SHAWNEE POST ACUTE REHABILITATION CENTER
For profit - Corporation
101 Beds
THE ENSIGN GROUP
Data: November 2025
Trust Grade
30/100
#222 of 295 in KS
Photo by Shawnee Post Acute and Rehabilitation Center
Photo by R. Taylor (Tayloredkc)
Photo by Shawnee Post Acute and Rehabilitation Center
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Shawnee Post Acute Rehabilitation Center has received a Trust Grade of F, indicating significant concerns and that it is among the poorest rated facilities. It ranks #222 out of 295 nursing homes in Kansas, placing it in the bottom half of all facilities, and #24 out of 35 in Johnson County, meaning only a handful of local options are worse. The facility's performance is worsening, with reported issues increasing from 3 in 2023 to 24 in 2024. Staffing is a major weakness, reflected by a 1-star rating and a turnover rate of 59%, which is above the Kansas average of 48%, suggesting instability among caregivers. There have been concerning incidents, including a resident experiencing a significant weight loss of 28.38% due to inadequate monitoring and dietary management, and another resident lost 14.29% of their weight without proper intervention. Additionally, the facility lacks sufficient registered nurse coverage, falling below 94% of Kansas facilities, which raises concerns about the quality of care.
- Trust Score
- F
- In Kansas
- #222/295
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $28,558 in fines. Higher than 84% of Kansas facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for Kansas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 25%
Needs review
3 → 24 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2023: 3 issues
2024: 24 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Kansas average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 59%
13pts above Kansas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $28,558
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (59%)
11 points above Kansas average of 48%
The Ugly 40 deficiencies on record
2 actual harm
Mar 2024
24 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
TThe facility identified a census of 80 residents. The sample included 18 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to obtain ...
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TThe facility identified a census of 80 residents. The sample included 18 residents with one reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to obtain accurate weights and verify weight changes related to Resident (R)28's physician-ordered weekly weights to effectively monitor weight trends and identify concerns before a significant weight loss occurred. The facility further failed to ensure staff served R28 a diet he could safely consume. As a result of the deficient practices, R28 had a significant unplanned weight loss of 28.38 percent (%) within one month.
Findings Included:
- The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion).
R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS indicated R28 had no behaviors, used a wheelchair, and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments, required set-up assistance with his meals, and had problems with choking or coughing during meals. The MDS noted he weighed 147 pounds (lbs.) and was on a mechanically altered diet.
R28's Nutritional Status Care Area Assessment (CAA) completed 02/27/24 noted he was on a mechanically altered diet due to his cognition. The CAA noted he had difficulty swallowing with his dysphagia. The CAA noted he was on the grazing program (a weight loss program for dementia that increased opportunities for nutritional intake) due to his dementia.
R28's Activity of Daily Living Functional/Rehabilitation Potential CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADL).
R28's Care Plan initiated on 02/14/24 indicated he had a nutritional problem related to his medical diagnosis. The plan instructed staff to provide his diet as ordered (02/14/24). The plan instructed staff to monitor for signs of dysphagia, coughing, drooling, and difficulty swallowing (02/27/24). The plan instructed staff to provide dietary supplements as ordered and weigh him weekly for four weeks (02/27/24). The plan noted he was placed on a grazing program on 03/21/24. The plan instructed staff to provide a slightly thick liquid consistency.
R28's EMR under Orders revealed his diet was regular, minced, and moist on 03/19/24.
R28's EMR under Orders noted an order dated 02/15/24 instructing staff to complete daily weights for three days, then weekly weights for four weeks, then monthly weights.
A Mini-Nutritional Assessment completed on 02/16/24 revealed a score of six indicating he was malnourished (lack of nutrients, which can result in stunted growth, wasting, and underweight).
A Nutrition Evaluation completed 02/16/24 indicated R28 weighed 147.5 lbs. The evaluation indicated his ideal body weight range was 142 lbs. The assessment indicated he was on a soft and bite-sized diet and required limited assistance with meals. The assessment indicated his appetite was poor and often refused meals. The assessment noted supplements were ordered and the registered dietician would be available as needed.
R28's EMR under Weight History between 02/14/24 through 03/26/24 revealed his weight upon admission was 148 lbs. on 02/14/24. The EMR revealed he weighed 107 lbs. on 03/07/24, indicating a 27.70% weight loss since his admission (23 days). The EMR revealed his weight decreased to 106 lbs. on 03/12/24 indicating a 28.38% weight loss since his admission to the facility (28 days).
R28's EMR under Tasks revealed the facility entered and struck out three weights marked as incorrect entries on 02/20/24 (146.5 lbs.), 03/04/24 (106 lbs.), and 03/04/24 (109.2 lbs.). The review revealed the lack of weights or reweighs for R28 between 02/17/24 and 03/07/24 during his significant weight loss timeframe.
A Weight Change note completed on 03/15/24 indicated a weight warning triggered his weight as 106 lbs. on 03/07/24. The note indicated a significant weight loss occurred, but the facility was unable to assess its related concerns with weight accuracy. The note recommended reweighing R28.
R28's EMR as of 03/26/24 at 08:00 AM revealed R28 had not been reweighed.
On 03/27/24 at 10:00 AM the facility weighed R28 upon request. R28 weighed 108 lbs.
On 03/25/24 at 08:10 AM R28 slept in his bed. His bed was in the low position with a fall mat positioned to the left side. At 11:50 AM R28's representative arrived and woke him up. She stated he slept through breakfast and needed to get up for lunch. She stated he had times of confusion and would not understand where he was or what times meals were. She stated he wore the same clothes he had on the day prior, and she had to remind the facility to give him baths and brush his teeth.
On 03/26/24 at 09:09 AM R28 laid supine in his bed with the head of his bed elevated. R28 ate his breakfast of oatmeal and scrambled eggs. R28 consumed his supplement drink and reported no concerns with breakfast. R28 stated he is not always hungry and would often refuse to eat certain meals. He stated he knew he had lost a lot of weight and he stated his normal weight was 160 lbs.
On 03/26/24 at 01:14 PM, R28 was in the dining room and served minced chicken and potato salad. R28's plate also contained three uncut Brussels sprouts he was unable to eat. A review of R28's meal ticket noted he was to be served a regular diet that was minced and moist. At 01:20 AM Certified Nurse Aide (CNA) Q offered to cut up the Brussels sprouts. R28 declined to eat them.
On 03/26/24 at 10:00 AM, CNA Q stated each resident was weighed based on their orders. She stated some residents were weighed daily, weekly, or monthly. She stated she thought R28 had weekly weights due to his dementia and weight loss risk. She stated if a resident refused weights the nurse would be notified. She stated multiple attempts would be made to complete the weight before rescheduling the next day. She stated the nurse would be notified of the weight changes.
On 03/27/24 at 10:26 AM Licensed Nurse (LN) G stated weight changes were reported to the registered dietician (RD) and medical provider. She stated weights should be completed based on the physician's orders and the risk level of the residents. She stated that missed weights should be attempted the next possible day to ensure consistent monitoring. She stated the facility had multiple scales if accuracy concerns appeared.
On 03/27/24 at 02:42 PM Administrative Nurse D stated she believed R28 was on weekly weights due to his medical diagnoses. She stated she expected staff to review the weights collected and report the changes to herself, the RD, and the medical provider. She stated the interdisciplinary team (IDT) reviewed weight loss weekly and provided interventions to combat the weight loss such as dietary adjustment, snacks, supervision, supplementation, and reviews. She stated the facility implemented a Grazing Program to assist with residents with dementia. She stated R28 had recent weight loss. She stated staff should make multiple attempts to weigh the residents and reschedule the missed weight for the next possible day.
The RD was not available for interview on 03/28/24.
The facility provided a Weight Monitoring policy revised 01/2022 indicated the facility would establish a baseline weight upon admission and continue to weigh the resident using the same scale. The policy indicated staff were to record and report weight changes to the interdisciplinary team.
The facility failed to obtain accurate weights and verify weight changes related to R28's physician-ordered weekly weights to effectively monitor weight trends and identify concerns before a significant weight loss occurred. The facility further failed to ensure staff served R28 a diet he could safely consume. As a result of the deficient practices, R28 had a significant unplanned weight loss of 28.38% within one month.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for dignity. Ba...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21 was treated with respect, and dignity related to personal hygiene, and the facility also failed to ensure a dignified dining experience when staff stood over R25 and R57 instead of sitting beside him while assisting them with meals. These deficient practices placed the residents at risk for negative psychosocial outcomes and decreased dignity.
Findings included:
- R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and need for assistance with personal care.
The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R21 required partial to moderate assistance from staff for her hygiene.
R21's Functional Abilities Care Area Assessment (CAA) dated 02/15/24 documented she required assistance with activities of daily living.
R21's Care Plan dated 11/03/23 directed staff she required maximum assistance with personal hygiene.
On 03/25/24 at 08:01 AM R21 propelled her wheelchair in the hallway toward the dining room for breakfast. R21's hair was uncombed and was sticking up on the back of her head.
On 03/26/24 at 08:08 AM R21 sat in her wheelchair at the dining room table as she drank a cup of coffee. R21's hair was uncombed and was sticking up.
On 03/27/24 at 07:38 AM R21 sat at the dining room table and drank her coffee. R21's hair was uncombed and sticking up. R21 stated the staff did not always offer or assist her with combing her hair. R21 stated she was too old to ask for help.
On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated R21 needed more assistance after she was sick. CMA R stated R21 started to be stronger and was doing more for herself. CMA R stated she did not always have to assist R21 with her hygiene.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated staff should offer R21 assistance with her care. LN K stated R21's hair should be combed and not standing straight upwards.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected staff to assist or offer R21 with personal hygiene. Administrative Nurse D stated staff should make sure R21's hair was combed.
The facility's Promoting/Maintaining Resident Dignity policy dated 01/01/23 documented it was the practice of the facility to protect and promote a resident's right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances a resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.
The facility failed to ensure R21 was assisted with combing her hair. This deficient practice placed R21 at risk for negative psychosocial outcomes and decreased dignity.
- On 03/25/24 at 12:16 PM R25 sat in his high-back wheelchair at the dining room table. Certified Medication Aide (CMA) R stood next to him and assisted him with his lunch.
On 03/26/24 at 12:30 PM, R57 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table, she was served a ham sandwich and cheese puffs. The ham sandwich consisted of white bread and deli-styled ham. Certified Nurse Aide (CNA) O stood beside R57's Broda chair and assisted her with a few bites and walked away and did not offer R57 a drink.
On 03/26/24 at 12:33 PM, R25 sat at the dining room table in his high-back wheelchair at lunchtime. CMA R stood beside his wheelchair and offered him a few bites of his meal.
On 03/27/24 at 12:28 PM, R57 sat upright at the dining room table in her Broda chair. CMA R stood on R57's right side and assisted her with eating.
On 03/26/24 at 12:33 PM, R25 sat at the dining room table in his high-back wheelchair at lunchtime. CMA R stood beside his wheelchair and offered him a few bites of his meal.
On 03/27/24 at 01:01 PM, CMA R stated she stood next to the resident during mealtime because she could not give her attention to only one resident. CMA R stated she must help everyone in the dining room, so she needed to be able to move around all the time.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated the staff cannot always sit and help only one person. LN K stated it depends on how many residents are in the dining room that require assistance. LN K stated the staff must be able to help everyone.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected staff to sit down and assist a resident who required assistance.
The facility's Promoting/Maintaining Resident Dignity policy dated 01/01/23 documented it was the practice of the facility to protect and promote a resident's right and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances a resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.
The facility failed to ensure R25 and R57 were treated with dignity during dining. This deficient practice placed the residents at risk for weight loss and impaired dignity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents with 18 residents included in the sample. The facility identified 54 residents who were discharged from Medicare Part A services. Based on interview an...
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The facility identified a census of 80 residents with 18 residents included in the sample. The facility identified 54 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) with the required information for Resident (R) 49 and R 336. This failure placed the residents at risk for decreased autonomy and impaired decision-making.
Findings included:
- R49's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/19/23 and ended on 03/09/23. R49 remained in the facility for custodial care. The facility issued SNF ABN 10055 lacked an estimated cost for continued services.
R336's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 12/11/23 and ended on 01/03/24. R336 remained in the facility for custodial care. The facility issued SNF ABN 10055 lacked an estimated cost for continued services.
On 03/26/24 at 10:45 AM Social Services X stated that she was unaware that form 10055 needed an estimated cost for continued services if the resident was staying in the facility.
The facility did not provide a policy for advance beneficiary notices.
The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired decision-making.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) for Resident (R)43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) for Resident (R)43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebrovascular accident (CVA-stroke- the 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) effecting left non-dominant side, and epilepsy (brain disorder characterized by repeated seizures).
The Quarterly Minimum Data Set (MDS) dated 02/19/24 documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS indicated R43 was dependent on staff for all activities of daily living (ADLs).
R43's Functional Care Area Assessment (CAA) dated 12/14/23 documented R43 needs assistance with his care due to a CVA, right hip fracture, seizures, and COPD.
The Discharge MDS dated 03/20/24 for R43 documented an unplanned discharge to an acute hospital with an anticipated return to the facility.
R43's Entry MDS dated 03/25/24 documented a reentry to the facility from an acute hospital.
R43's Care Plan dated 01/18/24 documented R43 had no plans to be discharged from the facility and planned to stay at the facility. R43's Care Plan dated 01/18/24 documented to monitor his progress and revise his plan as needed.
A Progress Note dated 03/20/24 documented that R43 was lethargic with a half-full bag of red bloody urine. The provider gave a verbal order to send R43 to the emergency department (ED) for evaluation. Staff called the ambulance and it arrived at the facility and transported R43 to the hospital. The nurse notified R43's daughter of the resident's condition.
A Progress Note dated 03/25/24 documented that R43 was readmitted to the facility from an acute care hospital visit.
The facility was unable to provide evidence a written notification of transfer or discharge was provided to the resident and/or representative for the facility-initiated transfer to the hospital from [DATE] to 03/15/24.
The facility was unable to provide evidence notification of the transfer was sent to the LTCO.
On 03/26/24 at 08:12 AM R43 lay in bed resting comfortably.
On 03/26/24 at 10:35 PM Administrative staff A stated facility does not have the written notification of transfer. Administrative staff A stated that R43's daughter was notified verbally when he was transferred and given an update on his condition.
The facility policy Admission, Transfer and Discharge Rights policy revised 10/2023 documented it is the policy of the facility that discharge planning and evaluation will be provided by the Social Services staff for each resident. Discharge planning involves the resident, family or responsible party, interdisciplinary team (IDT), and others involved in the resident's care plan.
The facility failed to provide written notice of transfer as soon as practicable to R43 and their representative and failed to provide notification to the LTCO as well. This placed the resident at risk for miscommunication between the facility and the resident/family and possible missed opportunities for healthcare service for R43.
The facility identified a census of 80 residents. The sample included 18 residents with two residents sampled for hospitalization and one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide written notice of transfer as soon as practicable to Resident (R) 27 and R43 or their representative for their facility-initiated transfers and/or discharge. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R27 and R43.
Findings included:
- The electronic medical record (EMR) for R27 documented diagnoses of hypertension (HTN- elevated blood pressure), hemiplegia and hemiparesis following cerebral infarction (paralysis and muscle weakness on one side of the body after a stroke), and dementia (a progressive mental disorder characterized by failing memory, confusion).
The Significant Change Minimum Data Set (MDS) dated 12/19/23 documented R27 had both short and long-term memory problems. R27 had severely impaired cognitive skills for daily decision-making. R27 utilized a wheelchair for mobility. R27 was dependent on staff for all activities of daily living (ADLs).
R27's Discharge MDS dated 12/02/23 documented a discharge to an acute hospital with a return anticipated 12/02/23.
The Nutrition Care Area Assessment (CAA) dated 12/27/23 documented R27 was on a mechanically altered diet, had a history of hemiplegia and hemiparesis, and needed assistance to be fed. R27 had his gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) removed. The area was not completely closed, and he had drainage. R27 will be care planned for nursing to assist with nutrition and hydration.
A Nursing Note dated 12/02/23 at 02:25 PM documented R27 had not tolerated his 08:00 AM or 12:00 PM G-tube flush. R27 had significant residual from his G-tube noted. R27's stomach was severely distended (swollen due to pressure from the inside) when assessed and palpated. R27's dressing to his G-tube was saturated with bodily fluids and significant drainage from the G-tube was noted. R27's provider was called and notified. An order was received from the provider to send the resident out to the hospital for further evaluation. The emergency contact was called with no answer. The resident was transported by emergency medical services (EMS).
An admission Note dated 12/13/23 at 11:40 PM documented R27 had readmitted to the facility at 07:15 PM via a stretcher and was accompanied by his wife and the transport drivers. R27's provider was notified of his readmission at that time.
The Misc. tab of the EMR lacked any document for discharge summary.
