.
Staff would report improvements and declines to the MD
Staff would provide education as to the causes of skin breakdown.
Staff would monitor dressing.
Staff would apply moisture to the resident's buttocks.
Staff would turn and reposition the resident at least every 2 hours.
Weekly treatment documentation included measurement of each pressure ulcer.
Review of the 10/11/22 Skin Observation Tool revealed the resident had a pressure injury on the left buttock, which measured 3 centimeters (cm) long by 1 cm wide, with a reddened peri-wound. The right buttock also had a pressure injury, which measured 0.25 cm length by 0.25 cm width.
Review of the 10/12/22 Nurse's Note revealed the resident admitted to the facility the previous day. The resident's skin looked pretty good. The resident had an open area identified as pea size on the right buttock. The note lacked any assessment of the left buttock wound.
Review of the 10/15/22 Skin Observation Tool revealed the resident had small open areas on both inner buttocks, both approximately 0.2 cm x 0.2 cm., the observation lacked any further description of the wound.
Review of the 10/16/22 Nurse's Note revealed the resident had tiny open areas on both inner buttocks. The note lacked any further description of the wound.
Review of the 10/17/22 Nurse's Note revealed the facility requested a dressing change for the super superficial areas on the resident's buttocks and the dry peeling skin.
Review of the 10/20/22 Nurse's Note revealed the resident had dry, flakey skin that was slightly pink with no signs or symptoms of infection, such as bruising, drainage, odor and no open areas. The note lacked identification of where the resident had pink, dry, flakey skin. The Note lacked evidence of what skin was assessed to be intact or evidence the pressure injuries the resident admitted to the facility with were healed.
Review of the 10/22/22 Skin Observation lacked any documentation about the resident's buttock wounds and/or the resident's pink, dry, flakey skin.
Review of the 10/23/22 Nurse's Note revealed the resident had no skin breakdown. The resident had a skin tear to his left elbow. The nurse's note lacked documentation of how the resident obtained the skin tear to his left elbow. The record further lacked any additional assessment of the skin tear, which included measurements, description, or treatment of the wound.
Review of the 10/28/22 Nurse's Note revealed the resident's buttock wound healed at this time.
Review of the 11/12/22 Skin Observation Tool revealed the resident had a red, raw area, which measured 1.4 cm x 0.8 cm on the left heel. Both feet had dry, flaky skin on the soles.
Review of the 11/12/22 Nurse's Note revealed the resident had peeling skin on both feet and a raw area noted to the left heel. The resident wore boots with an open heel when in his recliner or bed and staff were to keep pressure off of the wound.
Review of the 11/19/22 Skin Observation Tool revealed the resident's heel was pink and healing well. The observation lacked any measurements of the wounds.
Review of the 11/28/22 Nurse's Note revealed the resident returned to the facility from the hospital with a dressing to the right upper outer thigh [related to a surgical wound]. The resident had dry and peeling feet. The resident had an open area to the buttocks, which measured 7 cm around area from left to right buttock cheek area with pea size black area in the middle of the red/purple area, which did not blanch when touched.
Review of the 12/02/22 Nurse's Note revealed the resident's buttocks were looking much better the black area that was on buttock last night was gone and the resident had peeling skin, which was dry with some very small open areas.
Review of the 12/03/22 Skin Observation Tool revealed the resident had a reddened left heel red, pressure ulcer to gluteal cleft, and incision to thigh. The observation lacked any measurements or any further description of the wounds.
Review of the 12/04/22 Nurse's Note revealed the resident's buttock was red/purple with an open area to inner right buttock cheek (with no measurements provided). The left buttock cheek had a 0.3 cm black hard area noted (the note lacked any further description of the area). The resident's left heel was pink and healed.
Review of the 12/08/22 Nurse's Note revealed the resident had blood in his brief at bedtime and the nurse assessed his buttocks and noted pinpoint openings and a larger purplish area (no measurement) on the left buttock.
Review of the 12/09/22 Nurse's Note revealed regarding the resident's buttocks the entire area (no measurements) had an underlying brown coloring to it and documented it as dry and scaly. The resident's left buttock had a purple, pink area (no measurement) with a yellow drainage area that was open later in the night. It appeared that the yellow drainage area now had a small pinpoint scab.
Review of the 12/10/22 Skin Observation Tool revealed the resident had a small scab on his coccyx (1st observation of wound on coccyx). The observation documented otherwise skin integrity is fine. The note lacked any observation of the brown coloring or yellow drainage area noted on the resident's buttocks noted in the 12/09/22 nurse's note. The observation further lacked any measurement of the scab or wounds.
Review of the 12/17/22 Skin Observation Tool lacked any concerns related to the resident's skin.
Review of the 12/18/22 Nurse's Note revealed the resident had a red/purple are on the right buttock (no measurement) with open area to the inner right buttock cheek (no measurement) The resident had a 0.3 cm black hard area on the left buttock.
The later 12/18/22 Nurse's Note revealed the resident had mild redness on buttocks with small opening on left buttocks.
Review of the 12/23/22 Nurse's Note revealed the resident had a red area to the upper left thigh/low groin area. The note lacked any measurement of the area.
Review of the 12/24/22 Skin Observation Tool revealed the resident had a light purple bruise on his left wrist (no measurement), a dime-sized purple bruise on the right forearm, and a
skin tear (no measurement or description) on the back of right hand. The note lacked any further investigation into how the resident obtained the wounds.
Review of nurse's notes from 12/24/22 to 01/07/22 (14 days) lacked any additional documentation of the coccyx wound, darkened/purple/red area to right buttock, scab on left buttock, red area to upper left thigh groin area, bruises and/or skin tear mentioned in prior Nurse's Notes or Skin Observation Tools.