The facility was unable to provide the required written notification of discharge for R27's 12/02/23 discharge upon request.
On 03/26/24 at 07:45 AM R27 rested in bed. His bed was in a low position, with fall mats on both sides of the bed.
On 03/26/24 at 10:35 AM Administrative Staff A stated the facility normally would just call the representative to notify them when a resident was being discharged to the hospital. Administrative Staff A was not aware that a written notification needed to be sent/mailed to the resident and or resident representative with the required information on it. Administrative Staff A stated he would begin providing the written notification from here forward.
The facility provided an Admission, Transfer, and Discharge Rights policy revised in October 2023 that the subject matter was for discharge planning. This policy did not address the aspect of the required written notice of transfer/discharge.
The facility failed to provide written notice of transfer as soon as practicable to R27 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R27.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents sampled for hospitalizat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents sampled for hospitalization and discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 43 or to their family representative when R43 was transferred to the hospital. This deficient practice placed R43 at risk for impaired ability to return to the facility or his same room.
Findings include:
- The electronic medical record (EMR) for R 43 documented diagnoses of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebrovascular accident (CVA-stroke- the 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) effecting left non-dominant side, and epilepsy (brain disorder characterized by repeated seizures).
The Quarterly Minimum Data Set (MDS) dated 02/19/24 documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS indicated R43 was dependent on staff for all activities of daily living (ADLs).
R43's Functional Care Area Assessment (CAA) dated 12/14/23 documented R43 needs assistance with his care due to a CVA, right hip fracture, seizures, and COPD.
The Discharge MDS dated 03/20/24 for R43 documented an unplanned discharge to an acute hospital with an anticipated return to the facility.
R43's Entry MDS dated 03/25/24 documented a reentry to the facility from an acute hospital.
R43's Care Plan dated 01/18/24 documented R43 had no plans to be discharged from the facility and planned to stay at the facility. R43's Care Plan dated 01/18/24 documented to monitor his progress and revise his plan as needed.
A Progress Note dated 03/20/24 documented that R43 was lethargic with a half-full bag of red bloody urine. The provider gave a verbal order to send R43 to the emergency department (ED) for evaluation. Staff called the ambulance and it arrived at the facility and transported R43 to the hospital. The nurse notified R43's daughter of the resident's condition.
A Progress Note dated 03/25/24 documented that R43 was readmitted to the facility from an acute care hospital visit.
The facility was unable to provide evidence a bed hold notification was provided to the legal representative when R43 transferred to the hospital from [DATE] to 03/15/24.
On 03/26/24 at 08:12 AM R43 lay in bed resting comfortably.
On 03/26/24 at 10:35 AM Administrative Staff A stated he only had the bed hold notification the resident signed on admission. Administrative Staff A stated he did not have a bed hold notice for R43 for the 03/20/234-03/25/24.
The facility was unable to provide a policy related to bed hold notification.
The facility failed to provide a bed hold with the required information to R43 and his family representative when R43 transferred to the hospital. This deficient practice placed R43 at risk for impaired ability to return to the facility or his same room.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the f...
Read full inspector narrative →
The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)28 and R17. This deficient practice placed the residents at risk for infections and decreased psychosocial well-being.
Findings Included:
- The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion).
R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of ten indicating moderate cognitive impairment. The MDS indicated he had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments. The MDS noted he required substantial to maximal assistance for bathing, dressing, personal hygiene, toileting, and transfers.
R28's Functional Abilities CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADLs).
R28's Care Plan initiated 02/14/24 indicated R28 was at risk for impaired cognitive function, behaviors, nutrition, and falls related to his medical diagnoses. The plan noted R28 lacks insight into his condition and risk factors. The plan noted he required two staff assistants for bed mobility and transfers. The plan indicated he required staff assistance for bathing, personal hygiene, dressing, toileting, and mobility with his wheelchair.
A review of R28's Documentation Survey Report between 02/14/24 and 03/26/24 indicated he received bathing opportunities on three occasions (2/26, 3/11, and 3/26). The report indicated that NA was marked on seven occasions. The report indicated R28 refused on two occasions.
On 03/25/24 at 12:04 PM R28 was woken up by his representative. R28 was wearing grey food-stained jogging clothing. His hair was greasy, and his fingernails were dirty. R28's representative reported staff let him sleep all morning and he missed breakfast. She stated R28 needed frequent reminders of mealtimes and hygiene. She stated she had to remind the facility to bathe him. She stated he was wearing the same clothing he had on was she visited him yesterday. She stated when R28 first arrived he didn't receive bathing for a week after he arrived.
On 03/26/23 at 10:00 AM Certified Nurse Aid (CNA) Q stated resident had designated days for bathing. She stated if a resident refused or was not available for the bath, they would have been rescheduled for the next available time or day. She stated multiple attempts would be documented and reported to the nurse for intervention.
On 03/27/24 at 10:26 AM Licensed Nurse (LN) G stated shower days were listed in the EMR and alerted staff who was due on what day. She stated direct care staff can input the recorded bathing into the EMR and should designate the status of the provided bath or shower. She stated this would include bed baths, showers, and whirlpools.
On 03/27/24 at 02:42 PM Administrative Nurse D stated staff should not be charting NA under the bathing. She stated it should be charted given the type of bath provided or if refused. She stated the residents would be provided a bath at the same time of day if they were not available. She stated the residents should receive a minimum of two baths per week and could request more or change their days if they wish.
A review of the facility's Activities of Daily Living policy revised 10/2022 stated that bathing opportunities provided to the residents promote cleanliness, and comfort, and provide observations of the resident's skin. The policy noted that all bathing should be documented in the resident's EMR. The policy noted that if a resident refuses to bath the staff will notify the nurse.
The facility failed to provide consistent bathing opportunities for R28. This deficient practice places him at risk for infections and decreased psychosocial well-being.
- The electronic medical record (EMR) for R17 documented diagnosis of hypertension (HTN-elevated blood pressure), type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel).
R17's Annual Minimum Data Set (MDS) dated 03/24/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R17 required extensive assistance from one staff for activities of daily living (ADLs). R17 received insulin injections seven of seven days during the lookback period.
R17's Quarterly MDS dated 12/21/23 documented a BIMS score of 15 which indicated intact cognition. R17 was dependent on staff for shower/bathing and did not transfer to the shower/bath.
R17's ADL Care Area Assessment (CAA) dated 04/07/23 documented R17 had a self-care and mobility deficit and balance problems. R17 was bed-bound per her choice. R17 was at risk for a decline in ADLs, falls, 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), contractures (abnormal permanent fixation of a joint or muscle), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle wasting (decrease in size and wasting of muscle tissue) and infections.
R17's Care Plan last revised on 12/27/23 directed staff that R17 was dependent on staff to provide a bath as necessary. Staff was directed to do care in pairs and R17 required two-person assistance with a Hoyer lift (total body mechanical lift) for transfers.
Under the Tasks tab of the EMR R17's preferred shower days were Tuesday and Friday.
Review of R17's January 2024 Documentation Survey Report revealed R17 received a bath, shower, or sponge bath on 01/02/24, 01/07/24, 01/13/24, 01/21/24, 01/23/24, 01/28/24, and 01/30/24. There was no bathing recorded for the week of 01/14-20/24. 01/23/24, 01/28/24, and 01/30/24. R17 refused bathing on 01/05/24.
Review of R17's February 2024 Documentation Survey Report revealed R17 received a bath, shower, or sponge bath on 02/02/24, 02/05/24, 02/06/24, 02/12/24, 02/13/23, 02/14/24, 02/16/24, 02/23/24, and 02/29/24. R17 refused a bath/shower on two instances 02/09/24 and 02/20/24.
A review of R17's March 2024 Documentation Survey Report revealed R17 received a bath, shower, or sponge bath on 03/08/24, and 03/22/24 (14 days with no bathing).
On 03/26/24 at 08:36 AM R17 lay in her bed. Her hair was disheveled. R17 wore a hospital gown with visible food residue on it. R17 stated that she did not always get her baths as scheduled on Tuesdays and Fridays. R17 stated that she would only get a bed bath sometimes/ She stated when agency staff worked, the agency staff just did not want to take the time to do it. R17 stated she likes to be bathed and her hair washed every couple of days, or she just feels dirty. R17 stated staff told her she was on the list for a bath that day.
On 03/27/24 at 01:59 PM Certified Nurse Aide (CNA) P stated there was a bath/shower book on the unit that had daily showers listed by day and room. CNA P stated the aide was to complete a bath sheet for all residents scheduled for bathing each day and if the resident refused the nurse was to be notified. CNA P stated all the shower sheets at the end of the day were to be given to the nurse so the nurse could sign off on them and tell the next shift aides to offer a bath to the residents who had refused. CNA P stated not applicable (NA) and should not be charted for a bath, the tasks in point of care (POC) have abbreviations that should be used for shower, full bath, and sponge bath.
On 03/27/24 at 02:00 PM Licensed Nurse (LN) I stated the shower book listed the bath/showers for the day. LN I stated she would give the aides the list of who was to be showered that day and she expected the aide to fill out a shower sheet for each of those residents. LN I stated the aide was to give her the sheets at the end of the shift and should notify her when a resident had refused the shower. LN I stated staff should not document NA on days that a shower was given and would expect staff to use the appropriate abbreviation code when they charted in POC.
On 03/27/24 at 03:15 PM Administrative Nurse D stated each resident has scheduled shower/bath days at least twice weekly. Administrative Nurse D stated each unit should have a shower book that listed who was to receive a shower each day. Administrative Nurse D stated CNAs should not at any time be charting NA when a shower was given on unscheduled days. Administrative Nurse D stated she expected staff to chart in POC using the appropriate abbreviations and complete the shower sheets daily. Administrative Nurse D stated that the facility had been having issues with some of the agency staff not performing duties as expected and those agency staff had since been asked not to return.
The Activities of Daily Living (ADLs) policy revised 01/01/23 documented the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs did not deteriorate unless unavoidable. Care and services would be provided for ADLs such as bathing, dressing, grooming, and oral care. The facility would develop a comprehensive care plan to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. A resident who was unable to carry out the ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral care.
The facility failed to ensure staff provided consistent bathing to R17, who was unable to carry out ADLs. This deficient practice placed R17 at risk for impaired care and decreased quality of life.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R36's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R36's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (a progressive mental disorder characterized by failing memory, confusion), and a pressure ulcer of the left heel Stage 3 (full thickness pressure injury extending through the skin into the tissue below).
The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented that R36 was dependent on staff for rolling from side to side. The MDS documented R36 was at risk for pressure ulcers during the observation period and had a Stage 3 pressure ulcer during the observation period. The MDS documented that a pressure-reducing device was in place in R36's chair and on her bed during the observation period.
R36's Pressure Ulcer Care Area Assessment (CAA) dated 05/19/23 documented R36 was free from pressure-related skin impairments but was at risk for skin breakdown or development of pressure ulcers related to mobility, impaired cognition, and incontinence.
The Braden Scale (a scale for predicting pressure sore risk) dated 01/29/24 documented a score of fifteen indicating a low risk for pressure wounds.
R36's Care Plan dated 12/07/23 documented that staff would assist R36 with repositioning about every two hours. The care plan dated 12/07/23 documented R36 was to wear bilateral heel float boots when she was in bed or chair and staff would ensure R36 had the boots on when in bed.
R36's EMR under the Orders tab revealed the following physician orders:
Ensure the left heel dressing is in place and clean, dry, and intact. Utilize as needed (PRN) order if soiled, frayed, or saturated. Notify the physician of any abnormal findings and document dated 12/15/23.
Apply pillow boots to bilateral extremities as tolerated while in bed and up in chair every shift for pressure prevention dated 12/15/23.
Left heel wound- cleanse the wound with normal saline, apply Skin-prep (liquid skin protectant) to the peri-wound area, and apply Santyl (prescription medicine that removes dead tissue from wounds so they can heal) to the wound bed only. Apply collagen powder (powders to absorb wound exudate or as a gel to provide moisture to the wound site) over Santyl and cover with border gauze dressing every other day order dated 03/26/24.
On 03/27/24 at 07:01 AM R36 laid asleep on her bed. R36 was not wearing boots and her bilateral heels rested directly on the mattress.
On 03/27/24 at 07:03 AM Licensed Nurse (LN) K stated R36's boots were in her room last week. LN K helped look for the boots, and she could not find R36's boots in the resident's room. LN K stated the boots may have gotten soiled and gone to laundry. LN K stated she would be back in a half hour to do the wound dressing. R36's heels remained directly on the mattress.
On 03/27/24 at 07:38 AM LN K stated there was an order to float R36's heels. LN K said the Certified Nursing Aides (CNA) were responsible for the boots and that task was documented in the EMR. LN K stated the nurse should follow up and sign on R36's Treatment Administration Record (TAR) after verifying the boots were on.
On 03/27/24 at 07:50 AM CNA 0 stated she knew how to find the [NAME] (a nursing tool that gives a brief overview of the care needs of each resident). CNA O stated she could find out what R36 needed for her care.
On 03/27/24 at 08:20 AM CNA R stated she did not know how to access the residents' [NAME]. CNA R stated the nurse lets her know what duties she needs to do for the residents.
On 03/27/24 at 02:41 PM Administrative Nurse D stated she was not aware that staff were unable to find R36's bilateral float heel boots. Administrative Nurse D stated she expected the staff to float R36's heels if there was an order to do so. She stated nurses should be checking to ensure the boots are on before they sign the TAR.
The facility's Skin Management System policy revised 12/2019 documented any resident who enters the facility without a pressure ulcer will have appropriate preventive measures taken to ensure that the resident does not develop pressure ulcers, or that resident admitted with wounds will not develop signs and symptoms of infect, unless the resident clinical condition makes the development unavoidable.
The facility failed to ensure that pressure-reducing boots were placed on R36's bilateral lower extremities as ordered. This deficient practice placed the resident at risk for delayed healing and/or wound worsening.
The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 57's and R36's bilateral lower extremities. This deficient practice placed these residents at risk of developing pressure ulcers and worsening of current wounds.
Findings included:
- R57's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), 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) of the sacrum (large triangular bone/area between the two hip bones) region Stage 4 (full thickness tissue loss with exposed bone), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R57 required partial to moderate assistance from staff for eating. The MDS documented R57 was at risk for pressure injuries and had one unhealed pressure ulcer. The MDS documented R57 had pressure relieving devices on the bed and in the chair for prevention and reduction of pressure in place during the observation period.
R57's Pressure Ulcer Care Area Assessment (CAA) dated 03/13/24 documented she was at risk for pressure-related ulcers and currently had a sacral wound.
R57's Care Plan dated 03/04/24 documented she required pressure relieving or reducing devices on her bed.
R57's EMR under the Orders tab revealed the following physician orders:
Monitor wound on sacral every shift for signs or symptoms of infection dated 02/29/24.
R57's EMR under the Assessment tab revealed a Braden Scale (a scale for predicting pressure sore risk) dated 02/29/24 documented a score of nine indicating a very high risk for pressure wounds.
On 03/25/24 at 09:51 AM R57 laid on her back in her bed. R57's bilateral heels rested directly on the mattress, and her pressure-relieving boots laid on top of the dresser at the foot of her bed.
On 03/26/24 at 08:13 AM R57 laid back asleep on the bed with her heels resting directly on the mattress. R57's pressure-relieving boots lay on top of her dresser at the foot of her bed.
On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated if R57 had pressure relieving boots they should be when she was in bed.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated pressure relieving boots should be placed on any resident with a physician's orders. LN K stated if a resident was at risk for pressure injuries staff would lay down in bed between meals, monitor their skin, and offer supplements. LN K stated she was not sure if R57 had orders for pressure-relieving boots.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected the staff to apply pressure relieving devices if they had an order to do so. Administrative Nurse D stated every resident who was at risk for pressure-related injuries should have pressure-relieving devices in place. Administrative Nurse D stated the orders would be placed on the Medication Administration record (MAR) or the Treatment Administration record' (TAR) and on tasks. Administrative Nurse D stated that pressure-relieving devices should be included in the resident's plan of care.
The facility's Skin Management System policy revised 12/2019 documented any resident who enters the facility without a pressure ulcer will have appropriate preventive measures taken to ensure that the resident does not develop pressure ulcers, or that resident admitted with wounds will not develop signs and symptoms of infect, unless the resident clinical condition makes the development unavoidable.
The facility failed to ensure pressure-reducing measures were placed on R57's bilateral lower extremities who currently had a pressure-related ulcer. This deficient practice placed R57 at risk of developing further pressure ulcers and worsening or current pressure injuries.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for position an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 57 was provided services and treatment to prevent her contractures (abnormal permanent fixation of a joint or muscle) from worsening in her left and right hands. This deficient practice left R57 at risk for further decline and decreased range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). or mobility.
Findings included:
- R57's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of protein-calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), 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) of the sacrum (large triangular bone/area between the two hip bones) region Stage 4 (full thickness tissue loss with exposed bone), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of two which indicated severely impaired cognition. The MDS documented R57 required partial to moderate assistance from staff for eating.
R57's Nutritional Status Care Area Assessment (CAA) dated 03/13/24 documented she received a mechanically altered diet and had a pressure ulcer.
R57's Care Plan dated 03/13/24 documented she was dependent on staff for transfer, bathing bed mobility, and dressing. The plan of care lacked direction for staff to provide treatment for R57's hand contractures.
On 03/26/24 at 12:30 PM, R57 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining room table; she was served a ham sandwich and cheese puffs. The ham sandwich consisted of white bread and deli-styled ham. Certified Nurse Aide (CNA) O stood beside R57's Broda chair and assisted her with a few bites and walked away and did not offer R57 a drink. R57's fingers on both hands were bent at the knuckles and she was unable to hold her water glass.
On 03/27/24 at 11:40 AM Therapy Director GG reviewed R57's occupational therapy discharge note dated 03/14/24 and confirmed no preventive treatment was in place for R57's right and left contractures from worsening. Therapy Director GG stated the therapy department had a list of residents with contractures and reevaluated each resident for a decrease in ROM. Therapy Director GG provided documentation R57 would be reevaluated in three months and reattempt under Medicare Part B services.
On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated usually therapy would usually recommend some type of brace or splint for a resident's contractures. CMA R stated she was not aware of any type of treatment for R57's bilateral hands. CMA R stated R57 was able to feed herself small bites using her hands but was unable to hold a glass of water in her hands because of her contractures. CMA R stated nursing did not provide any type of treatment for R57's hands.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated she was not aware of any concerns with R57's pain in her bilateral hands related to the contractures. LN K was not aware of any treatment for R57's right and left contractures to prevent a decline in her ability to participate in her activities of daily living.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she was not aware of any treatment in place for R57's bilateral hand contractures. Administrative Nurse D stated therapy would track the contractures every three months.
The facility's Range of Motion policy last revised 10/2023 documented it was the policy of the facility to prevent a resident's loss of range of motion (ROM). Appropriate treatment and services would be administered to increase the range of motion and/or prevent further decrease in the range of motion.
The facility failed to ensure R57 received services and treatment for her multiple contractures to prevent an avoidable reduction of ROM and/or mobility. This deficient practice left R57 at risk for further decline and decreased ROM.
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 identified a census of 80 residents. The sample included 18 residents with three reviewed for falls. Based on obser...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for falls. Based on observation, record review, and interviews, the facility failed to provide an environment free of accident hazards resulting in Resident (R)28's non-injury fall in the facility's spa room. The facility additionally failed to implement wandering interventions for R28 and failed to provide safe transferring practices for R25. These deficient practices placed both residents at risk for preventable falls and injuries.
Findings Included:
- The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion).
R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of ten indicating moderate cognitive impairment. The MDS indicated he had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments. The MDS noted he required substantial to maximal assistance for bathing, dressing, personal hygiene, toileting, and transfers. The MDS noted no history of falls. The MDS entry for wandering was left incomplete.
R28's Care Area Assessment (CAA) was not triggered for falls.
R28's Functional Abilities CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADLs).
R28's Care Plan initiated 02/14/24 indicated R28 was at risk for impaired cognitive function, behaviors, nutrition, and falls related to his medical diagnoses. The plan noted R28 lacks insight into his condition and risk factors. The plan noted he required two staff assistants for bed mobility and transfers. The plan instructed staff to ensure all needed items were left within his reach. The plan instructed staff to keep his bed in the lowest position (02/20/24), offer toileting before laying him in bed (02/20/24), utilize an anti-rollback device on his wheelchair (02/20/24), and place floor mats bedside his bed (02/20/24), and ensure staff assist with all transfers (02/26/24). The care plan lacked documentation related to interventions for wandering behaviors as noted on 03/18/24.
A review of a facility-provided fall investigation dated 03/18/24 indicated R28 had an unwitnessed fall in the second-floor spa room. The investigation indicated he was confused and wandered into the room. The report noted he told staff he was going to the post office. The report noted he was assessed with no injuries. The report indicated an anti-rollback device was added to his wheelchair. The report lacked documentation related to the resident's wandering into the spa room.
On 03/25/24 at 12:45 PM, R28 was in his room with his representative. His representative stated R28 had days where he could get really confused and wander if not supervised. She stated his recent fall occurred because he thought he was going to the post office and fell out of his chair. An inspection of R28's room revealed his bed was in the low position and his fall mat was in place. R28 had non-slip socks on his feet. R28's wheelchair was positioned next to his bed with an anti-rollback device attached.
On 03/25/24 at 01:24 PM, An inspection of the second-floor spa room revealed no lock on the entry doors. No chemicals or Sharps containers were stored in the room. All cabinets were locked. No electrical concerns were present.
On 03/26/23 at 10:00 AM Certified Nurse Aid (CNA) Q stated R28 had moments of confusion but was usually redirectable. She stated he rarely propelled himself and often staff would have to move him. She stated residents should not be alone in the shower/spa room due to the risk of falls from the flooring being slick. She stated the spa doors were usually closed.
On 03/27/24 at 02:42 PM Administrative Nurse D stated the shower rooms should always be closed to deter falls from cognitively impaired residents. She stated wandering interventions should be included in the care plans for residents at risk.
The facility's provided Fall Management System policy revised 12/2023 indicated the facility will provide a safe environment that remains free from accidents and falls. The policy indicated each resident would be assessed for potential high-risk factors and provided implemented interventions to address potential accidents. The policy indicated assessment would be completed after falls to identify the underlying causes and prevent further falls/injuries.
The facility failed to provide an environment free of accident hazards resulting in R28's non-injury fall in the facility's spa room. The facility additionally failed to implement wandering interventions for R28 after his non-injury fall to prevent further accidents. These deficient practices placed the resident at risk for preventable falls and injuries.
- R25's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), muscle weakness, difficulty walking, need for assistance with personal care, and dysphagia (swallowing difficulty).
The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R25 required supervision or touch assistance for eating.
R25's Functional Abilities Care Area Assessment (CAA) dated 02/14/24 documented he required assistance with his activities of daily living related to his glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow).
R25's Care Plan dated 02/07/24 documented that staff would ensure he was wearing appropriate footwear when walking.
R25's EMR under the Assessment tab revealed a Fall Risk Evaluation dated 03/14/24 which documented R25 as a high fall risk.
On 03/27/24 at 07:43 AM R25 laid on his bed in the lowest position. Certified Medication Aide (CMA) R explained to R25 she was going to assist him to the bathroom. CMA R assisted R25 into a sitting position. CMA R raised the bed, placed R25's walker in front of R25, and asked him to stand up. R25 was wearing socks on his feet, and CMA R assisted R25 to the bathroom while holding the resident's arm. The CNA did not place R25's tennis shoes on his feet or use a gait belt during the walk from the bed to the bathroom. The gait belt hung from the hand sanitizer dispenser on the wall by the bathroom and R25's tennis shoes laid on the floor next to his wheelchair at the foot of his bed.
On 03/27/24 at 01;01 PM, CMA R stated R25 was a high fall risk. CMA R stated she was supposed to use a gait belt when walking with R25. CMA R stated she had planned to put R25's shoes on after she assisted him with dressing.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated R25 was a high fall risk and had a couple of recent falls. LN K stated R25 should be wearing his shoes when walking and that staff should always use a gait belt when walking with a resident.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected staff to use a gait belt when walking with a resident. Administrative Nurse D stated she expected staff to use the appropriate footwear for a resident who was a high fall risk.
The facility's Fall Management System policy revised 12/2023 documented the facility would provide a safe environment that remained free from accidents and falls. The policy indicated each resident would be assessed for potential high-risk factors and provided implemented interventions to address potential accidents. The policy indicated assessment would be completed after falls to identify the underlying causes and prevent further falls/injuries.
The facility failed to ensure staff applied the appropriate footwear and utilized a gait belt during ambulation for R25 who had a history of falls and was a high fall risk. This deficient practice placed R25 at risk of further falls and possible injuries.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with four reviewed for bowel and bladder management. Based on observations, record reviews, and interviews, the facil...
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The facility identified a census of 80 residents. The sample included 18 residents with four reviewed for bowel and bladder management. Based on observations, record reviews, and interviews, the facility failed to follow standards of practice related to sanitary catheter care for Resident (R)50. This deficient practice placed R25 at risk for complication-related urinary tract infections (UTI).
Finding included:
- R50's Electronic Medical Record (EMR) documented a diagnosis of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), and generalized muscle weakness.
The admission /Medicare Minimum Data Set (MDS), dated 08/24/23, documented R50 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R50 required partial to moderate assistance with bathing and lower body dressing. The MDS further documented R50 had an indwelling catheter.
The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 08/24/23, documented R50 had an indwelling catheter, neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and paraplegia. The CAA further documented that nursing staff helped with R50's catheter care and that R50 was at risk for urinary tract infections (UTI-an infection in any part of the urinary system).
R50's Care Plan with an initiated date of 03/06/24, documented R50 had a urinary tract infection. An intervention with an initiated date of 09/01/23, directed staff to position R50's catheter bag and tubing below the level of the bladder. Interventions with an initiated date of 09/01/23, directed staff to provide catheter care every shift and as needed and to monitor, record, and report signs and symptoms of a UTI to the doctor.
On 03/27/24 at 09:13 AM R50 was in his room in bed. R50's catheter tubing and collection bag contained urine. Licensed Nurse (LN) I performed catheter care on R50 and stated she needed to change his brief. LN I raised R50's catheter collection bag above the level of his bladder and laid it on top of the other side of R50's bed. R50's collection bag and tubing contained urine at that time, and the urine was noted to flow backward in his tubing. As LN I began to change R50's brief, R50's catheter collection bag fell on the floor, and LN I pulled it back onto his bed by the tubing. R50 asked LN I when the next time his catheter collection bag would need to be changed and LN I lifted R50's catheter bag to the level of her chest (above the level of R50's bladder) to inspect the date on R50's catheter collection bag and stated that it did not need to be changed at that time. There was no longer urine noted in R50's catheter tubing after R50's brief change was completed, and the backflow was observed.
On 03/27/24 at 02:00 PM, LN I stated that she probably should have moved R50's catheter collection bag to the other side of his bed and hung it there before she began his brief change and turned him in bed. LN I further stated that she should not have raised his catheter collection bag to chest level while she inspected the date on his catheter collection bag.
On 03/27/24 at 02:41 PM Administrative Nurse D stated staff should never raise a catheter collection bag to a level above a resident's bladder as it could cause urine in the catheter tubing to flow back into the resident's bladder. Administrative Nurse D stated she expected staff to drain the catheter tubing of urine and place the catheter collection bag on the other side of a resident's bed, before turning them in bed to prevent urine from flowing back into the resident's bladder. Administrative Nurse D further stated urine flowing back into a resident's bladder, from the catheter tubing, could potentially cause an infection.
The facility provided a Catheter Care, Indwelling policy with a revised date of 07/2013, and directed staff to keep catheter tubing below the level of the bladder.
The facility failed to ensure R50's catheter collection bag was kept below his bladder during catheter care and a brief change. This deficient practice placed R50 at increased risk for infection and catheter-related complications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based ...
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The facility identified a census of 80 residents. The sample included 18 residents with one resident reviewed for dialysis (blood purifying treatment given when kidney function is not optimum). Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Resident (R) 46. This deficient practice placed R46 at risk of delayed services, potential adverse outcomes, and physical complications related to dialysis.
Findings included:
- R46's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on renal dialysis.
The Annual Minimum Data Set (MDS), dated 10/09/23, documented R46 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented R46 was independent of activities of daily living (ADL) and received dialysis services.
The Nutritional Status Care Area Assessment (CAA) dated 10/09/23, documented R46 was on dialysis three times a week.
R46's Care Plan with an initiated date of 11/24/22, documented R46 had ESRD with hemodialysis. An intervention with an initiated date of 11/24/22 documented R46 received dialysis every Monday, Wednesday, and Friday. An intervention with an initiated date of 06/28/23 documented R46 would refuse to go to dialysis at times.
R46's EMR under the Orders tab revealed physician orders:
Receives dialysis on Monday, Wednesday Friday at 05:40 AM with a start date of 03/22/24.
Dialysis communication form to be completed and filed after dialysis treatment ordered 03/20/24.
R46's EMR under the Miscellaneous tab revealed scanned dialysis communication forms. Dialysis communication forms, under the Miscellaneous tab, reviewed from 12/29/23 to 03/27/24 (90 days) revealed no dialysis communication forms scanned for the following dialysis dates: 01/12/24, 02/02/24, 02/12/24, 02/16/24, 02/21/24, 02/23/24, 02/28/24, 03/08/24 and 03/22/24.
R46's EMR under the Progress Notes tab lacked evidence of R46's refusal to attend his dialysis appointments for the above dates.
R46's dialysis communication forms for the above dates were requested from the facility and the facility was unable to provide a dialysis communication form or evidence R46 refused dialysis for the above dates.
On 03/27/24 at 09:30 AM R46 was propelled in a wheelchair down the hallway to his room. Licensed Nurse (LN) I entered R46's room and began a post-dialysis assessment on R46. R46 stated he left dialysis early because he did not feel well.
On 03/27/24 at 02:00 PM, LN I stated dialysis communication forms were scanned into R46's EMR and found under the Miscellaneous tab. LN I stated the forms were completed by the nurse once R46 returned to the facility and the forms would have been sent to medical records to be scanned into the EMR. LN I stated the facility did not keep dialysis communication forms in a book or binder and that they were instead scanned into the EMR. LN I stated if R46 refused to go to dialysis staff should have documented his refusal in a progress note.
On 03/27/24 at 02:41 PM Administrative Nurse D stated staff were expected to have filled out a dialysis communication forms the morning before the resident left for dialysis. Administrative Nurse D stated the facility expected to receive the communication forms back once the resident returned from their dialysis appointment; however, Administrative Nurse D further stated the dialysis staff were not always fantastic about sending the forms back with the resident. Administrative Nurse D stated sometimes the nurse would have called the dialysis center to request the forms be sent, but the forms would not always make it back to the facility. Administrative Nurse D stated dialysis communication forms would have been sent to medical records to be scanned and uploaded into the resident's EMR. Administrative Nurse D stated R46 would sometimes refuse to go to his dialysis appointments due to transport running late to pick him up and she further stated R46 would refuse to reschedule for a later time if offered. Administrative Nurse D stated if R46 refused a dialysis appointment she expected staff to document the refusal in a progress note in R46's EMR. Administrative Nurse D stated the facility did not have the dialysis communication forms for the dates requested and stated she believed they were not returned from the dialysis center.
The facility provided a Dialysis (Renal), Pre- and Post-Care policy with an original date of 03/2009, documented it was the policy of the facility to participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The care of the resident receiving dialysis services will reflect ongoing communication, coordination, and collaboration between the nursing home and dialysis staff. Documentation related to pre-and post-dialysis care will be placed in the clinical record.
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for R46. This deficient practice placed R46 at risk of delayed services, potential adverse outcomes, and physical complications related to dialysis.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview Based on...
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The facility identified a census of 80 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview Based on observation, record review, and interview the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R)28's Seroquel (antipsychotic medication). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.
Findings Included:
- The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion).
R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated R28 had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments. The MDS indicated he was not taking psychotropic medications upon admission.
R28's Functional Abilities CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADLs).
R28's Care Plan initiated 02/14/24 indicated he was started on antipsychotic medication related to behaviors. The plan noted he took Seroquel and instructed staff to monitor for changes in mood/behaviors and potential side effects. The plan noted Seroquel had a black box warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). The plan noted that non-pharmacological interventions provided for R28 included back rubs, redirections, snacks, pain assessment, activities, and reassurance.
R28's EMR under Orders indicated an order started on 03/06/24 for staff to administer 25 milligrams (mg) of Seroquel by mouth twice daily for dementia with behaviors and agitation.
R28's clinical record lacked documentation showing appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits before R28's medication was started. The facility was also unable to provide this documentation upon request.
The facility provided an email for review from the physician dated 03/27/24 which indicated the medical provider acknowledged R28 was combative with aggressive behaviors during care. The email indicated staff exhausted non-pharmacological interventions including individual groups, speech therapy, and placement at the nurses' station for supervision and support.
On 03/25/24 at 12:04 PM R28 was woken up by his representative. R28 was wearing grey food-stained jogging clothing. His hair was greasy, and his fingernails were dirty.
On 03/27/24 at 10:29 AM Licensed Nurse (LN) G stated antipsychotic medication should not be used for dementia diagnoses alone but sometimes was used with other behavioral illnesses.
On 03/27/24 at 02:45 PM Administrative Nurse D stated dementia was not an appropriate diagnosis for antipsychotic medications but was used when other symptoms were present. She stated the facility had tried multiple interventions for R28's behaviors and the medical provider closely reviewed the medication use but was unable to provide the documentation.