Review of the 01/07/22 Skin Observation Tool lacked any description of the wounds
An interview at 10:10 AM on 02/01/23 with Certified Nurse Aide (CNA) N and CNA O revealed they did not believe the resident had any current wounds. They would tell the nurse if skin concerns arose.
An interview at 10:15 AM on 02/01/23 with Licensed Nurse H revealed the facility monitored wounds by scheduling the same Nurse's most of the time so they could check in and see how the wounds were doing. They would notify the physician if they had concerns with wound healing after a few days. The licensed nurse reported there was not a lot of documentation on size, since most of the wounds they identified were fairly small. The resident's wounds were supposed to be documented. The LN reported it would have been nice if they said the wounds were healed or documented the progress of the wounds.
An interview on 02/01/23 at 11:10 AM with Administrative Nurse D revealed the facility did not really have a big problem with wounds. She stated for a while, she would not say they had a [wound] tracking system. The wounds would be treated every day so a nurse would see them. Most often two nurses looked at wounds. If there was a skin problem identified, the LN would go to the MDS coordinators who are essentially nurse managers for each side, and they would consult the doctor. Administrative Nurse D stated there is no formal process for tracking and/or monitoring wounds. If a skin issue was identified staff would fill out an incident report and would add an intervention to the care plan. Facility staff gave the incident reports to the Licensed Nurse manager, and they would review those with falls. Administrative Nurse D stated she would expect measurements of wounds, but there was currently not any sort of formal process in place.
Review of the policy Skin Protocol - Staging and Care updated 08/12/22 revealed the policy directed staff to utilize the following equipment for residents at risk for skin breakdown: pressure reducing devices, lotion for pressure areas and moisture barrier, temporary care plans, and Braden pressure ulcer risk assessments. Staff were directed to review residents for immobility, use Braden scaled to determine risk on admission, utilize individualized repositioning schedules with pressure reducing devices, and document date, time and describe skin conditions in resident records.
The facility failed to establish and maintain a system to identify, track, and measure wounds when R51 admitted to the facility with 2 pressure injuries (partial-thickness loss of skin with exposed dermis) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record.
- Review of R9's Electronic Health Record (EHR) revealed the resident had the following diagnoses: history of 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) and pain.
The 07/14/22 Annual Minimum Data Set (MDS) noted R9 with a BIMS score of two, indicating severe cognitive impairment. The resident required extensive one staff assistance with most activities of daily living (ADL) and she used a walker and wheelchair for mobility. The MDS documented the determination of pressure ulcer risk included a formal assessment instrument/tool and clinical assessment. The MDS noted the resident was not at risk of developing pressure ulcers, had no unhealed pressure ulcers, and did not have venous or arterial ulcers. The MDS documented the received skin and ulcer treatments included a pressure reducing device for her chair, turning/repositioning program, applications of ointments/medications other than to feet, and application of dressings to her feet (with or without topical medications).
The 10/13/22 Quarterly MDS noted the resident with a BIMS score of one, indicating severely impaired cognition. The resident required extensive assistance of one-to-two staff for most ADL, was totally dependent upon one staff for bathing, and used a walker and wheelchair for mobility. The MDS determination of pressure ulcer risk included a formal assessment instrument/tool and clinical assessment, and documented the resident was not at risk of developing pressure ulcers, she had no unhealed pressure ulcers, and she did not have venous or arterial ulcers. The MDS documented received skin and ulcer treatments included a pressure reducing device for her chair and application of ointments/medications other than to feet.
The 01/12/23 Quarterly MDS noted R1 continued with a BIMS score of one, required extensive one staff assistance with most ADL, and used a walker and wheelchair for mobility. The MDS determination of pressure ulcer risk included formal assessment instrument/tool and clinical assessment and documented the resident was not at risk of developing pressure ulcers, she had no unhealed pressure ulcers, and did not have venous or arterial ulcers. The MDS did note the resident had other open lesion(s) on her foot and she received skin and ulcer treatments to include a pressure reducing device for her chair and application of ointments/medications other than to feet.
The 01/19/23 Nursing Concerns section of the Care Plan noted R9 had a hospital stay and tried to go home but could not care for herself due to increased weakness. The Care Plan had an intervention dated 07/23/22 which noted the resident had a scab on her right toes and interventions included for staff to tent the blanket over her toes, and apply lotion as needed (PRN).
The 01/10/23 Physician Order included an order, which started on 07/09/20, for a weekly skin assessment by a Licensed Nurse (LN) one time a day every Thursday.
The Skin Observation Tool, located in the Assessment Tab in Electronic Health Record, is an electronic skin assessment form which displays outlined drawings of the full frontside and backside of the human body and notes 55 sites on the body, plus has an area each Licensed Nurse (LN) can specifically type in the body area of concern, if not included in the numbered 55 sites. The form also included a list of definitions for pressure ulcer stages as follows:
Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wo[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with one resident sampled for an injury of unknown origin. Based on observation, interview, and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with one resident sampled for an injury of unknown origin. Based on observation, interview, and record review the facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries.
Findings included:
- Review of the R51's Electronic Health Record revealed the resident had diagnoses of fracture of the right femur (thigh bone) and Parkinson's Disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness).
Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of two, which indicated severely impaired cognition. The resident required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and extensive assistance of one staff for personal hygiene.
Review of the Care Plan initiated 10/26/22 revealed the following interventions:
Staff would know the resident had an Activity of Daily Living (ADL) self-care performance deficit related to weakness.
Staff would know the resident had limited physical mobility related to weakness, Parkinson's disease, and a recent hip fracture/surgery.
Staff would assess, record, and monitor wound healing.
Staff would assess and document the status of wound perimeter, wound bed and healing progress.
Staff would report improvements and declines to the MD
Staff would provide education as to the causes of skin breakdown.
Staff would monitor dressing.