A review of the facility's provided Psychotropic medication policy revised 08/2017 indicated the facility will ensure all residents with psychotropic medications were closely reviewed for correct indication and appropriateness.
The facility failed to ensure an appropriate indication or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic for R28, who had a diagnosis of dementia. This placed the resident at risk for unnecessary psychotropic medications and related complications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not ...
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The facility identified a census of 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to administer Resident (R)62 ' s medications as ordered. This resulted in a medication error rate of 26.67%.
Findings included:
- R62's Electronic Medical Record (EMR) under Physician ' s Orders revealed the following:
An order dated 12/30/23 instructing to administer 400 milligrams (mg) of Gabapentin (medication used to treat nerve pain) via an enteral (within or via the small intestine) tube each morning for neuromuscular pain.
An order dated 12/30/23 instructing to administer 200 mg of Amiodarone (medication used to treat irregular heart rhythms) via enteral tube each morning for irregular heartbeat.
An order dated 12/30/23 instructed to administer one tablet of Sennoside docusate (laxative) via enteral tube each morning for constipation.
An order dated 12/29/23 instructing to administer 5 mg of Eliquis (medication used to prevent the blood from clotting) via enteral tube each morning to prevent blood clots related to irregular heartbeat.
A review of R62 ' s Physician Orders lacked evidence of any order allowing enterally administrated medications to be given orally.
On 03/27/24 at 09:10 AM Licensed Nurse (LN) G completed hand hygiene and prepared R62 ' s medications for oral administration. R62 received his amiodarone (200mg), Gabapentin (400mg), senna-lax (8.6mg-50mg), and Eliquis (5mg) medications by mouth. LN G stated R62 preferred to receive his medication by mouth except for his liquid supplement.
On 03/27/24 at 02:42 PM Administrative Nurse D stated staff were expected to follow the physician's orders and notify the physician of changes in the resident ' s status and orders.
The facility ' s provided Medication Error and Adverse Reactions revised 01/2022 indicated the facility will ensure each resident ' s medications were prescribed accurately and administered following the appropriate order, route, patient, dosage, time, and medication.
The facility failed to ensure the medication error rate did not exceed five percent. This resulted in a medication error rate of 26.67%.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 was free from sign...
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The facility identified a census of 80 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 was free from significant medication errors when staff failed to administer insulin (a hormone that lowers the level of glucose in the blood) and antihypertensive (class of medication used to treat high blood pressure) medications as ordered. This placed R17 at risk for adverse side effects and medical complications.
Findings included:
- The electronic medical record (EMR) for R17 documented diagnosis of hypertension (HTN-elevated blood pressure), type 2 diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel).
R17's Annual Minimum Data Set (MDS) dated 03/24/23 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R17 required extensive assistance from one staff for activities of daily living (ADLs). R17 received insulin injections seven of seven days during the lookback period.
R17's ADL Care Area Assessment (CAA) dated 04/07/23 documented R17 had a self-care and mobility deficit and balance problems. R17 was bed-bound per her choice. R17 was at risk for a decline in ADLs, falls, 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), contractures (abnormal permanent fixation of a joint or muscle), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), muscle wasting (decrease in size and wasting of muscle tissue) and infections.
R17's Care Plan last revised on 09/26/23 directed staff to give diabetic medication as ordered. Staff was directed to monitor/document for side effects and effectiveness.
R17's Care Plan revised 07/04/23 directed staff to take blood pressure as ordered and as needed. The staff was directed to give antihypertensive medications as ordered.
R17's February 2024 Medication Administration Record (MAR) documented an order dated 06/22/23 for carvedilol (a beta blocker used to lower blood pressure) 25 milligrams (mg) tablet by mouth twice a day for hypertension hold for systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) below 110, heart rated below 55, call the physician for blood pressure greater than 175.
R17's February 2024 MAR documented an order for hydralazine (medication used to treat HTN) tablet 25 mg give two tablets by mouth three times a day for HTN. Hold if SBP was less than 120 and/or pulse was below 60.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/09/24 for Levemir 100unit/milliliter (ml) (a long-acting insulin that starts to work in 15 minutes, peaks within 60 minutes, and its effects last for three to five hours) to inject 27 units subcutaneously (beneath the skin) at bedtime for DM.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/16/24 for Levemir 100 units/ml to inject 30 units SQ one time a day for DM. This order was discontinued on 02/20/24 at 03:25 PM.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/16/24 for Levemir 100 units/ml to inject 30 units SQ at bedtime for DM. This order was discontinued on 02/20/24 at 03:25 PM.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/20/24 at 03:25 PM for Levemir 100unit/ml to inject 30 units SQ one time a day for DM until 02/21/24 at 11:59 PM.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/20/24 at 03:25 PM for Levemir 100unit/ml to inject 30 units SQ at bedtime for DM until 02/22/24 at 11:59 PM.
R17's Order Summary Report dated 02/01/24 to 02/29/24 documented an order dated 02/02/24 for basaglar 100 unit/ml (long-acting insulin) to inject 50 units SQ at bedtime for DM2 start once finished with current Levimir pens. This order was discontinued on 03/06/24.
R17's February 2024 MAR lacked staff sign-off that Levemir was injected on 02/20/24 at bedtime as scheduled or on 02/21/24 at 07:00 AM.
R17's February 2024 MAR documented on 02/23/24 at bedtime that her basaglar was not administered as ordered due to R17 still having Levemir pens left however R17's MAR documented the basaglar was administered on 02/22/24 and 02/24/24.
R17's February 2024 MAR lacked documentation on 02/25/24 the 08:00 AM carvedilol was given and not applicable (NA) was documented for the blood pressure and pulse readings.
R17's February 2024 MAR lacked documentation on 02/25/24 at midday that her blood pressure and pulse were monitored and her physician ordered hydralazine was administered as ordered.
R17's EMR lacked a Progress Note or other documentation to address the missed administration of the above medications.
On 03/26/24 at 08:36 AM R17 stated that she filed a grievance and her daughter called in a complaint when she missed her insulin injections and her blood pressure medication last month around 02/20/24 through 02/25/24. R17 stated the facility needs to make sure they have staff that will give the residents the medications they were supposed to have.
On 03/27/24 at 01:52 Licensed Nurse (LN) I stated that a blood pressure medication cannot be signed off as given until the blood pressure and pulse readings were entered into the MAR. LN I stated R17's insulin should have been given or the nurse should have documented to explain why the insulin was not administered as ordered.
On 03/27/24 at 03:10 PM Administrative Nurse D stated she was in the process of providing education to the medication aides and the nurses to ensure that medication was being given as ordered and if the medication was not given or was not available that the nurse needed to be documenting a nurse note to reflect why the medication was not given. Administrative Nurse D stated the MAR would not allow the user to sign off that a blood pressure medication had been given until the reading had been entered so she was to assume that the medication had not been given. Administrative Nurse D stated she did not have an answer as to why R17 had not been administered her insulin as ordered.
The Medication Errors and Adverse Reactions policy last revised in January 2022 documented adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. Nursing services must immediately implement and follow the physician's orders.
The facility failed to ensure R17 was free from significant medication errors when staff failed to administer her insulin and antihypertensive medications. This placed R17 at risk for adverse side effects and medical complications.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for nutritional diets. Based on observation, record review, and interviews, the facility failed t...
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The facility identified a census of 80 residents. The sample included 18 residents with three reviewed for nutritional diets. Based on observation, record review, and interviews, the facility failed to follow Resident (R)28's specialized dietary requirements during meal services. This deficient practice placed the residents at risk for impaired nutrition and aspiration (inhaling foreign material or vomit).
Findings Included:
- The Medical Diagnosis section within R28's Electronic Medical Records (EMR) included diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), dysphagia (difficulty swallowing), cognitive-communication disorder, and dementia (a progressive mental disorder characterized by failing memory, confusion).
R28's admission Minimum Data Set (MDS) completed 02/20/24 noted a Brief Interview for Metal Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS indicated R28 had no behaviors. The MDS indicated he used a wheelchair and was dependent on staff for mobility. The MDS indicated he had no upper or lower extremity impairments. The MDS noted he required set-up assistance with his meals. The MDS indicated he had problems with choking or coughing during meals. The MDS noted he weighed 147 pounds and was on a mechanically altered diet.
R28's Nutrition Care Area Assessment (CAA) completed 02/27/24 noted he was on a mechanically altered diet due to his cognition. The CAA noted he had difficulty swallowing with his dysphagia. The CAA noted he was on the grazing program (a weight loss program for dementia that increased opportunities for nutritional intake) due to his dementia.
R28's Functional Abilities CAA completed 02/27/24 indicated he required assistance with his care. The CAA noted he was weak and working to recover his strength. The CAA noted he was at risk for falls, depression, infections, and a decline in his activities of daily living (ADLs).
R28's Care Plan initiated on 02/14/24 indicated he had a nutritional problem related to his medical diagnosis. The plan instructed staff to provide his diet as ordered (02/14/24). The plan instructed staff to monitor for signs of dysphagia, coughing, drooling, and difficulty swallowing (02/27/24). The plan instructed staff to provide dietary supplements as ordered and weigh him weekly for four weeks (02/27/24). The plan noted he was placed on a grazing program on 03/21/24. The plan instructed staff to provide a slightly thick liquid consistency (03/21/24).
R28's EMR under Orders revealed his diet was changed to minced and moist (regular diet) on 03/19/24.
R28's dietary meal ticket revealed he was to be served a regular diet that was minced and moist.
On 03/26/24 at 01:14 PM, R28 was in the dining room. R28 was served minced chicken and potato salad. R28's plate also contained three uncut Brussels sprouts he was unable to chew them. At 01:20 AM Certified Nurses Aid (CNA) Q offered to cut up his Brussels sprouts. R28 Refused to eat them.
On 03/26/23 at 10:00 AM Certified Nurse Aid (CNA) Q stated the dining staff filled the food order and the kitchen staff were responsible for verifying what was on the plate matched the meal ticket.
On 03/26/24 at 01:30 PM, Dietary Staff BB stated each resident on a specialized diet was listed on the diet tickets. He stated kitchen staff were expected to review the tickets and ensure the correct food was placed in the resident's place before serving.
The facility provided a Diet Orders policy (undated) which indicates the facility will ensure each resident's dietary needs, preferences, and assessed abilities are respected and followed. The policy noted accurate communication between dietary and nursing staff was expected to ensure the accuracy of the meal service. The policy indicated each resident's diet would be reviewed during meal service by both dietary and nursing staff.
The facility failed to follow R28's specialized dietary requirements during meal services. This deficient practice placed the resident at risk for impaired nutrition and aspiration.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for hospice ser...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 80 residents. The sample included 18 residents with three residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to describe the services and equipment provided to Resident (R) 21 by hospice. This deficient practice created a risk for missed or delayed services and impaired physical, and psychosocial care for R21.
Findings included:
- R21's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and need for assistance with personal care.
The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R21 required partial to moderate assistance from staff for her personal hygiene. The MDS documented R21 had received hospice services during the observation period.
R21's Functional Abilities Care Area Assessment (CAA) dated 02/15/24 documented she required assistance with activities of daily living.
R21's Care Plan dated 02/15/24 documented the hospice service contact information. The plan of care also directed staff to observe closely for pain, administer pain medications as ordered, and notify the physician immediately if there was breakthrough pain. The plan of care documented the registered nurse would visit weekly and as needed; a Certified Nurse Aide (CNA) would visit weekly and as needed, and the social worker and chaplain would visit as needed. The plan of care directed the facility to work collaboratively with the hospice provider team to ensure R21's spiritual, emotional, intellectual, physical, and social needs were met. The plan of care lacked a description of the additional services provided by hospice including equipment and medication.
R21s EMR under the Orders tab revealed the following physician orders:
Admit to hospice with a diagnosis of sarcopenia (an age-related involuntary loss of skeletal muscle mass and strength) dated 02/02/24.
A review of R21's communication book provided by hospice lacked a hospice care plan, signed admission paperwork with the physician documentation of a terminal diagnosis for admission to hospice services, services, or equipment that would be provided by hospice.
On 03/27/24 at 07:38 AM R21 sat at the dining room table and drank her coffee. R21's hair was uncombed and sticking up. R21 stated the staff did not always offer or assist her with combing her hair. R21 stated she was too old to ask for help.
On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated she would know who was on hospice services when staff from the hospice providers would stop her in the hallway and ask about specific residents. CMA R stated the hospice book would contain information about what was provided by the hospice company. CMA R stated she was not certain what was provided by R21's hospice services provider.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K confirmed R21's communication book provided by hospice lacked a hospice care plan, signed admission paperwork with the physician documentation of a terminal diagnosis for admission to hospice services, and services or equipment that would be provided by hospice. LN K stated R21's care plan should contain information about what the hospice provider would provide.
On 03/27/24 at 02:43 PM, Administrative Nurse D confirmed R21's communication book provided by hospice lacked a hospice care plan and signed admission paperwork with the physician documentation of a terminal diagnosis for admission to hospice services, services, or equipment that would be provided by hospice. Administrative Nurse D stated the hospice provider for R21 was new and would have to investigate the information that was not in the communication book. Administrative Nurse D stated R21's Care Plan should have what medical equipment and medication are covered by the hospice provider listed on her care plan.
The facility's Hospice Program Policy dated 10/2023 documented that when a resident participated in the hospice program, a coordinated plan of care between the facility, hospice agency, and resident/family would be developed and would include directives for managing pain and other uncomfortable symptoms. The care plan would be revised and updated as necessary to reflect the resident's status.
The facility failed to ensure collaboration between the facility and the hospice provider and failed to develop a care plan both by hospice and the facility that included a description of the services, medication, and equipment provided to R21 by hospice. This deficient practice placed R21 at risk for delayed services which could affect her mental, and psychosocial well-being.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with two residents where on transmission-based precautions. Based on observation, record review, and interviews, the ...
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The facility identified a census of 80 residents. The sample included 18 residents with two residents where on transmission-based precautions. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene, the disinfecting of shared equipment, and the replacement of respiratory equipment. The facility also failed to ensure laundry temperatures for laundry including laundry from transmission-based precaution rooms with infectious diseases were assessed for appropriate temperatures. This deficient practice placed the residents at risk for complications related to infectious diseases.
Findings included:
- Observation on 03/25/24 at 10:52 AM Resident (R) 56's oxygen tubing was dated 01/03/24. R56 stated he asked staff to change the oxygen tubing and staff informed him the facility did not have long enough tubing to replace it.
Observation on 03/26/24 at 08:14 AM Licensed Nurse (LN) G pushed her medication cart down the hallway and stopped at R29's room. LN G donned gloves pushed the vitals machine into R29's room and applied the blood pressure cuff onto R29's right upper arm. LN G obtained R29's temperature with the forehead contact sensor and then placed the thermometer back into the basket of the vital sign machine without disinfecting the thermometer. LN G removed the blood pressure cuff and placed the cuff back onto the vital sign machine without disinfecting the blood pressure cuff. LN G pushed the vital sign machine from R29's room back into the hallway. LN G removed her gloves, did not perform hand hygiene, and donned a new pair of gloves. She prepared R29's medication and administered the medication to R29. LN G exited R29's room, doffed her gloves but did not perform hand hygiene. LN G pushed the medication cart and the vital sign machine down the hallway to another resident's room. LN G entered the room with the vital sign machine.
On 03/26/24 at 11:29 AM survey of the laundry room revealed the washing machine water temperatures were monitored weekly. Maintenance Director U stated he tested and recorded the water temperatures weekly. Maintenance Director U stated the facility did have two residents currently in isolation. Maintenance Director U stated the only way he could think to ensure the water temperatures were sufficient to kill the germs from the transmission-based precautions rooms, one with COVID-19 (highly contagious respiratory virus) and clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements), would be to monitor the water temperature with each load of transmission based laundry at least.
On 03/27/24 at 01:01 PM, Certified Medication Aide (CMA) R stated shared medical equipment was disinfected by the night shift. CMA R stated she would perform hand hygiene between donning and doffing her gloves and between each resident.
On 03/27/24 at 01:45 PM, Licensed Nurse (LN) K stated shared equipment should be disinfected between each use. LN K stated she would perform hand hygiene between each resident when administering medication.
On 03/27/24 at 02:43 PM, Administrative Nurse D stated she expected the staff to disinfect shared equipment between each use and perform hand hygiene between providing care. Administrative Nurse D stated she expected staff to change the oxygen tubing as indicated.
The facility's Handling Linen policy dated 08/29/17 documented that soiled laundry /bedding would be handled in a manner that prevented gross microbial contamination of the air and persons handling the linen.
The facility's undated Hand Hygiene policy documented the facility considered hand hygiene the primary means to prevent the spread of infections.
The facility failed to ensure staff practiced standard infection control precautions to prevent the spread of infection when staff failed to perform hand hygiene during glove changes and between administration of medication, also failed to replace oxygen tubing as ordered and perform disinfecting of shared equipment. The facility also failed to ensure laundry temperatures for laundry including infectious disease from transmission-based precaution rooms were assessed for appropriate disinfecting temperatures. This had the potential to increase the risk of transmission of infectious diseases to residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
The facility identified a census of 80 residents. The sample included 18 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility fai...
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The facility identified a census of 80 residents. The sample included 18 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 42, R27, and R23 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) as consented. This placed the residents at increased risk for complications related to pneumonia.
Findings included:
- R42's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. A review of Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination form for R42 dated 10/19/23 provided by the facility revealed a signed consent to receive the pneumococcal vaccination. The form indicated R42 was provided educational information related to the vaccination but never received the PCV 20 vaccination. The facility was unable to provide evidence the PCV20 was administered to R42.
R27's EMR revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. A review of Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination form for R27 dated 10/19/23 provided by the facility revealed a signed consent to receive the pneumococcal vaccination. The form indicated R27 was provided educational information related to the vaccination but never received the PCV 20 vaccination. The facility was unable to provide evidence the PCV20 was administered to R27.
R23's EMR revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. A review of Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination form for R23 dated 10/19/23 was provided by the facility and revealed a signed consent to receive the pneumococcal vaccination. The form indicated R23 was provided educational information related to the vaccination but never received the PCV 20 vaccination. The facility was unable to provide evidence that PCV 20 was administered to R23.
On 03/27/24 at 10:45 AM Administrative Nurse E, the facility Infection Preventionist, stated she had obtained the consent for the pneumococcal vaccination during influenza season. Administrative Nurse E stated the facility started giving pneumococcal vaccinations to the eligible resident in February 2024.
On 03/27/24 at 11:03 AM, Administrative Nurse D stated she expected the pneumococcal vaccination to be administered at the time of consent.
The facility's undated Pneumococcal Vaccine policy documented it was the facility's policy to offer residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Center guidelines and recommendations.
The facility failed to provide R42, R27, and R23 with the PCV20 vaccination as consented. This placed these residents at increased risk for complications related to pneumonia.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
The facility had a census of 80 residents. The sample included 18 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent rec...
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The facility had a census of 80 residents. The sample included 18 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift. This placed the 14 residents with controlled substances on the cart at risk for misappropriation of medications. The facility also failed to ensure Resident (R) 42's physician-prescribed medication was available from the pharmacy for administration. This placed R42 at risk for ineffective medication regimen and related complications.
Findings included:
- On 03/26/24 at 08:14 AM, observation on the Maple Hill One medication cart Controlled Drug Record flow sheet lacked evidence the staff completed the narcotic reconciliation for day shifts on 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/09/24, 02/10/24, 02/12/24, 02/16/24, 02/19/24, 02/23/24 02/26/24, 02/27/24, 03/01/24, 03/02/24 03/03/24, 03/04/24, 03/07/24, 03/08/24, 03/09/24, 03/15/24, 03/16/24, 03/17/24, 03/18/24, 03/22/24, and 03/25/24, for night shifts; 02/01/24, 02/02/24, 02/03/24, 02/09/24, 02/10/24, 02/11/24, 02/12/24, 02/16/24, 02/19/24, 02/12/24, 02/26/24, 02/27/24, 03/01/24, 03/02/24, 03/03/24, 03/06/24, 03/14/24, 03/15/24, 03/16/24, 03/17/24, 03/18/24, and 03/25/24 (forty-eight times out of possible 109 work shifts).
On 03/26/24 at 08:15 AM, Licensed Nurse (LN) J stated nurses were expected to count the narcotics with another nurse each shift. LN J stated the nurse coming on duty and the nurse going off duty should ensure the narcotic count is correct each shift. LN J stated the facility has a policy regarding controlled substances, and everyone was educated on the policy and expectations of counting narcotics.
On 03/27/24 at 02:41 PM, Administrative Nurse D stated she expected the nurse coming on duty and the nurse leaving duty to count their narcotic cards and bottles on all carts. Administrative Nurse D stated nurses or medication aides count each card, and the total number was recorded. Administrative Nurse D stated the two nurses together determined the count was correct.
The Controlled Medication policy revised 12/2023 stated controlled medications reconciliation is conducted by two licensed nurses and is documented on an audit record at each shift change. Any discrepancies in the controlled medication should be reported to the Director of Nursing Services immediately.
The facility failed to provide a consistent reconciliation of controlled drugs at the end of daily work shifts, placing the 14 residents with controlled substances on the cart at risk for misappropriation of medications by staff.
- The electronic medical record for R42 documented diagnoses of hypothyroidism (a condition characterized by decreased activity of the thyroid gland), hypotension (low blood pressure), and dementia (progressive mental disorder characterized by failing memory, and confusion).
R42's Annual Minimum Data Set (MDS) dated 02/10/24 documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R42 utilized a walker and wheelchair for mobility. R42 required setup to supervision/touching assistance with his activities of daily living (ADLs). R42 had no history of falls since the last assessment.
R42's ADL Care Area Assessment (CAA) dated 02/22/24 documented he needed assistance with his care. R42 ambulated with a walker. Nursing provided ADL, mobility, and transfer assistance as needed.
R42's Care Plan last revised 02/27/24 directed staff to administer medications as ordered.
R42's Order Summary Report documented an order dated 03/17/22 for levothyroxine (a medication used to treat hypothyroidism) 75 micrograms (mcg) by mouth 30 minutes before breakfast daily for hypothyroidism.
R42's January 2024 Medication Administration Record (MAR) on 01/01/24, 01/02/24, and 01/03/24 recorded a seven (7- other/see nurse notes) in the administration box for his levothyroxine.
On 01/1/24 at 05:36 AM an eMAR-Medication Administration Note documented staff were waiting on the delivery from the pharmacy.
On 01/2/24 at 05:09 AM an eMAR-Medication Administration Note documented levothyroxine sodium tablet 75 mcg; the medication was not available, and the pharmacy was notified.
On 01/3/24 at 04:13 AM an eMAR-Medication Administration Note documented staff continued waiting on a delivery from the pharmacy. Staff would notify the day nurse to call the pharmacy.
On 03/26/24 at 08:38 AM R42 sat in a chair at the dining table eating breakfast; his walker was beside his chair.
On 03/27/24 at 01:55 PM Certified Medication Aide (CMA) S stated she would let the pharmacy know when a resident had five or fewer doses left of a medication to ensure that the medication was received before the medication was out. CMA S stated if she noticed that a resident was out of medication, she would immediately call the pharmacy to order the medication as well as notify the nurse that the medication was out and had been ordered.
On 03/27/24 at 01:58 PM Licensed Nurse (LN) I stated a medication that was almost out should be ordered several days to a week before being completely out to ensure that the medication was received before completely out. LN I stated at times medications were not available from the pharmacy to be delivered due to a holiday or some other circumstance. LN I stated she would not expect a resident to be without medication for more than one day and would expect the nurse to document a reason why the medication was not available.
On 03/27/24 at 03:15 PM Administrative Nurse D stated nursing staff had been educated numerous times to make sure that medication was ordered at least five days before being out to ensure the medication was received before being out. Administrative Nurse D stated she could not say for certain why R42's medication had run out or had not been ordered/received.
The Pharmacy Services/Nursing Services policy revised in July 2015 documented drugs and biologicals that were required to be refilled must be ordered from the issuing pharmacy not less than three days before the last dosage being administered to ensure that refills were on hand.
The facility failed to ensure R42's physician-ordered levothyroxine was available for administration. This deficient practice placed R42 at risk for ineffective medication regimen and related health consequences.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
The facility identified a census of 80 residents. The facility had one main kitchen and four kitchenettes with dining areas. Based on observation and interview, the facility failed to ensure staff sto...
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The facility identified a census of 80 residents. The facility had one main kitchen and four kitchenettes with dining areas. Based on observation and interview, the facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness, and cross-contamination (the transfer of harmful substances to food).
Findings included:
- Observation during the initial kitchen tour on 03/25/24 at 07:15 AM revealed in the kitchen storage freezer were two open bags of fried potatoes that had no label or date and were not in a sealed bag. The walk-in freezer unit leaked and had ice around some of the pipes. The walk-in freezer had an area of what appeared to be water that had dripped from the freezer unit and froze on the floor.
Observation during the lunchtime services of food on 03/25/24 at 12:23 AM in the Maple Hills 2 dining area revealed that plates, bowls, and saucers were stored right-side up on the counter. An unidentified dietary staff wore gloves while serving food on the resident's plates. She left the serving area to obtain a bowl from the cupboard and returned to the serving area without changing her gloves or performing hand hygiene.
Observation on 03/26/24 at 11:18 AM revealed during the preparation of the puree foods by Dietary CC failed to sanitize the metal food container and the lid after each food item was pureed. Dietary CC rinsed the food container and lid under hot water at the sink after each food item.
On 03/26/24 at 11:35 AM Dietary CC stated normally he washed and sanitized the food container and lid in the dishwasher. Dietary CC stated he was running behind and it was a simple mistake he made since the surveyor was observing him.
On 03/26/24 at 11:15 AM Dietary BB stated that any staff that was assisting during the dining task should be washing their hand and performing hand hygiene after serving each resident. The dietary staff serving the food did wear gloves but were expected to change the gloves and perform hand hygiene if they had left the serving line. Dietary BB stated staff would be re-educated to ensure proper hand hygiene was being performed during food service. Dietary BB stated Dietary CC should have properly washed and sanitized the container and lid after pureeing each food item.
On 03/27/24 at 03:15 PM Administrative Nurse D stated staff was expected to perform hand hygiene during meal service just as they would during care of the residents. Hand hygiene should be performed after the service of each resident.
The Routine Procedures- General Food Handling/Storage/Preparation policy reviewed in 2021 documented that it was the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. This included the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. Refrigerated items should be covered, labeled, and dated with an expiration date indicated. Dishes should be cleaned and sanitized using the proper water temperature and with the appropriate concentration of sanitizer solution. The dishes must be held in the sanitizing solution for the proper amount of time, and all dishes must be air-dried. Nurses, CNAs, and other staff members who handle and distribute food to residents must receive training on good food safety practices.
The facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of food-borne illness, and cross-contamination.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
The facility identified a census of 80 residents. The facility had one main kitchen and four dining areas. Based on observation, record review and interview the facility failed to ensure the director ...
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The facility identified a census of 80 residents. The facility had one main kitchen and four dining areas. Based on observation, record review and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.
Findings included:
- On 03/26/24 at 11:28 AM Dietary BB stated he and Dietary CC had not completed the course yet to become a CDM. Dietary BB stated he and Dietary CC had begun the courses. Dietary BB stated both himself and Dietary CC had completed the ServSafe class and said he would provide a copy of the certification.
The facility did not provide a policy for Qualified Dietary Staff but did provide the Federal regulation guideline 483.60(a)(1).
The facility failed to ensure the director of food and nutrition services was a certified dietary manager. This deficient practice placed the affected residents at risk for unmet dietary and nutritional needs.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected most or all residents
The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure direct care staff received the required communication training. This placed the r...
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The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure direct care staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life.
Findings Included:
- On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following:
CNA PP's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course.
CNA QQ's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE and mental health courses.
LN L's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses.
LN NN's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses.
LN OO's facility-provided credentialling file lacked documented and completed training completed for communication. The file noted she had ANE training and mental health courses.
On 03/27/24 at 12:45 PM Administrative Nurse D stated the selected agency that provided the staff was new to the facility. She stated the only documentation available for the agency staff was on the online portal.
On 03/27/24 at 12:45 PM Administrator A stated he had very limited ability to view the online documentation provided by the contract agency for the selected employees. He stated he could not open the files of training courses noted as passed to verify what material they covered.
The facility's provided Nursing Staff Competency policy revised 12/2023 indicated the facility will ensure all staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable well-being of each resident.
The facility failed to ensure the completion of the required communication training for staff who provided care in the facility. This placed the residents at risk for impaired care and decreased quality of life.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected most or all residents
The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure all staff were educated on the rights of the residents and the facility's respons...
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The facility identified a census of 80 residents. Based on record review and interviews, the facility failed to ensure all staff were educated on the rights of the residents and the facility's responsibility to provide proper care. This placed the residents at risk for impaired care and decreased quality of life.
Findings Included:
-On 03/27/24 at 11:40 AM a review of the facility's training for Certified Nurses Aid (CNA) PP, CNA QQ, Licensed Nurse (LN) L, LN NN, and LN OO revealed the following:
CNA PP's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she passed abuse, neglect, and exploitation (ANE) and a mental health course.
CNA QQ's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE and mental health courses.
LN L's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses.
LN NN's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses.
LN OO's facility-provided credentialling file lacked documented and completed training completed for resident rights. The file noted she had ANE training and mental health courses.
On 03/27/24 at 12:45 PM Administrative Nurse D stated the selected agency that provided the staff was new to the facility. She stated the only documentation available for the agency staff was on the online portal.
On 03/27/24 at 12:45 PM Administrator A stated he had very limited ability to view the online documentation provided by the contract agency for the selected employees. He stated he could not open the files of training courses noted as passed to verify what material they covered.
The facility's provided Nursing Staff Competency policy revised 12/2023 indicated the facility will ensure all staff have the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable well-being of each resident.
The facility failed to ensure all staff were educated on the rights of the residents and the facility's responsibility to provide proper care. This placed the residents at risk for impaired care and decreased quality of life.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
The facility had a census of 80 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) reviewed for required in-service training. Based on record review and interview, the fa...
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The facility had a census of 80 residents. The sample included 18 residents and five Certified Nurse Aides (CNA) reviewed for required in-service training. Based on record review and interview, the facility failed to ensure one of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care.
Findings included:
- A review of the facility's in-service records revealed the following:
CNA N, hired 06/07/19, had 3.50 hours of in-service education in the past 12 months.
On 03/27/24 at 08:10 AM Administrative Staff A stated staff had from February through October to complete their yearly education and that the system flagged all of the staff that completed their assigned education for the year. Administrative Staff A stated CNA N's record showed their education as completed in the system and he was unsure as to why the system had reported so few hours. Administrative Staff A stated he compared CNA N's record with another CNA and found that the assigned education was not the same. Administrative Staff A further stated he contacted their compliance staff to discuss the issue and was unable to find an answer as to why CNA N's assigned education topics and hours were different. Administrative Staff A further stated he believed it may have been an issue with CNA N being an as-needed (PRN) employee. Administrative Staff A stated the education completion was tracked in the system, but no one reviewed the recorded hours for CNA N and it wasn't caught. Administrative Staff A stated the facility provided in-services education in addition to the online education courses; however, he stated CNA N's sister also worked at the facility and he was unable to tell the difference between their signatures to show that CNA N had completed the 12 hours of required education for the year.
The facility provided a CNA Orientation and Annual Training policy with a reviewed date of 02/24 documented the facility will complete a performance review of every CNA at least once every 12 months and will provide regular in-service education. The in-service training will be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year.
The facility failed to ensure one of the five CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for inadequate care.
Nov 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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 79 residents. The sample included three residents reviewed for grievances. Based on record rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 79 residents. The sample included three residents reviewed for grievances. Based on record review, observations, and interviews, the facility failed to log grievances received from or about Resident (R) 1 and failed to record actions taken and provide a resolution to the resident and/or representatives regarding the grievances. This deficient practice placed the residnet at risk for unresolved grievances and decreased quality of care.
Findings include:
- R1's Electronic Medical Record (EMR), under the Diagnosis tab, listed diagnoses of chronic congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath); cognitive communication deficit (communication problems that have an underlying cause in a cognitive deficit- like from a stroke); generalized anxiety (a condition with exaggerated tension, worrying, and nervousness about daily life events), and depression (a mental state of low mood and aversion to activity).
The Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status score of 15 which indicated R1's cognition was intact. The MDS documented R1's mood score was eight indicating depression. R1 was mostly independent or required only supervision with most activities of daily living (ADL).
R1's Care Plan revised 11/01/23 recorded R1 was at risk for impaired cognitive function related to confusion at times and directed staff to keep R1's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The plan documented social services provided psychosocial support as needed. The plan recorded R1 had a potential mood problem related to diagnoses of depression and anxiety and medications were used. It directed staff to assist the resident to identify strengths, provide positive coping skills and reinforce these. It further directed to encourage R1 to express feelings, offer support and reassurance, anticipate and meet R1's needs and assist R1 to develop appropriate methods of coping and interacting. The care plan noted R1 would, at times, make threats to call staff, obsess regarding health concerns, and fixate on past concerns that were resolved.
Review of the Psychology Services Note dated 11/6/23 and 11/13/23 located in the EMR under the Misc. tab, recorded R1 had a depressed, angry mood, and documented R1 had a negative interaction with a staff member.
Review of the Psychology Services Note dated 11/20/23 R1 had a depressed, angry mood, and discussed an issue R1 was having with facility staff but did not feel she was believed (by staff). R1 and psychology services discussed appropriate staff advocacy to conflict resolution.