Review of the 12/24/22 Skin Observation Tool revealed the resident had a light purple bruise on his left wrist (no measurement), a dime-sized purple bruise on the right forearm, and a skin tear (no measurement or description) on the back of right hand. The note lacked any further documentation into how the resident obtained the wound, how the skin tear was treated, interventions to prevent further injuries, and healing of the areas.
The facility failed to provide an investigation into how the resident obtained the bruising to his left wrist, right forearm, and skin tear, which he obtained on 12/24/22.
Observations on 02/02/23 revealed the resident rested in his chair with no sign/symptoms of distress or fear. The resident had no observable injuries or wounds at the time of the observation.
An interview at 10:10 AM on 02/01/23 with Certified Nurse Aide (CNA) N and CNA O revealed they would tell the nurse if they had any concerns related to the resident's skin or care.
An interview at 10:15 AM on 02/01/23 with Licensed Nurse H revealed there was not a lot of documentation on wounds, since the ones they identified were fairly small. The resident's wounds were supposed to be documented. The LN stated she would look into how bruising and skin tears occurred and report further if needed.
An interview on 02/01/23 at 11:10 AM with Administrative Nurse D revealed the facility did not really have a big problem with wounds. She stated for a while, she would not say they had a [wound] tracking system. If there was a skin problem identified, the LN would go to the MDS coordinators who are essentially nurse managers for each side, and they would consult the doctor. Administrative Nurse D stated there is no formal process for tracking and/or monitoring wounds. If a skin issue was identified staff would fill out an incident report and would add an intervention to the care plan. Facility staff gave the incident reports to one of the Licensed Nurse managers and they would review those with falls. Administrative Nurse D stated she would expect measurements of wounds, but there was currently not any sort of formal process in place. Administrative Nurse D further verified the injuries to the resident's wrist, forearm, and hand were not reported and further investigated by the facility. Administrative Nurse D stated she would have expected the wounds to be investigated.
Review of the facility policy Abuse, Neglect, Exploitation including Social Networking updated 03/30/17 revealed all personnel would promptly report any incident, which included injuries of an unknown source to the supervisor or charge nurse. The charge nurse would ensure an incident report would be completed and a confidential thorough investigation would be completed and documented.
The facility failed to initiate an investigation, when R51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with 4 sampled for pressure injuries. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care, when the resident developed a deep tissue injury to the left heel with no documentation or interventions in place on the resident's baseline care plan.
Findings included:
- Review of R54's Electronic Health Record revealed the resident had a diagnosis of fracture of the right lower leg.
Review of the 01/17/23 admission Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident required formal and clinical assessments for pressure injury risk. The resident had a risk of pressure injury development and had one or more unhealed pressure injuries. The resident had 1 unstageable pressure injury, which presented as a deep tissue injury and was present upon admission. The facility provided pressure injury care to the resident.
Review of the Pressure Injury Care Area Assessment dated 01/17/23 revealed the pressure injury CAA triggered secondary to level of assistance the resident needed with bed mobility, and the presence of a deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister). The resident was non-weight bearing on her right ankle and required extensive assistance for all activities of daily living. The note documented the resident also admitted with a deep tissue injury on her left heel, that she stated was from her fall before entering the facility. The resident's care plan would address the need for staff to monitor her injury and float her heels when she was not up in the wheelchair. She also had a risk for pressure injury development related to the level of assistance needed with activities of daily living.
Review of the Baseline Care Plan, utilized from R54's admission on [DATE] through 01/26/23 revealed the resident required limited assistance of one staff for bed mobility and extensive assistance one staff for transfers and toileting. The resident had intact skin and no skin breakdown. The baseline care plan lacked any indication the resident had a deep tissue injury to the left heel and/or any direction to staff regarding care of the wound and/or interventions (such as soft boots when in bed) in place to prevent worsening of the wound.
Review of the 01/12/23 Braden Scale for Predicting Pressure Score Risk revealed the resident was at risk for pressure injury development.
Review of the Skin Integrity section of the admission Assessment dated 01/12/23 and signed 01/17/23, lacked any indication the resident had wound on her left heel.
Review of the Skin Observation Tool opened on 01/12/23, but not locked until 1/19/23 revealed the resident had bruising to the left heel. The tool lacked any further documentation related to the wound on the resident's heel.
The resident's Nurse's Notes lacked any documentation regarding the wound on the resident's left heel until 01/14/23, 2 days after admission.
Review of the 01/14/23 Nurse's Note revealed staff called the nurse into the resident's room do observe a darkish reddish black area on her left heel the note further documented the area had red around it. The resident reported the area was very sore to touch and measured 5 centimeters (cm). The note lacked any further measurements of the wound or description to note what part of the wound measured 5 cm.
Review of the Skin Observation Tool on 01/14/23 and locked 1/14/23 lacked any documentation regarding the wound on the resident's heel.
Review of the Licensed Nurse Administration Documentation revealed staff checked the bottom of the resident's left heel each shift and noted the resident had a deep tissue injury. Staff were to make sure it was not getting worse every shift. Staff signed the record from 01/18/22 (6 days after the area was noted in the resident's record) through 1/24/23. The administration record lacked evidence the resident had a deep tissue injury on the left heel upon admission on [DATE].
Review of the 01/19/23 Nurse's Note revealed the resident reported the resident's left heel was tender to touch and looked bruised.
Review of the 01/19/23 Nurse's Note revealed the resident had a bruise on the left heel that was not painful unless you put pressure on it.
Review of the Skin Observation Tool dated 01/21/23 and locked 01/21/23 lacked any documentation of the wound to the resident's left heel.
Review of the 01/24/23 Nurse's Note revealed the resident had a full cast from knee to toes on the right lower leg. Staff were to put Iodine on the blister on the resident's left heel.
Review of the Licensed Nurse Administration Documentation revealed an order of iodine to the blister on the resident's left heel every evening shift for wound care, which stared 01/24/23. The administration record lacked evidence the facility treated the resident's deep tissue injury prior to 01/24/23.