Review of the facility Grievance Log for October and November 2023 lacked documentation of any concerns and/or complaints expressed by the resident.
On 11/20/23 at 01:07 P.M. R1 sat on the side of her bed. R1 complained of her shower water temperature and pressure being too low and explained there was a staff member that she did not want to assist her. R1 explained there was a previous incident with the same staff member and the former administrative staff knew this; the staff member was reassigned to a different unit. R1 accused the staff member of entering her room in the early morning recently to empty her commode and stated the staff member said, cover yourself, I can see your lady parts. R1 stated she did not want that staff fired, just wanted the staff member not to work in her area. She said she did not want to see that staff again. R1 stated she left some voice messages on Administrative Staff A's office phone but had not received any response.
On 11/20/23, over the course of several interviews which concluded around 02:00 P.M. Administrative Staff A denied having received any complaint, grievance, or concern from R1 regarding a staff member being inappropriate. Administrative Staff A acknowledged he received a letter a couple of weeks ago from R1's case manager regarding R1's concern with the shower water temperature and pressure, and stated the facility began an investigation and provided educations. Administrator A stated the resident recently verbalized grievances regarding being able to display her cat decorations at the nursing station and wanting reimbursed for a bed mattress which she purchased and believed the facility destroyed or discarded. Administrative Staff A stated he was also aware that R1 wanted reimbursed for a cell phone she purchased and her complaints that staff were unable to read.
The facilities policy titled 'Resident Rights and Grievances' revised 11/23/2016 documented, It is the policy of this facility to establish a grievance process to address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents; and other concerns regarding their facility stay, Make prompt efforts to resolve grievances the resident may have.
The facility failed to log known grievances for R1 and failed to take action to alleviate concerns and provide resolution to R1 and/or her representatives. This deficient practice placed the residnet at risk for unresolved grievances and decreased quality of care.
May 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 91 residents. The sample included six residents with one resident sampled for communication....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 91 residents. The sample included six residents with one resident sampled for communication. Based on observations, record review, and interview, the facility failed to provide effective communication for Resident (R) 1. This deficient practice had the risk for miscommunication of needs between R1 and facility staff and a risk for a decline in psychosocial well-being related to ineffective and unfulfilling communication.
Findings included:
- R1 admitted to the facility on [DATE].
The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and need for assistance with personal care.
The admission Minimum Data Set (MDS) dated 02/06/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of two which indicated severe cognitive impairment. R1 was usually able to make herself understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time. R1 usually understood others with missing some part or intent of a message but comprehended most of the conversation.
The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 02/06/23 documented R1 was a new admission to facility after a 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).
The Care Plan dated 02/01/23, documented R1 was at risk for a communication problem related to a language barrier, was Korean speaking only, and had a recent stroke that altered her speech. The Care Plan documented the following interventions: staff anticipated and met R1's needs, assisted with word finding as needed/appropriate, discussed with resident/family any concerns or feelings regarding communication difficulty, monitored the effectiveness of communication strategies and assistive devices, provided a translator as necessary to communicate with resident, and referred to speech therapy for evaluation and treatment as ordered.
The Notes tab of R1's EMR revealed the following:
An Incident Note on 03/31/23 at 09:41 PM documented at 06:30 PM, R1 was observed on her bathroom floor by a Certified Nurse Aide (CNA). R1 was last seen in the dining room eating dinner. Due to the language barrier, R1 was not able to make herself completely understood. R1 was assessed and denied pain, no injuries noted. All responsible parties were notified, and neurological checks were started. R1 rested in bed at that time with call light in reach, bed in lowest position with fall mat next to bed.
A Nursing Note on 04/01/23 at 12:50 PM documented at approximately 12:40 PM, R1 dialed 911 as stated by the receptionist. R1 was not in distress and was in her room sitting upright eating lunch. R1 declined to get out of bed for lunch. When staff approached R1, she pointed to a piece of paper next to her bed and stated call. Staff assisted R1 with the call and Emergency Medical Services (EMS) arrived to view resident then departed shortly after. There were no concerns at that time and R1 spoke to who she was trying to call.
An Incident Note on 04/16/23 at 11:11 PM documented at 03:05 PM, R1 was observed by a CNA on the bathroom floor between her wheelchair and toilet. R1 spoke very little English and was unable to describe events. It appeared R1 was trying to transfer herself to the toilet. There were no injuries noted and all responsible parties were notified with neurological checks started.
A Nursing Note on 04/21/23 at 09:02 PM documented R1 had a fall in her room. Upon assessment, R1 was lying on her back with her feet towards the door and her head partially under the bed. R1 was alert and verbally expressive. She had no apparent injuries and vital signs were stable. Staff continued to monitor R1.
In a statement on 04/26/23 at 08:19 AM, CNA M stated on 04/21/23 at 07:00 PM, another CNA came to her and told her R1 was on the floor. CNA M stayed with R1 while the other CNA went to get the nurse. While CNA M stayed with R1, R1 kept requesting CNA M to pick her up as she always did when she was on the floor. CNA M stated R1 was in a safe position, and she could not pick her up because facility policy had to be followed. She stated R1 was furious because CNA M did not pick her up. CNA M kept telling R1 they had to wait for the nurse to do the fall assessment. She stated on 04/24/23 around 04:00 PM, R1's call light was on and CNA M went to answer it because the other CNA was busy. R1 told CNA M, no, since she had remembered what happened on 04/21/23. CNA M stated she thought R1 saw her as mean because she did not understand why CNA M could not help her from the floor.
On 05/02/23 at 02:30 PM, R1 laid in her bed with her eyes open. When the surveyor asked R1 how she was today, R1 stated she was good. R1 appeared to have difficulty understanding further questions and only answered with yes. Observation of R1's room did not reveal a communication board or a method to effectively communicate with R1.
On 05/02/23 at 11:20 AM, R1's representative stated R1 had a difficult time communicating in English, but she understood what was going on at times. R1's representative stated R1 would not have been able to articulate descriptions of events in English like she did in Korean.
On 05/02/23 at 03:04 PM, CNA N stated she communicated with R1 using visual cues and simple questions. She stated R1 does not have a communication board but stated it could be helpful.
On 05/02/23 at 03:16 PM, Licensed Nurse (LN) H stated she was just in R1's room and was able to talk to her. She stated if she had difficulty communicating with R1, she could use a translator or could communicate with her family. LN H stated the report sheet documented R1 spoke Korean and a little bit of English.
On 05/02/23 at 04:21 PM, Administrative Nurse D stated the facility had a language link interpreter available but R1 did speak English and knew what staff were going to do such as when staff would say they needed a blood sugar, R1 put her finger out.
On 05/02/23 at 04:22 PM, Administrative Nurse E stated R1 was able to tell where her pain was and articulated her needs such as what she wanted to eat. He stated R1 was very shy and did not talk a lot.
The facility's Communication with Residents of Limited English Proficiency policy, last revised January 2023, directed the facility provided services for those residents of limited English proficiency for effective communication. Services were provided at the cost of the facility, not the individual with limited English proficiency.
The facility failed to provide effective communication for R1. This deficient practice had the risk for miscommunication of needs between R1 and facility staff and a risk for a psychosocial decline related to ineffective and unfulfilling communication.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
The facility identified a census of 91 residents. The sample included six residents with three sampled for pain management. Based on observations, record review, and interviews, the facility failed to...
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The facility identified a census of 91 residents. The sample included six residents with three sampled for pain management. Based on observations, record review, and interviews, the facility failed to provide effective pain management for Resident (R) 2. This deficient practice had the risk for increased and unnecessary pain and decreased psychosocial well-being for R2.
Findings included:
- The Diagnoses tab of R2's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities) lumbar (low back) region with neurogenic claudication (condition when nerves get pinched within the center of the lumbar spine, causing intermittent leg pain).
The Annual Minimum Data Set (MDS) dated 07/06/22, documented R2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. R2 received scheduled pain medication and complained of occasional pain rated highest of four out of 10 in the last five days of the assessment period. R2 received opioid (pain medication) medications seven days in the seven-day lookback period.
The Quarterly MDS dated 01/26/23, documented R2 had a BIMS score of 11 which indicated moderate cognitive impairment. R2 received scheduled and as needed (PRN) pain medication and complained of occasional pain rated highest of five out of ten in the last five days of the assessment period. R2 received opioid medications seven days in the seven-day lookback period.
The Pain Care Area Assessment (CAA) dated 07/07/22, documented R2 reported pain and that she was unable to sleep or do daily activities without pain.
The Care Plan dated 10/31/18, last revised 05/20/22, documented R2 had chronic pain and used pain medications of Percocet (opioid pain medication) and Xtampza (opioid pain medication). The Care Plan directed staff anticipated R2's need for pain relief and responded immediately to any complaint of pain and followed pain scale to medicate as ordered.
The Orders tab of R2's EMR documented an order with a start date of 12/03/19 for Tylenol (acetaminophen- pain reliever) 650 milligrams (mg) every six hours as needed for pain scale of one to four out of 10; an order with a start date of 10/27/20 and discontinued date of 04/25/23 for Percocet (Oxycodone-Acetaminophen) 5-325 mg one time a day for pain; an order with a start date of 10/27/20 and discontinued date of 04/25/23 for Percocet 5-325 mg every 12 hours as needed for pain scale of five to 10 out of 10; an order with a start date of 02/10/22 and discontinued date of 04/25/23 for Xtampza Extended Release (ER) 27 mg every 12 hours for pain; an order with a start date of 03/14/23 to monitor level of pain every shift; an order with a start date of 04/25/23 and discontinued date of 04/25/23 for Percocet 5-325 mg every four hours as needed for severe pain; an order with a start date of 04/25/23 and discontinued date of 04/26/23 for Percocet 5-325 mg every four hours as needed for severe pain; and an order with a start date of 04/25/23 and discontinued date of 04/26/23 for oxycodone hydrochloride (HCl) 30 mg every 12 hours for moderate to severe pain; an order with a start date of 04/26/23 for oxycodone HCl 30 mg every 12 hours for moderate to severe pain.
Review of R2's Medication Administration Record (MAR) for April 2023 revealed the following:
R2 received her last dose of Xtampza on the evening of 04/24/23. R2 did not receive her scheduled Xtampza on 04/25/23 morning or evening.
R2 received her last dose of scheduled Percocet on 04/25/23 at 10:00 AM.
R2 received a PRN Percocet on 04/25/23 at 07:42 PM for pain rated 10 out of 10 with documentation that it was ineffective.
R2 received PRN Tylenol on 04/25/23 at 07:36 AM for pain rated eight out of 10 with documentation that it was effective.
R2 received a PRN Percocet on 04/26/23 at 12:25 AM for pain rated seven out of 10 with documentation that it was effective. R2 received a PRN Percocet on 04/26/23 at 08:19 AM for pain rated 10 out of 10 with documentation that it was effective.
R2 did not received scheduled oxycodone 30 mg on 04/26/23 morning. R2 received her first dose of oxycodone 30 mg on 04/26/23 evening.
R2 received PRN Tylenol on 04/26/23 at 03:44 PM for pain rated nine out of 10 with documentation that it was effective.
R2 had documented pain monitoring of seven out of 10 on 04/25/23 day shift, three out of 10 on 04/25/23 evening shift, 10 out of 10 on 04/26/23 day shift, nine out of 10 on 04/26/23 evening shift, six out of 10 on 04/28/23 day shift, five out of 10 on 05/01/23 day shift, seven out of 10 on 05/01/23 evening shift, and five out of 10 on 05/02/23 day shift.
The Notes tab of R2's EMR documented the following:
An eMAR Note on 04/25/23 at 08:40 AM documented Xtampza was ordered and the nurse practitioner (NP) was aware.
An eMAR Note on 04/25/23 at 07:29 PM documented Xtampza was on reorder.
An eMAR Note on 04/25/23 at 07:42 PM documented PRN Percocet was given per R2's request with follow up at 08:36 PM that documented PRN administration was ineffective with pain rated 10 out of 10.
A Nursing note on 04/25/23 at 11:35 PM documented order confirmed for oxycodone HCl 30 mg every 12 hours for moderate to severe pain.
An eMAR Note on 04/26/23 at 12:25 AM documented PRN Percocet was given for R2's complaint of generalized pain.
A Nursing note on 04/26/23 at 07:00 AM documented R2 was at the nurses desk complaining of pain. Staff encouraged Tylenol and she refused. Staff offered R2 to lay in bed, meditation, and to read her bible. R2 refused. Staff went over new medications with her and she said she understood then went to her room.
A Nursing note on 04/26/23 at 07:50 AM documented R2 was yelling very loudly and when staff entered her room, she continued to yell and say that she could not handle this. Staff encouraged PRN Tylenol and she refused. Staff encouraged repositioning in bed and reminded R2 she would get her medications soon.
An eMAR Note on 04/26/23 at 08:18 AM documented oxycodone HCl 30 mg was ordered and the NP was aware.
An eMAR Note on 04/26/23 at 08:19 AM documented PRN Percocet was given for pain all over as R2 requested and staff gave as R2 yelled out. Follow-up documentation at 08:53 AM documented PRN administration was effective but documented R2 rated her pain nine out of 10 and continued to be in pain. The NP was at the facility and was aware R2 needed Percocet and oxycodone.
A Nursing note on 04/26/23 at 11:01 AM documented new order by Consultant GG to discontinue R2's PRN Percocet. Staff called Consultant GG to clarify with no answer.
An eMAR Note on 04/26/23 at 12:33 PM documented agitation was noted, R2 paced the halls throughout the day and yelled out at time due to pain.
A Nursing note on 04/26/23 at 01:06 PM documented staff placed another call to Consultant GG to clarify Percocet order that was discontinued with no answer again.
A Nursing note on 04/26/23 at 01:21 PM documented staff spoke with the pharmacy and ordered oxycodone 30 mg STAT (urgent/immediately).
A Nursing note on 04/26/23 at 01:46 PM documented staff asked R2 if she wanted to go to the hospital and she said not yet. R2 was aware that medication was ordered STAT.
An eMAR Note on 05/01/23 at 03:37 PM documented R2 received PRN Tylenol and follow-up documentation at 06:54 PM that documented PRN administration was ineffective with a pain rating of seven out of 10.
An eMAR Note on 03:14 PM documented R2 received PRN Tylenol for complaints of pain all over with follow-up documentation at 04:31 that documented PRN administration was ineffective with a rating of nine out of 10.
Upon request, the facility provided Consultant GG's Progress Note from 04/26/23. The Progress Note documented R2 was seen to follow up on pain management and had been taking Xtampza ER to help her symptoms. R2's insurance was not covering the medication for her any longer. Consultant GG documented he discussed with R2 the recent changes to her medications to an equivalent dose of OxyContin (oxycodone) and she expressed disappointment stating that she needed more pain medication. Consultant GG stated he explained to R2 that he wanted to assess how she did on the new medication before switching to anything else since she had not been getting her usual pain medication. The Progress Note documented the plan was Xtampza ER was discontinued with OxyContin put in its place.
On 05/02/23 at 02:56 PM, R2 stated she was in pain and did not have a PRN order anymore. She stated she received pain medication at 08:00 AM and 08:00 PM but did not have a PRN order for during the day. She rated her pain nine out of 10 at that time and stated her pain over the weekend was moderate. She stated she could not take the pain any longer and it was not right that she was hurting so bad. R2 stood in her room, appeared distress, and uncomfortable with grimacing and moaning observed.
On 05/02/23 at 03:06 PM, Licensed Nurse (LN) G stated R2 was on Xtampza for pain but her insurance was not covering it so it was changed to oxycodone 30 mg twice a day. R2 was in so much pain that staff called on-call provider during the night and got an order for Percocet every four hours as needed. She stated Consultant GG came in the next day and had ordered the oxycodone 30 mg and discontinued R2's PRN and scheduled Percocet. LN G said she had reached out to the on-call NP today and was told to offer Tylenol to R2. LN G stated she told the NP that R2 did not want Tylenol and the NP said she would see R2 tomorrow.
On 05/02/23 at 04:21 PM, Administrative Nurse D stated R2's insurance stopped covering Xtampza and the facility had reached out to their medical director to get a replacement pain medication. She stated the nurses had reached out to the pharmacy who said they did not have the script for oxycodone, and she reached out to the pharmacy who sent it out STAT. Administrative Nurse D stated R2 still had extensive pain and she notified the medical director today to see R2 because her pain was uncontrolled. She stated the delay in receiving the scheduled oxycodone caused increased pain. Administrative Nurse D stated staff were to notify the on-call provider if they needed additional pain medication and the medical director would not have approved of the nurses reaching out to him directly without using the on-call service.
The facility's Recognition and Management of Pain policy, last revised July 2017, directed the facility assisted each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by interviewing or observing the resident to determine if pain was present, identifying circumstances when pain can be anticipated, evaluating pain and working with the resident to develop a plan of care that considered their needs and goals, and developed and implemented a plan using nonpharmacologic and/or pharmacologic interventions to manage and/or prevent pain. The policy directed if the pain management program was not effective, the LN contacted the resident's physician and consulted the physician for additional interventions if pain was not relieved by current orders.
The facility failed to provide effective pain management for R2. This deficient practice had the risk for increased and unnecessary pain and decreased psychosocial well-being for R2.
Oct 2022
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 17 residents with seven reviewed for nutrition. Based on observat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 17 residents with seven reviewed for nutrition. Based on observation, interview, and record review, the facility failed to respond to an unplanned, ongoing weight loss and failed to identify and implement further interventions to prevent weight loss for Resident (R)22 who had a significant unplanned weight loss of 14.29 percent ( in six months.
Findings included:
-The Medical Diagnosis section within R22's Electronic Medical Record (EMR) included diagnoses of unspecified severe protein-calorie malnutrition, macular degeneration (progressive deterioration of the retina), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), abnormal weight loss, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion), dysphagia (swallowing difficulty), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear)and weakness.
The Annual Minimum Data Set (MDS) dated [DATE] recorded R22 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R22 required extensive assistance for most activities of daily living (ADL) except eating, for which she required limited assistance of one staff. The MDS recorded R22 was 57 inches tall, weighed 91 pounds (lbs.), had no issues with chewing, and no known weight loss.
The Quarterly MDS, dated 07/15/22, documented R22 had moderately impaired cognition, had no delirium (sudden severe confusion, disorientation and restlessness), psychosis (any major mental disorder characterized by a gross impairment reality testing), or behaviors. R22 required limited assistance of one staff with eating. She had no known issues chewing or swallowing but received mechanically altered diet, weighed 86 lbs. and had no known weight loss.
The Nutrition Care Area Assessment (CAA), dated 05/04/22, documented R22 received a mechanically altered diet and required assistance from staff with feeding and encouragement.
R22's Care Plan recorded an intervention dated and last revised on 03/16/22 which directed R22 could hold her cup, feed herself, and eat finger foods independently. R22's Care Plan initiated on 03/02/21 and last revised on 07/12/22 recorded she had a nutritional problem related to protein calorie malnutrition (PCM), gastro- esophageal reflux (GERD, backflow of stomach contents to the esophagus), dysphagia; she needed supplements and a mechanically altered diet. The care plan documented nutrition diagnoses of impaired chewing/swallowing related to dysphagia as evidenced by need for mechanical soft diet with nectar thick liquids. R22 had a history of weight loss and overall decline in condition, advanced age with suboptimal oral intake evidenced by the need for nutritional supplements. R22's Care Plan documented on 07/05/22, R22 triggered for weight loss of 7.5 percent in 90 days and 10% in 180 days .
R22's Care Plan recorded interventions dated 03/09/21 which directed staff to monitor, document and report to the medical doctor signs and symptoms of malnutrition, emaciation, significant weight loss. R22's Care Plan revised on 04/11/21 further directed staff to offer and encourage snacks and fluids between meals and directed staff to assist and cue at meals as needed. The care plan recorded an intervention revised on 01/06/22 which directed staff to provide supplements as ordered; Med Pass (liquid high calorie nutritional supplement) 120 milliliters three times daily (TID), nectar thick fluids and liquid protein TID. On 01/06/22 Magic cup (fortified nutritional ice cream product) two times daily for 10 days was added .
On 03/03/21 a Physician Order directed Med Pass (a dietary supplement) 120 milliliters (ml) three times a day.
On 07/20/21 a Physician Order directed liquid protein 30 ml, three times a day with thickened liquids in beverage of choice.
A Nutrition Progress Note dated 01/14/22 recorded staff notified the RD of R22's continued poor oral intake. The note recorded the Magic Cup was increased to three times a day and continue to monitor .
A Weight Change Note dated 01/25/22 documented a weight warning with a weight of 87.6 lbs., which indicated a loss of 7.5%. The note recorded R22 triggered for weight loss, had Covid (potentially life-threatening respiratory infection) and was on Magic Cup twice daily for 10 days. The note recorded the registered dietician (RD) would restart the Magic Cup and monitor.
On 01/25/22 a Physician Order directed staff to administer to R22 the dietary supplement Magic Cup, two times a day for weight loss.
On 02/01/22 a Physician Order directed staff to provide a pureed (food blended until smooth) textured diet with thin liquids consistency for R22.
R22's EMR recorded the following weights:
03/01/22: 98.0 lbs.
04/04/22: 94.0 lbs.
05/02/22: 90.8 lbs.
05/17/22: 90.0 lbs.
A Nutrition Evaluation dated 04/04/22 by Consultant GG recorded R22 had a weight drop that month. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends.
The Weight Warning Progress Note, dated 05/18/22, documented a significant weight loss of 7.5 % noted in 90 days. R22's base line weight was 95-100 lbs. Nutrition interventions in place included multiple supplements: liquid protein, Magic Cup and Med Pass. R22 received a regular pureed diet. No new recommendations were made.
R22's EMR recorded a weight of 86.4 lbs. on 06/01/22 which indicated a 11.84% loss in 90 days.
The Weight Warning Progress Note, dated 06/07/22, documented a 7.5% change and 10% change. R22 triggered for continued slow weight loss. R22 was a variable eater, received liquid protein and Med Pass three times a day, and Magic cup twice a day. The note lacked any new recommendations or interventions to address the loss.
R22's EMR recorded a weight of 86 lbs. on 07/01/22.
A Nutrition Evaluation dated 07/03/22 by Consultant GG recorded R22 had a wound to her buttocks and coccyx (area at the base of the spine). R22's weight was 86 lbs. and intake at meals varied but was usually greater than 50%. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends, continue current diet and supplements as ordered.
The Weight Warning Progress Note, dated 07/05/22, documented a 7.5% change and 10% change. R22 was at risk for continued weight loss with 7.5% loss for three months. R22 was a variable eater and received liquid protein and Med Pass three times a day, and Magic Cup twice a day. The note lacked new interventions for continued weight loss.
R22's EMR recorded a weight of 85.5 lbs. on 08/01/22.
The Weight Warning Progress Note, dated 08/02/22, documented a 10% weight change. R22 was at risk for weight loss and was down 10% since March. R22 continued supplements. The physician and resident's representative were updated on R22's weight loss of 10% in 180 days. No new orders were received. The note lacked new interventions to address the continued weight loss.
R22's EMR recorded a weight of 84 lbs. on 09/06/22 which indicated a 14.29 % loss in six months.
The Weight Warning Progress Note, dated 09/07/22, documented R22 had a weight loss of 10% in five months. R22 continued supplements; her appetite varied. The note directed staff to continue to monitor. The note lacked new interventions to address the significant weight loss.
A Nutrition Evaluation dated 09/28/22 by Consultant GG recorded R22 had a current weight of 84 lbs. and intake at meals varied but was usually greater between 50-75%. R22 had weight loss and abnormal nutrition-related labs due to overall decline in condition, and advanced age with suboptimal oral intake. The note directed to encourage oral intake, and monitor weight trends, continue current diet and supplements as ordered.
On 10/04/22 at 12:20 PM, observation revealed R22 sat in the dining room in a wheelchair. R22 requested help because she could not find her silverware. Staff brought R22's silverware. R22 asked for help. Staff spooned several bites of chili into the resident's mouth, then left the table. R22 then asked for assistance again and staff stood next to R22 and spooned several more bites of chili and then left the table again .
On 10/04/22 at 12:28 PM, observation revealed R22 repeatedly stated I can't reach you, could you help me? Staff responded and said they would help her but walked away briefly before returning to the table to assist the resident with eating.
On 10/05/22 at 08:35 AM, Certified Nurse Aide (CNA) M reported staff must cue and encourage R22 with each bite at all meals. The CNA said R22 was able to drink independently.
On 10/05/22 at 07:46 AM, Licensed Nurse (LN) G reported R22 received three different supplements due to weight loss. LN G reported an interdisciplinary team reviewed the weights and notified the physician of weight changes.
On 10/05/22 at 09:33 AM, Administrative Nurse D verified R22 had weight loss of 10% in the past six months. Administrative Nurse D verified the interdisciplinary team monitored the weight loss but had not implemented new intervention to prevent R22's continued loss.
On 10/05/22 at 11:31 AM, Consultant GG verified R22 received three dietary supplements for weight loss. She verified R22 had a significant weight loss and noted the lack of new intervention to attempt to prevent further weight loss.
On 10/06/22 at 09:25 AM, Consultant HH said R22 had weight loss and the facility should attempt interventions to prevent further weight loss.
The facility Weight Monitoring policy, dated 01/2022, documented the facility to regularly monitor the weight of all residents and address those residents at risk or that experience a variance in weight, either unintended loss, or unanticipated gain. Significant weight loss/gain is monitored monthly by the Dietary Manager and/or the Registered Dietician. Additionally, the resident is referred to the weight committee, an interdisciplinary team that meets weekly to identify individuals' interventions that may be beneficial in maintaining current weight and avoid further weight loss or gain. A weight variance protocol is completed to ensure a systematic review that ranges resident meal/food choices, meal monitoring, current diet and hydration, medication, commercial supplements, and ability to perform ADL's (meal assistance) as necessary adaptive devices of potentially contributing factors to weight loss. Alternatives such as prescribed appetite stimulants may be considered for those residents that continue to lose weight, after careful consideration and other measures have been exhausted.
The facility failed to respond to an unplanned, ongoing weight loss and failed to identify and implement further interventions to prevent weight loss for R22 who had a significant unplanned weight loss of 14.29% in six months .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents. Based on observation, interview, and record review,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to report Resident (R) 4's allegation of verbal, emotional, and physical abuse to State Agency (SA) as required. This deficient practice placed R4 at risk of ongoing abuse.
Findings included:
-The Medical Diagnosis section withing R4's Electronic Medical Record (EMR) included diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, 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), post-traumatic stress disorder (PTSD- psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture), somatization (the production of recurrent and multiple medical symptoms with no discernible or cause).
The Annual Minimum Data Set (MDS), dated [DATE], documented R4 had intact cognition, had no signs or symptoms of psychosis (any major mental disorder characterized by a gross impairment in reality testing) or exhibited behaviors. R4 required extensive assistance of one staff for activities of daily living, was not steady, but was able to stabilize without staff assistance with transition and balance, and had speech, occupational, and physical therapy treatment. The MDS further documented R4 received antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) anticoagulant (class of medication to prevent blood clotting), diuretic (medication to promote the formation and excretion of urine )and an opioid (class of medication to treat moderate to severe pain) medication daily.
The Psychotropic Drug Use Care Area Assessment (CAA), dated 07/07/22, documented R4 took antidepressants and antianxiety medications. The CAA further documented R4's mood was stable and she saw psychiatry routinely.
The Care Plan, dated 07/08/22, documented R4 had behavioral symptoms related to diagnoses of depression, anxiety, and PTSD. R4 had made statements that blur previous events with current events and thinking that the event happened again or that an event happened in a different way. The Care Plan directed staff to identify strengths, positive coping skills, and to reinforce them. Monitor and record R4's mood to determine if problems seem to be related to external causes. The resident was attention seeking and when R4 got upset, she exhibited impatient and demanding behaviors, and she often felt she was not listened to. Further interventions directed staff to allow R4 opportunity to express herself in a calm manner.
The Care Plan on 10/02/22, documented R4 will make false accusations about staff and the intervention was to provide care in pairs.
Review of the facility's Investigation of the event revealed Administrative Nurse D learned of the allegation on 10/02/22. Administrative Nurse D obtained statements from staff which were dated 10/01/22 (which included alleged abuser), and 10/04/22, as well as undated statements. The investigation included a skin assessment signed by Administrative Nurse D on 10/04/22 but dated as effective 10/03/22.
On 10/04/22 at 10:04 AM R4 stated she had experienced verbal, emotional, and physical abuse from one of the staff nurses. R4 stated the staff nurse came into her room on 10/02/22 and called her names, stated no one liked R4, then slapped R4 on the upper arm several times. R4 reported the staff nurse shook her finger in her face and would not leave the room when R4 asked her to leave. R4 stated she reported this allegation to Administrative Nurse D but was uncertain which day.
On 10/05/22 at 09:24 AM, Administrative Nurse D reported she was notified by staff at 09:00 PM R4 had stuck a nurse with her walker and called the nurse bad names. Administrative Nurse D suspended the nurse on 10/02/22 at approximately 10:00 PM, pending an investigation of the allegation of abuse. Administrative Nurse D stated she had asked R4 if the police should be called and R4 told Administrative Nurse D not to notify the police until R4 had time to discuss the situation with a family member. Administrative Nurse D stated she had not reported the alleged abuse to the state agency due to R4 changing description of the event and did not want the police called.
The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy, dated 01/2022, documented residents must not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, the resident representative, families, friends or other individuals. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that alleged violations involving abuse are reported immediately, but not later than two hours after the allegation is made if the event that cause the allegation involves abuse or results in serous bodily injury. Ensure that alleged violations are reported to the administrator, the state survey agency, and adult protective services as appropriate. The policy further documented after receipt of a report of possible abuse, neglect, mistreatment, exploitation or misappropriation of resident property steps are immediately taken to protect the resident.
The facility failed delayed report of R4's allegation of abuse to the SA while conducting the investigation (which was not concluded until after the 24 hour reporting window). This failure placed the resident at risk of further abuse.
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
The facility had a census of 79 residents. The sample included 19 residents of which seven were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony ...
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The facility had a census of 79 residents. The sample included 19 residents of which seven were 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 observation, record review and interview, the facility failed to implement a soft heel boot as directed by the provider to treat a facility-acquired pressure ulcer for Resident (R)71. This placed R71 at risk for further skin breakdown and delayed healing.
Findings included:
- R71's Physician Order Sheet dated 10/03/22, included diagnoses of anxiety (mental or emotional reaction characterized by apprehension), diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cerebrovascular accident (CVA- 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 right-side hemiplegia (paralysis of one side of the body).
R71's Quarterly Minimum Data Set (MDS) assessment, dated 09/22/21, recorded the resident had a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of one staff for bed mobility, transfers, locomotion on and off the unit, toilet use, personal hygiene, and had functional impairment of upper and lower extremities on one side. The MDS further documented the resident had no skin issues.
The 07/22/22 Activities of Daily Living (ADL) Care Area Assessment (CAA) did not trigger. The Pressure Ulcer CAA documented the resident required extensive staff assistance with bed mobility, and staff to encourage the resident to turn and reposition while in bed. The CAA documented the resident had no skin issues. The Fall CAA documented the resident had unsteady balance, had a recent hospitalization for a stroke with right sided weakness.
The Braden Scale Assessment for predicting pressure ulcer risk, dated 07/20/22, documented a score of 15.0 which indicated the resident was at low risk for pressure ulcer development.
The ADL Care Plan, dated 07/21/22 directed the staff to monitor for skin for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The Care Plan documented the resident required a Hoyer lift (total body mechanical lift used to transfer residents) with two staff for transfer and physical assistance to turn and reposition with bed mobility.
The Progress Notes, dated 09/16/22 at 05:43 PM, recorded R71 was up in her wheelchair and propelled with her feet in the hall.
The Progress Notes, dated 09/26/22 at 07:21 PM, recorded R71 was noted with a pressure area on her right heel. The area was cleansed with wound cleanser, prepped with skin prep (liquid skin barrier) and covered with border gauze. Staff notified the provider to evaluate in the morning.
The Skin Evaluation, dated 09/27/22, documented R71 had a fluid filled area on her right heel, measuring 1.5 (cm) centimeters by 1.3 cm. Staff notified the provider who ordered staff to apply skin prep to the area twice daily and directed the resident to wear a soft boot at all times.
The Skin Pressure Ulcer Weekly Evaluation, dated 10/03/22, documented R71 had an unstageable pressure ulcer (term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive dead tissue or skin) of the right heel which was tender when touched, and not present on admission. The Nurse Practitioner ordered the staff to apply skin prep twice daily and continue with the soft boot.
The Progress Notes, dated 10/03/22 at 10:05 AM, recorded the provider saw the resident and ordered skin prep twice daily to the right heel, no dressing, and a soft boot on at all times.
On 09/28/22 at 01:30 PM, R71 sat in a wheelchair at the nurse's station dressed in street clothes drinking apple juice. Observation revealed the resident had on gripper socks and did not have a pressure relieving boot (soft boot) to the right heel. Continued observation revealed the resident frequently took her right foot off the metal wheelchair pedal and then put it back on the pedal while sitting at the nurse's station.
On 10/03/22 at 09:45 AM, R71 sat at the nurse's station complaining of her right heel hurting. R71 was not wearing a soft boot on either foot. Licensed Nurse (LN) G removed the resident's non slip sock on the right foot and stated oh, you don't have a dressing on either. The nurse took R71 to her room, cleansed the right heel with wound cleanser, applied skin prep and placed the pressure relieving boot on R71's right foot. The wound measured 1.08 cm by 1.51 cm and was fully covered with eschar (dead tissue).