Review of the Skin Observation Tool dated 01/28/23 revealed the resident had a blister to the left heel. The observation lacked any measurements or further description of the wound on the resident's left heel.
Review of the 01/26/23 Nurse's Note revealed the resident wore a blue boot on the left foot for her deep tissue injury. The note lacked any further description of the resident's deep tissue injury.
Review of the 01/28/23 Nurse's Note revealed the dark area where blister was on the resident's left heel was intact with no fluid present. The note lacked any further description of the injury to the resident's left heel.
Review of the 01/29/23 Nurse's Note revealed the bottom of the resident's left heel was looking better where the blood blister was.
Observation on 01/31/23 at 05:03 PM revealed License Nurse (LN) G entered the resident's room, washed hands, and approached the resident who gave permission to remove her shoe and sock and for the surveyor to observe the wound to her left heel. The resident sat in her recliner with her shoes on and a thick sock in place on the left foot. The LN commented that the resident had a heavy sock on with her shoe. The wound to the left heel presented as a deep purple, irregular circular shape, which was approximately the size of a quarter. The LN did not measure the wound at this time and stated she would measure the wound later this shift. The LN commented the wound looked better. The wound also presented with a hardened peri-wound, which extended out around the entire border of the deep purple area and the LN identified as hard. The resident had pressure relieving boots laying on her bed, in her room. The resident reported the wound was not as painful at this time as it was in the past and at one point it hurt worse than the broken bones she had on the other leg.
An interview with the resident on 01/31/23 at 11:15 AM revealed the area to her left foot was healing up. She reported she had not really had any pain to the heel this day. The resident stated they were trying to put her shoe back on so that she could transfer with it. She reported staff were applying iodine to dry up the area on the left heel. She stated staff had not talked to her about what caused the wound to develop, so she thought if it was a bruise, it was probably from the fall. The resident reported she wore a soft boot on her foot at nighttime when she slept. The resident denied being provided education related to the rationale for the use of the boot. The resident reported she had had little pain in the left broken foot, but the right heel was very painful at times. The resident reported she was not aware she had the wound to the left heel until she moved to the facility, she stated it was far underneath the foot, so took a while for anyone to see it. The resident further reported when staff did notice it, it looked bad and was black, blue, and purple.
An interview on 01/31/23 at 03:14 PM with Certified Nurse Aide (CNA) M revealed the resident admitted to the facility when she broke her ankle. She reported she has not seen the wound to the left heel, but thought she got it when she broke her ankle. She stated the facility was putting iodine on the resident's heel and the resident had boots for when she was in bed to remove the pressure.
An interview on 01/31/23 at 04:50 PM with LN G revealed Physician KK called the wound a blood blister (review of documentation revealed the physician identified the area as a blister) and ordered iodine as a treatment. The LN reported she thought the wound was from the fall when she fell and broke the ankle. She reported she saw the wound every night to know how the wound was progressing, when she put the iodine on it. The LN reported she was not routinely measuring the wound, but did measure it the first time she saw it. She stated she documented information regarding the wounds some in the nurse's notes. They used a boot in bed to float the resident's heels. When the wound was first identified, she looked at it then the MDS nurse said it was a deep tissue injury. The LN reported the soft boots were added when the MDS nurse thought it was a deep tissue injury and not a bruise. The LN reported there should be a care plan for the resident regarding her wound and the boots she wore at night. The LN reported she would measure the wound and put a note in later this day and would add interventions to the resident's care plan.
An interview on 02/01/23 at 11:18 AM with Administrative Nurse D revealed the facility really did not have a specific system for tracking wounds. If a someone found a wound, they would go get one of the two RNs to look at it and confirm it and they also decided what caused the wound. Administrative Nurse D would expect measurements and documentation on a deep tissue injury. She further would expect to see a deep tissue injury and interventions such as a pressure relieving (soft) boot on the resident's care plan.
Review of the policy Skin Protocol - Staging and Care updated 08/12/22 revealed for deep tissue injuries would be defined as intact or non-intact skin with localized area of persistent non-blanchable deep red, [NAME], purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain will often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The policy directed staff to utilize the following equipment for residents at risk for skin breakdown: pressure reducing devices, lotion for pressure areas and moisture barrier, temporary care plans, and Braden pressure ulcer risk assessments. Staff were directed to review residents for immobility, use Braden scaled to determine risk on admission, utilize individualized repositioning schedules with pressure reducing devices, and document date, time and describe skin conditions in resident records.
The facility failed to develop and implement a baseline care plan for R54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care of the resident's deep tissue injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with one resident sampled for non-pressure related skin conditions. Based on observation, interv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 54, with one resident sampled for non-pressure related skin conditions. Based on observation, interview, and record review the facility failed to identify, document, track, and measure skin issues when Resident (R) 23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record.
Findings included:
- Review of R23's Electronic Health Record revealed the resident had a diagnosis of unilateral primary osteoarthritis (inflammation of one or more joints), dysthymic disorder (chronic form of depression), and erythema intertrego (inflamed areas from skin-to-skin contact).
Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed R23 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The resident required limited assistance of one staff for bed mobility, transfer, toilet use, personal hygiene, and dressing.
Review of the 03/17/22 Pressure Injury Care Area Assessment (CAA) revealed R23's level of activity of daily living assistance, her time spent in the recliner, edema and occasional incontinence put her a risk for pressure ulcers.
put
Review of the Care Plan revealed the resident required limited assistance with most transfers.
The Skin Care Plan reviewed 12/22/22 revealed the R23 did not have chronic skin problems. It stated she was at risk for pressure injury and high risk for skin tear due to fragile skin. The nurse should do a skin assessment weekly to monitor for any changes in skin condition. did not address skin issues. The Wound Care Plan sheet had the following additions:
1/24/21 Skin tear to left wrist, assist with watch band, ensure its not to tight.
9/11/21 Skin tear to right forearm, continue to monitor old/new bruises.
1/15/22 Skin tear to left hand, maintenance to pad corners of side table.
9/11/22 Bruise to right wrist, continue interventions in place
9/13/22 Skin tear to left forearm, follow wound care orders.
12/22/22 skin tear left elbow, pad corners of table, follow wound care orders.
Review of the Nurse's Note dated 12/27/21 revealed R23 sustained a 6.5-centimeter (cm) skin tear to her right forearm. R23 stated she scratched her arm and noticed the blood. Staff covered the area with gauze and paper tape. The note lacked any further description of the wound.
The Nurses Note dated 12/28/21 revealed R23 had a long scratch on her right forearm. The area was cleansed with normal saline and a band aid applied. The note lacked any further description of the wound.
Review of the Nurses Note dated 01/3/22 revealed the area to the right forearm was closed and was left open to air. The note lacked any further description of the wound.
Review of the 07/27/22 Nurses Note revealed R23 went out to an appointment for removal of a left ear lesion. R23 returned with a band aid intact and no bleeding noted. New order revealed to clean the left pineal wound area daily, apply triple antibiotic ointment, and cover if needed. Sutures were to be removed 08/08/22. The note lacked any further description of the wound.
Review of the 07/28/22 Nurses Note revealed the band-aide to the left ear was removed. Tiny amount of bleeding was noted from the stitch at the top of the ear. Note continued to reveal the sutures were intact, the area was cleansed with normal saline, triple antibiotic ointment utilized, and band-aid replaced. R23 was noted to have pain in the ear and was taking routine pain medications. The note lacked any further description of the wound.
Review of the 07/30/22 Nurses Note revealed staff completed wound care to the left ear. Old blood to band aid was noted during wound care. Sutures were intact and no bleeding was noted. Triple Antibiotic Ointment was applied, and the area was left open to air. The note lacked any further description of the wound.
Review of the 08/08/22 Nurses Note revealed R23 went to the clinic to have sutures removed from the left ear where a squamous cell cancer was removed. New orders were given to continue application of triple antibiotic ointment for three days. The note lacked any further description of the wound.
Review of the 09/13/22 Nurses Note revealed a direct care staff reported R23 received a skin tear putting her house coat on. The skin tear was on her left forearm, circular in shape. The area was cleansed and Opti foam (adhesive foam dressing) was placed. The note lacked any further description of the wound.
The Nurses Note dated 09/25/22 revealed the Opti foam dressing was changed to the left arm skin tear. Part of the area was still open and bled a tiny amount. Staff cleansed the area with normal saline and an Opti foam dressing was applied. The large reddish-purple bruise surrounding the skin tear was faded. The note lacked any further description of the wound.
Review of the Nurses Note on 12/22/23 revealed R23 bumped her left elbow when taking off her dress. R23 sustained a 0.4-centimeter (cm) C shaped skin tear to her outer left elbow. Area cleansed with normal saline and a band aide was applied. The note lacked any further description of the wound.
A 12/23/22 Nurses Note revealed that R23's left elbow skin tear that was covered with a band aid had a large amount of bloody drainage. The band aid was discontinued, and Opti-foam dressing was placed on the area. The note revealed there was a small amount of bleeding during the dressing change. The note lacked any further description of the wound.
Review of the Skin Observation Tool date d 12/23/22 revealed a skin tear and bruising to left elbow. The note lacked any further description of the wound.
Review of the 12/25/22 Nurses Note revealed the left elbow Opti foam was intact. The note lacked any further description of the wound.
Review of the 12/27/22 Nurses Note revealed the nurse was alerted that the Opti foam dressing on the left elbow was starting to come off. The note revealed there was another little sore where some adhesive was. This area was distal to the sore under the Opti foam. The skin tear was superficial and about dime sized. Both areas were cleansed with saline and dried. New Opti foam was applied to the left elbow and a Duoderm Dot(transparent dressing for wounds) was applied to the skin tear further down the forearm as the Opti foam did not cover both areas. The note lacked any further description of the wound.
Review of the 12/29/22 Nurse's Notes revealed the facility received a signed physician order for wound treatment for Opti foam to the left elbow skin tear. The note lacked any further description of the wound.
Review of the Skin Observation Tool dated 12/30/22 revealed there was a skin tear to the left elbow- Opti foam intact and a skin tear to left forearm below the left elbow skin tear, duoderm spot dressing intact. The note lacked any further description of the wound.
An observation on 01/23/23 at 02:28 PM, R23 self-propelled herself in wheelchair back from an activity. Arms covered with sweater; no bruising noted to hands. Oxygen in use, no signs of pain or discomfort noted.
Interview on 02/01/23 at 10:05 AM with Certified Nurse Aide (CNA) P revealed the resident was able to reposition herself and was able to make her needs known. He was not aware of any skin issues currently. He stated when a skin issue, skin tear, or bruise was seen staff should tell the nurse on duty.
Interview on 02/01/23 at 10:28 AM, Licensed Nurse (LN) I revealed that R23 was able to make her needs known. The resident did have skin tears at times that were cleansed and covered.
An interview on 02/01/23 at 11:18 AM with Administrative Nurse D revealed the facility really did not have a specific system for tracking wounds. If a someone found a wound, they would go get one of the two RNs to look at it and confirm it and they also decided what caused the wound. Administrative Nurse D would expect measurements and documentation on wounds. She further would expect to see an injury and interventions on the resident's care plan.
Review of the policy Wound Care last updated 08/12/22 revealed all wounds including skin tears and abrasions would be treated per standing physician's orders unless otherwise noted. Staff would document wound care by completing the nurse's note in the electronic charting system at least weekly.
The facility failed to identify, document, and track and measure skin issues when R23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
The facility reported a census of 54 residents. Based on observations, interviews, and record review the facility failed to ensure the competency of Licensed Nurses in the facility regarding wound/ski...
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The facility reported a census of 54 residents. Based on observations, interviews, and record review the facility failed to ensure the competency of Licensed Nurses in the facility regarding wound/skin issues of residents to include the monitoring, measuring, identifying of skin issues and pressure injuries (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). This deficient practice placed any resident with potential skin issues, at risk of worsening and further development of skin related injuries. (See F610, F655, F684, F686)
Findings included:
- Upon day one of survey in the facility on 01/30/23, the facility provided a Matrix form, which identified only Resident (R)51 with a stage I pressure ulcer.
Upon interview with Administrative Nurse D on 02/01/23 the facility provided another Matrix form (dated 02/01/23 at 09:40 AM), which identified R41with a stage II pressure ulcer and R51 with a stage I pressure ulcer.
Investigation revealed the lack of ensuring Licensed Nurse competencies regarding skin issues/wounds added to the deficient practice as follows:
1. The facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries. (See F610)
2. The facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care, when the resident developed a deep tissue injury to the left heel with no documentation or interventions in place on the resident's baseline care plan. (See 655)
3. The facility failed to identify, document, track, and measure skin issues when Resident (R) 23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record. (See F684)
4. The facility failed to establish and maintain a system to identify, track, and measure wounds when Residents (R) 51 admitted to the facility with two pressure injuries (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) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record. The facility further failed to identify, document, and track a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) on R54's heel, which included measurements, description, and/or follow up regarding the wound. As a result of the deep tissue injury the resident reported she experienced significant pain at the site of the injury. The facility also failed to have a system in place for the consistent tracking, monitoring, measuring, and assessing of R9's right great toe injury (initially identified as a skin issue in August of 2022, then a spider bite, then a pressure injury, later a stage II pressure injury, then a chronic ulcer) and required treatment and debridement of the ulcer in January of 2023. This deficient practice placed her at risk of worsening and further development of skin related injuries. The facility failed to establish and maintain a system to ensure the identification, tracking, monitoring, and measuring of R41's stage II pressure ulcers on his buttocks. This deficient practice placed the resident at risk of worsening and further development of skin related injuries. (See F686)
Interview on 01/31/23 at 05:11 PM with LN K revealed no one told her to measure a wound each time and stated she did not do so, but she saw the residents frequently and knew what the wounds looked like to know the difference. She stated she did not measure the wounds each time and no one at the facility had talked to her about measuring wounds.
Interview with LN H on 02/01/23 at 08:25 AM revealed she typically works the hallway in which R9 resides. LN H stated she really did not need to look at the care plans as she is here all of the time, but she knew where the care plans were and she received updates prior to every shift. LN H stated she did not measure the wound each time and not one had told her to do so, but it made sense to do so. LN H said they put the observation of wounds on the weekly skin assessment, but stated they did not measure them, but she may say sometimes that it would be pea-size. When she sees something new regarding skin, she informs Administrative Nurse E or Administrative Nurse F and Administrative Nurse D and they can talk about the wound. LN H stated the facility had online competencies but admitted she had not completed any this year. LN H stated no one at the facility had talked to her about measuring wounds.
An interview on 02/01/23 at 08:56 AM with Administrative Nurse D revealed the facility really did not have a specific system for tracking wounds. If the staff found a skin issue, the staff informed either Administrative Nurse E or Administrative Nurse F and they would look at it and they classified it and decided what caused it. Administrative Nurse D stated R41 came in with those wounds and they would open and then heal, but he liked to sleep in his recliner and it was not pressure, but more of a shearing that was causing it. She stated she had not seen them recently. Administrative Nurse D stated R41 was not listed on the Matrix for pressure ulcer as they went off of the MDS to see who went on the Matrix. After clarification of the Matrix instructions, Administrative Nurse D did review and provide another Matrix which did list R41 with a stage II pressure ulcer. Administrative Nurse D expected measurements and documentation on wounds. She further expected to see wounds and interventions on the resident's care plan. Administrative Nurse D stated she had not specifically talked to her staff about measurements or wound care as that was more on the charge nurse. Administrative Nurse D state she did not review the Skin Observation Tool and could not say knew of the LN wound competencies on wound measurements. Administrative Nurse D later came back later that morning and discussed R41's wounds and stated she was not making an excuse, but felt the wound was chronic and the staff had become somewhat accustomed to the wound, and she thought that might be why they had not documented more consistently on the wound.
Review of the policy Wound Care last updated 08/12/22 revealed all wounds including skin tears and abrasions would be treated per standing physician's orders unless otherwise noted. Staff would document wound care by completing the nurse's note in the electronic charting system at least weekly.
The facility failed to ensure the competencies of Licensed Nurses in order to have a system to identify, track, and measure wounds; ensure wounds are reported and/or investigated to determine origin when not known; and ensure staff know to implement care plan interventions regarding deep tissue injuries. This deficient practice placed all resident with skin issues/potential skin issues and wounds at risk of worsening and further development of skin related injuries.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
The facility reported a census of 54 residents. Based on observation, interview, and record review the facility failed to ensure the QAPI committee developed and implemented timely action plans to add...
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The facility reported a census of 54 residents. Based on observation, interview, and record review the facility failed to ensure the QAPI committee developed and implemented timely action plans to address the quality deficiencies as identified in the annual health resurvey. This failure placed all resident with actual and/or potential skin integrity issues at risk.
Findings included:
- During the annual health resurvey conducted on 01/30-02/01/23 the following concerns were identified:
1. The facility failed to initiate an investigation, when Resident (R) 51 sustained bruising to his left wrist, right forearm, and a skin tear to the back of his right hand with no documentation or follow to determine the origin of the resident's injuries. The facility further failed to place interventions/protections, to ensure the resident did not sustain further injuries. (See F610)
2. The facility failed to develop and implement a baseline care plan for Resident (R) 54, which included instructions needed to provide effective and person-centered care of the resident and met professional standards of quality care, when the resident developed a deep tissue injury to the left heel with no documentation or interventions in place on the resident's baseline care plan. (See 655)
3. The facility failed to identify, document, track, and measure skin issues when Resident (R) 23 had multiple skin tears, bruising and surgical removal of a cancerous lesion on the ear and had no measurements, description or follow up documented in the R23's record. (See F684)
4. The facility failed to establish and maintain a system to identify, track, and measure wounds when Residents (R) 51 admitted to the facility with two pressure injuries (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) and had multiple wounds develop with no measurements, description, or follow up documented in the resident's record. The facility further failed to identify, document, and track a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) on R54's heel, which included measurements, description, and/or follow up regarding the wound. As a result of the deep tissue injury the resident reported she experienced significant pain at the site of the injury. The facility also failed to have a system in place for the consistent tracking, monitoring, measuring, and assessing of R9's right great toe injury (initially identified as a skin issue in August of 2022, then a spider bite, then a pressure injury, later a stage II pressure injury, then a chronic ulcer) and required treatment and debridement of the ulcer in January of 2023. This deficient practice placed her at risk of worsening and further development of skin related injuries. The facility failed to establish and maintain a system to ensure the identification, tracking, monitoring, and measuring of R41's stage II pressure ulcers on his buttocks. This deficient practice placed the resident at risk of worsening and further development of skin related injuries. (See F686)
5. The facility failed to ensure the competency of Licensed Nurses in the facility regarding wound/skin issues of residents to include the monitoring, measuring, identifying of skin issues and pressure injuries (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). This deficient practice placed any resident with potential skin issues, at risk of worsening and further development of skin related injuries.
Review of the provided QAPI Meeting Agenda outline for a scheduled meeting on 01/17/23 at Noon, and noted with an estimated duration of one hour, revealed some of the topics included in the agenda at each meeting were:
Previous Meeting action Plans
Quality Measure per [NAME] Report (specific measure to be focus on next quarter)
Compliance and Ethics Program (Status of policy)
Health Information Management (Audits)
Infection Prevention (Staffing Status)
Nursing Consultant (Recommendations, State Survey Status, Nursing Home Compare Status)
Policies and Procedures (Current Policies needed/begin updated)
Pharmacist Report (Consultant Findings and recommendations)
Incident Reporting by Administrative Nurse E (Falls and Wounds)
Staffing Status by Administrative Nurse D
Performance Improvement Projects (PIPs) by Administrative Nurse C (Current PIPs)
Electronic Interview with Administrative Nurse C on 02/02/23 at 03:26 PM revealed when a deviation from the expected performance or a negative trend occurs, the QAA Committee was aware due to any negative trend data was always reported at bi-monthly QAPI meetings. However, if the trend was in need of immediate attention, a PRN (as needed) QA meeting would be conducted to discuss the needed immediate corrective action. Administrative Nurse C reported all staff are educated during the orientation process about the facilities QAPI program. All staff are considered a part of the facilities QAPI program. The front-line staff are also included on PIP teams, and are encouraged to initiate their own projects. We have an environmental of open communication and encourage all staff to voice concerns. Administrative Nurse C, in response to the question of knowing which issues the facility needed to work on, reported: in addition to monitoring and reviewing traditional routine statistical reports (CASPER, call-light response time report, dietary assessments, consultant reports, etc.), every person at our QAPI meetings speaks to issues within their area. All issues are addressed, and decisions are made on how to proceed on all issues. All staff were encouraged to bring issues to me (the QAPI officer) at any time outside our meetings. These random issues were brought to the QAPI meetings for discussion. Administrative Nurse C reported all corrective actions (usually in the form of a PIP), were discussed at every QAPI meeting until the issue was resolved and included reports on what is being implemented, and the effectiveness. When asked if the QAPI team were aware of the issues regarding concerns identified on the current survey (skin issues, pressure ulcer/wound measurements, identification, tracking, reporting and investigating skin concerns such injuries of unknown origin), Administrative Nurse C responded the QAPI were aware of skin (wounds) are reported at our QAPI meetings. However, these are usually numbers, not specific cases, or specific descriptions and measurements. We report on pressure injuries, unknown origin injuries, trending of skin issues, etc. at every meeting. Administrative Nurse C reported the facility process when a skin issue is identified by the charge nurse, they then inform the nurse managers as well as fill out an incident report and noted they identified that some of the incident reports were not being filled out and they developed a PIP team to discuss nurse skills check-offs including wound care. When asked about corrective actions once the QAPI became aware of the issue, Administrative Nurse C further reported the QAPI developed a PIP team and they were in the discussion phase of what and how to implement the actions we decided upon.
Administrative Nurse C reported all issues that warrant corrective action were then followed-up and reported on, by the person assigned to head that PIP, at the next QAPI meeting. She noted if the follow-up report showed there was not a positive outcome, changes are discussed and implemented and that all PIPs were reported on at our QAPI meetings, and also PRN.
The Quality Assurance Performance Improvement (QAPI) policy, last updated 11/01/22, revealed QAPI was an ongoing, comprehensive data-driven methos for approaching decision making and problem solving and focuses on syst of care, outcomes of care, best practice and quality of life. The policy also noted the facility would systematically identify, report, track and investigate data and information related to adverse events with the goal of developing and implementing plans to prevent adverse events an ensure resident safety. The policy further defined examples of adverse events may include (but will not be limited to): Falls, skin wounds, . infections, pressure injuries . The policy noted Adverse event monitoring would include methods to systematically identify, report, track, investigate, analyze and use data to develop activities sot prevent adverse events.
The facility failed to ensure the QAPI program identified and implemented timely corrective actions to address the quality deficiencies cited on the current annual health resurvey.
Mar 2021
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents, with 11 included in the sample, and five reviewed for unnecessary medications. B...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 52 residents, with 11 included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of insulin (a hormone produced in the pancreas) when staff failed to report out of parameter blood glucose (main sugar that the body makes from the food in the diet) levels for Resident (R) 45, per physician's orders.
Findings included:
- Review of R45's signed Physician Order Sheet (POS) dated 03/02/21 documented the following diagnoses: Diabetes Mellitus (DM, when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and dementia (progressive mental disorder characterized by failing memory, confusion).
Review of R45's Annual Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) of 03, indicating severely impaired cognition. The MDS noted R45 had DM and she received daily insulin injections.
Review of R45's Nutritional Status Care Area Assessment (CAA) dated 02/11/21 documented that R45 received a low concentrated sweets diet.
Review of R45's Care Plan dated 02/18/21 documented R45 had DM and received insulin multiple times a day. Her insulin orders had decreased, and her oral meds for DM were increased due to blood glucose (BG, level of sugar in the blood) fluctuations and HbA1c (a laboratory blood test that measures the amount of blood sugar (glucose) attached to hemoglobin) results. The care plan noted her BG were checked as ordered and were sometimes out of range. The staff were to report out of range readings to her doctor, administer her medications, and check laboratory tests when ordered.
Review of R45's signed POS dated 03/02/21 documented staff were to obtain Accuchecks (blood glucose measuring system used for the monitoring of glucose) for R45 twice a day (started 09/08/20). Staff were to call the physician if the results were less than 80 milligrams per deciliter (mg/dL), or greater than 450 mg/dL, for further orders. Staff were to administer Levemir insulin subcutaneously as indicated in a sliding scale chart, as follows:
0 - 79 mg/dL = 0 units;
80 mg/dL- 150 mg/dL = 10 units;
151 mg/dL- 250 mg/dL= 15 units;
251 mg/dL- 350 mg/dL = 20 units;
351 mg/dL - 1000 mg/dL= 25 units.
Review of R45's Medication Administration Record (MAR) for the month of January 2021 documented six out of parameter elevated BG readings taken at 07:30 PM. (01/02/21 BG of 455 mg/dL, 01/05/21 BG of 456 mg/dL, 01/06/21 BG of 490 mg/dL, 01/10/21 BG of 497 mg/dL, 01/14/21 BG of 564 mg/dL, 01/17/21 BG of 559 mg/dL)
Review of R45's MAR for the month of February 2021 documented eight out of parameter elevated BG readings taken at 07:30 PM. (02/03/21 BG of 585 mg/dL, 02/04/21 BG of 488 mg/dL, 02/07/21 BG of 536 mg/dL, 02/12/21 BG of 584 mg/dL, 02/17/21 BG of 560 mg/dL, 02/19/21 BG of 516 mg/dL, 02/21/21 BG of 505 mg/dL, 02/26/21 BG of 478 mg/dL)
Review of R45's MAR for the month of March 2021 documented three of parameter elevated BG readings taken at 07:30 PM. (03/16/21 BG of 521 mg/dL, 03/19/21 BG of 489 mg/dL, 03/20/21 BG at 500 mg/dL)
Review of R45's Nurses Notes (NN) for the months of January, February, and March 2021 lacked documentation of notification to the physician for the out of parameter BG readings.
Observation on 03/24/21 at 03:09 PM revealed R45 laid in a low bed, covered in a blanket, with a call light in reach.
On 03/24/21 at 07:28 AM Certified Medication Aide (CMA) C revealed she obtained BG readings from residents and reported them to the nurse. She did not know the parameters for the resident and stated she would ask the nurse and if the nurse told her to do anything, she would.
On 03/24/21 at 02:14 PM with Licensed Nurse D revealed the CMA would obtain the BG and report to her and it would be her (LN) responsibility to report out of parameter readings to the physician.
On 03/24/21 at 02:41 PM with Administrative Nurse A revealed she expected the nurse to follow physician ordered parameters and notify the physician if the BG readings were outside of those parameters. Administrative Nurse A expected the orders received to be followed and documented, as well as the notification to the physician.
The facility's Physician Notification policy updated 08/16/19 documented that licensed nursing staff would notify the residents' Primary Care Physician (PCP) in a timely, efficient and effective manner.
The facility failed to notify the physician for R45's physician ordered out of parameter BG readings in order to ensure adequate monitoring of insulin.
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
- • Grade B+ (85/100). Above average facility, better than most options in Kansas.
- • No fines on record. Clean compliance history, better than most Kansas facilities.
- • 25% annual turnover. Excellent stability, 23 points below Kansas's 48% average. Staff who stay learn residents' needs.
Concerns
- • 15 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Bethel Home's CMS Rating?
CMS assigns BETHEL HOME an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Kansas, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Bethel Home Staffed?
CMS rates BETHEL HOME's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 25%, compared to the Kansas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Bethel Home?
State health inspectors documented 15 deficiencies at BETHEL HOME during 2021 to 2025. These included: 1 that caused actual resident harm and 14 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bethel Home?
BETHEL HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 56 certified beds and approximately 54 residents (about 96% occupancy), it is a smaller facility located in MONTEZUMA, Kansas.
How Does Bethel Home Compare to Other Kansas Nursing Homes?
Compared to the 100 nursing homes in Kansas, BETHEL HOME's overall rating (5 stars) is above the state average of 2.9, staff turnover (25%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Bethel Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Bethel Home Safe?
Based on CMS inspection data, BETHEL HOME 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 5-star overall rating and ranks #1 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 Bethel Home Stick Around?
Staff at BETHEL HOME tend to stick around. With a turnover rate of 25%, the facility is 21 percentage points below the Kansas average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Bethel Home Ever Fined?
BETHEL HOME 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 Bethel Home on Any Federal Watch List?
BETHEL HOME 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.