On 10/03/22 at 10:00 AM, LN G verified the resident developed a facility acquired unstageable pressure ulcer on the right heel.
On 10/04/22 at 09:00 AM, Administrative Nurse D verified the resident developed the unstageable pressure ulcer on the right heel on 09/26/22. Administrative Nurse D stated according to the resident's Braden assessment on admission, the resident was not at risk for skin breakdown and the resident did not require any preventative boots due to the admission skin assessment.
The Skin Management System, policy dated December 2019, documented it was the policy of the facility that any resident who enters the facility without pressure ulcers will have the appropriate preventative measures taken to ensure that the resident does not develop a pressure ulcer, or that the resident admitted with wounds will not develop signs and symptoms of infection, unless the resident's clinical condition makes the development unavoidable. The policy recorded the resident would have a head to toe skin assessment by a licensed nurse at the time of admission and any skin lesions would be documented on the Nursing admission Assessment. A Braden Scale Assessment would also be completed on admission to identify resident's at risk for skin breakdown and a score of 10 or lower is considered high risk and will have a care plan developed to address particular elements of the assessment that put the resident at risk for skin breakdown. The policy recorded a care plan would be initiated to address areas of actual skin breakdown and the care plan would be reviewed and revised as needed. A report of all wounds and their progress will be updated by the treatment nurse weekly. The Registered Dietician would provide nutritional support when appropriate.
The facility failed to implement the soft protective boots as directed by the provider to treat a right heel facility acquired unstageable pressure ulcer for R71, placing the resident at risk for further skin breakdown and delayed healing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents with two reviewed for behaviors. Based on observatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents with two reviewed for behaviors. Based on observation, record review and interview, the facility failed to provide the necessary behavioral health services and interventions for one of two sampled residents, Resident (R) 2. This placed the resident at risk for continued and worsened behaviors.
Findings included:
- The Physician Order Sheet, dated 09/02/22, recorded R2 had diagnoses of mild cognitive impairment, metabolic encephalopathy (chemical imbalance in the blood that impairs brain function), anxiety (mental health disorder characterized by worry and fear that interferes with daily life), and depression (abnormal emotional state characterized by exaggerated feelings of sadness and worthlessness).
The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R2 had a Brief Interview for Mental Status score of 15 (cognitively intact) and no behaviors. The MDS recorded R2 required extensive staff assistance with activities of daily living (ADLs), used a wheelchair for mobility, and was incontinent of bowel and urine.
The Behavior Care Plan, dated 09/21/22, recorded R2 had a potential for behavior problems due to her yelling for cares and services. The care plan directed staff to monitor R2's target behaviors (yelling/screaming, aggression toward staff, inappropriate language), responses to interventions and notify the physician of increased or worsened behaviors. R2's Care Plan lacked documentation of new behavior interventions after 06/16/22 (admission care plan).
Review of R2's behavior monitoring on the Medication Administration Record for agitation/delusions revealed the following:
June 2022: no behaviors recorded
July 2022: behaviors recorded on 07/15/22
August 2022: behaviors documented for 08/25/22 in the morning and 08/27/22 in the morning.
September: behavior recorded on 09/06/22
October: no behaviors recorded
A Physician's Order, dated 07/14/22, directed staff to obtain a psychiatry consult for R2's increased anxiety and yelling.
A Weekly Clinical/IDT [interdisciplinary team] Review dated 07/28/22 recorded R2 had daily behavior of yelling out staff names and continued with behavior monitoring.
A Social Service Summary note on 08/19/22 recorded
R2 was able to make her needs known to others. R2 often yelled out repeatedly for someone to help her. R2 often started yelling out at the same time she pushed the call light, or at times would not use the call light and only yell out.
A Nurse Note dated 08/24/2022 recorded R2 continued to call for staff after being changed several times. Staff tried to reassure R2 that the staff would ensure R2's safety but R2 continued to yell out. Staff called the provider on call and asked to reinstate R2's as needed Ativan (medication used to treat agitation and/or anxiety). The provider declined to reinstate the Atvian because the psychiatrist was trying other medications.
The Initial Psychiatric Evaluation, dated 08/30/22 (47 days after the physician order for the consult), recorded R2 had behaviors of persistent yelling and agitation, and required consistent behavior interventions and medication regimen.
On 10/03/22 at 12:28 PM, observation revealed R2 persistently screamed from her room many times over a 16-minute interval I'm hungry, bring me my food, and my diaper needs changed. Continued observation revealed R2's screaming comments could be heard in the dining room where 15 residents ate lunch.
On 10/04/22 at 10:33 AM, observation revealed R2 persistently screamed from her room over a 21-minute interval, and staff attempted three times to redirect her screaming behaviors. Continued observation revealed R2's persistent screaming disrupted a bingo activity for 16 residents.
On 10/03/22 at 01:52 PM, Certified Medication Aide (CMA) R stated R2 had screaming behaviors every day that disrupted other residents' meals, activities, and sleep. CMA R stated staff were not able to prevent or redirect R2's screaming and yelling behaviors.
On 10/04/2 at 02:10 PM, Licensed Nurse (LN) H stated R2 had frequent disruptive behaviors that agitated other residents, was difficult to redirect and staff should record and monitor the resident's behaviors. LN G stated R2 spent most of her time in her room in bed, and when R2 had behaviors outside her room other residents often confronted her with angry comments.
On 10/05/22 at 09:27 AM, Administrative Nurse D stated R2 had frequent disruptive behaviors that impacted other residents. Administrative Nurse D stated staff should monitor the resident's behaviors to identify causative factors and develop new interventions to prevent and/or redirect R2's behaviors.
The facility's Behavior Policy, dated 01/02/22, directed staff to record and monitor the residents' behaviors, complete accurate assessments, and implement intervention to prevent and/or redirect the behaviors.
The facility failed to provide the necessary behavioral health services and interventions for R2, placing the resident at risk for continued and worsened behaviors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Base...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a system where staff acknowledged, reported to the physician, and acted upon the Consultant Pharmacist (CP) recommendations for Resident (R) 6 who received routine insulin (medication used to lower blood sugar). This placed the resident at risk for complications related to high or low blood sugar levels.
Findings included:
- R6's Medical Diagnosis section withing the Electronic Medical Record (EMR) included diagnoses of chronic pain syndrome, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic neuropathy (nerve damage) and multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord).
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required extensive to total assistance of one to two staff for activities of daily living. The MDS further documented R6 received insulin.
The Nutrition Care Plan, dated 08/15/22, documented R6 had nutritional problem related to acute and chronic illness, had diabetes type two, needed a therapeutic diet, insulin and glipizide (oral medication to stabilize blood sugar). The care plan further documented R6 had nutritional diagnoses of obesity and impaired nutrient utilization related to lifestyle choices, decreased physical activity with excess calorie intake. The care plan directed staff to administer medications as ordered, obtain and monitor lab/diagnostic word as ordered.
The Physician Order Sheet, dated 09/14/22, directed staff to administer:
Glipizide 5 milligrams (mg) by mouth once daily related to type diabetes mellitus.
Glargine Insulin Solution (long acting insulin) inject eight units at bedtime for diabetes mellitus.
Linagliptin (mediation used to treat diabetes mellitus type 2) 5 mg by mouth once daily for diabetes mellitus.
Lispro Insulin Solution (fast acting insulin) inject eight units before meals and at bedtime for diabetes mellitus.
Novolog Solution (fast acting insulin) inject eight units before morning meal and at bedtime for diabetes mellitus.
The Pharmacy Review, dated 02/20/22, documented to consider blood glucose parameters for the use of Lispro insulin. The medical record lacked evidence stafff ackowledge/addressed the CP's recommendations.
On 10/03/22 at 09:35 AM, observation revealed staff providing personal cares for R6. R6 stated she took several medications to control her blood sugar levels.
On 10/04/22 at 08:59 AM, Licensed Nurse (LN) G verified the medical record lacked blood sugar parameter for the use blood sugar levels.
On 10/05/22 at 09:10 AM, Administrative Nurse D stated the pharmacist review and recommendations should be followed and blood sugar parameter should have been obtained from the physician.
The facility 's Medication Regimen Review (MMR), dated 08/2017, documented the pharmacist reviews each resident's medication regimen at least monthly in order to identify irregularities and to identify clinical significant risks and/or adverse consequences resulting from or associated with medications. The MMR includes identification or irregularities, medication related errors, adverse consequences, and use of unnecessary drugs.
The facility failed to ensure a system where staff acknowledged, reported to the physician, and acted upon the CP recommendations for R6 who received routine insulin. This placed the resident at risk for complications related to high or low blood sugar levels.
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 had a census of 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Base...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 79 residents. The sample included 19 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain blood sugar parameters for Resident (R) 6 who received routine insulin (medication used to lower blood sugar). This placed the resident at risk for complications related to high or low blood sugar levels.
Findings included:
- R6's Medical Diagnosis section withing the Electronic Medical Record (EMR) included diagnoses of chronic pain syndrome, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with diabetic neuropathy (nerve damage) and multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord).
The Quarterly Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, required extensive to total assistance of one to two staff for activities of daily living. The MDS further documented R6 received insulin.
The Nutrition Care Plan, dated 08/15/22, documented R6 had nutritional problem related to acute and chronic illness, had diabetes type two, needed a therapeutic diet, insulin and glipizide (oral medication to stabilize blood sugar). The care plan further documented R6 had nutritional diagnoses of obesity and impaired nutrient utilization related to lifestyle choices, decreased physical activity with excess calorie intake. The care plan directed staff to administer medications as ordered, obtain and monitor lab/diagnostic word as ordered.
The Physician Order Sheet, dated 09/14/22, directed staff to administer:
Glipizide 5 milligrams (mg) by mouth once daily related to type diabetes mellitus.
Glargine Insulin Solution (long acting insulin) inject eight units at bedtime for diabetes mellitus.
Linagliptin (mediation used to treat diabetes mellitus type 2) 5 mg by mouth once daily for diabetes mellitus.
Lispro Insulin Solution (fast acting insulin) inject eight units before meals and at bedtime for diabetes mellitus.
Novolog Solution (fast acting insulin) inject eight units before morning meal and at bedtime for diabetes mellitus.
The Pharmacy Review, dated 02/20/22, documented to consider blood glucose parameters for the use of Lispro insulin. The medical record lacked the pharmacist recommended blood glucose parameters.
On 10/03/22 at 09:35 AM, observation revealed staff providing personal cares for R6. R6 stated she took several medications to control her blood sugar levels.
On 10/04/22 at 08:59 AM, Licensed Nurse (LN) G verified the medical record lacked blood sugar parameters for the use blood sugar levels.
On 10/05/22 at 09:10 AM, Administrative Nurse D stated the pharmacist review and recommendations should be followed and blood sugar parameter should have been obtained from the physician.
The facility 's Medication Regimen Review (MMR), dated 08/2017, documented the pharmacist reviews each resident's medication regimen at least monthly in order to identify irregularities and to identify clinical significant risks and/or adverse consequences resulting from or associated with medications. The MMR includes identification or irregularities, medication related errors, adverse consequences, and use of unnecessary drugs.
The facility failed to obtain blood sugar parameters which placed R6 at risk of adverse consequences related to blood sugar levels and insulin use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review , and interview, the facility failed to secure a treatment cart and appropriately store...
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The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review , and interview, the facility failed to secure a treatment cart and appropriately store and label multiple-dose insulin (medication to lower blood sugar) pens (an injection device) located on the second-floor nursing unit for Resident (R) 59, R24 and R53. This deficient practice placed the residents at risk for ineffective medication and allowed unsafe access to medications.
Findings included:
- On 09/28/22 at 08:09 AM, during initial tour, observation revealed the medication cart had insulin pens which were not dated when opened for R59 and R24.
On 09/28/22 at 08:25 AM, during initial tour, observation revealed an unattended treatment cart located in the hall, which was unlocked and unattended. The unlocked treatment cart drawers contained multiple insulin pens. R53's multidose insulin pen lacked a date when opened.
On 09/28/22 at 08:09 AM, Licensed Nurse (LN) G verified R59 and R24 lacked opened dates on the insulin pens. LN G stated the pens should have been labeled with a date when put in use.
On 09/28/22 at 08:29 AM, LN H entered the hallway where the unlocked treatment cart was parked. LN H verified the cart had been unlocked and unsupervised as LN H had been in a residents' room with the door shut to the hallway. LN H stated the treatment cart should have been locked while unsupervised. LN H verified insulin pens stored in the top drawer and R53's two insulins pens which lacked opened dates.
On 10/05/22 at 09:18 AM, Administrative Nurse D verified insulin pens should be labeled with opened dates and the treatment cart should had been locked when not supervised.
The facility's Storage and Controlling Medication policy, dated 07/2017, documented to store medications safely, securely, and proper following manufacture's recommendations or those the supplier, and in accordance with federal and state laws and regulations. The medication supply is accessible only to authorized personnel.
The facility's Medication Labels policy, dated 03/2022, documented insulins after being opened for the first-time use, will have the date the medications was opened labeled on the pen, box or vial.
The facility failed to secure an unattended treatment care on one hall and failed to appropriately date insulin pens for R59, R24, and R53 which placed the residents at risk of ineffective medications and unsafe access to medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review and interview, the facility failed to prepare a pureed diet using professional standard...
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The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review and interview, the facility failed to prepare a pureed diet using professional standards to maintain nutritive and palatable value for three residents, Resident (R)22, R23, and R52. This placed the residents at risk for inadequate nutrition.
Findings included:
- On 10/03/22 at 11:00 AM, observation revealed Dietary Staff (DS) CC prepared three pureed diets. DS CC placed three servings (approximately three ounces each serving) of lemon peppered chicken in a food processor/blender. DS CC blended the chicken, added an unmeasured amount of chicken broth, to the pureed texture, then emptied the chicken into three stainless-steel food storage pans, then stored the pans in the oven. DS CC placed three servings (approximately four ounces each serving) of macaroni salad in a food processor/blender. DS CC blended the macaroni salad, added one half cup of milk, then blended to the correct pureed texture, emptied the macaroni salad on to the divided plates. Continued observation revealed DS CC placed three servings (approximately four ounces each serving) of pickled beets in a food processor/blender. DS CC blended the beets, with no added liquids needed, to the correct pureed texture, and emptied the beets on to the divided resident plates. DS CC placed three servings of brownie (approximately 2 inches by 2 inches) in a food processor/blender. DS CC blended the brownies with one-half cup of milk and the texture was too thin DS CC added two squirts of thickener (amount not measured) to the desired consistency.
On 10/03/22 at 11:30 AM, DS CC stated she was aware she needed to follow a pureed recipe but said she did not have one available. DS CC stated the facility had a book in the kitchen but it was not for the specific meal she was preparing. DS CC verified she had added a certain amount of the milk and some chicken broth but did not follow a recipe.
On 10/05 at 09:30 PM, Dietary Staff BB verified the dietary staff were expected to use a pureed recipe when preparing a pureed diet and the facility had a 3-ring binder that had the recipes available. Dietary Staff BB verified the binder did not have the recipe for the lemon peppered chicken, beets, macaroni salad or brownies. Dietary Staff BB verified the Registered Dietician would provide the recipes for the food prepared.
The facility's Dietary Services meals and Food policy, dated June 2017, recorded it is the policy of this facility to ensure dietary services are provided to our residents operating within the confines of state regulations. The policy recorded the CDM is responsible for the total food services of this facility. Menus are planned at least one week in advance and variations from the posted menus are documented. The policy documented therapeutic diets as ordered by the resident's physician are provided according to the service plan and food prepared for consumption by our residents is prepared according to all applicable food service regulations.
The facility failed to prepare a pureed diet using professional standards to maintain nutritive and palatable value for R22, R23, and R52. The placed the residents at risk for inadequate nutrition.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure a system that all staff implemented for r...
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The facility had a census of 79 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to ensure a system that all staff implemented for residents to file grievances . This placed residents at risk for unresolved concerns.
Findings included:
- Review of the resident council meeting minutes for the past year, lacked documentation residents reported grievances concerning Resident (R) 2's behaviors.
Review of the facility's grievance log for the past year, lacked documentation residents reported grievances concerning R2's behaviors.
The facility's Progress Note, dated 10/04/22 at 09:35 PM, recorded R2 had disruptive yelling behaviors throughout the afternoon, staff were not able to redirect the resident's behaviors, and other residents voiced complaints and threatened to call the police about R2's behaviors. The Progress Note also recorded a resident's family contacted the nurse, complained their family member was not able to sleep due to R2's yelling, and demanded a room change for their family member.
On 10/03/22 at 12:28 PM, observation revealed R2 persistently screamed from her room many times over a 16-minute interval I'm hungry, bring me my food, and my diaper needs changed. Continued observation revealed R2's screaming comments could be heard in the dining room where 15 residents were eating lunch.
On 10/04/22 at 10:33 AM, observation revealed R2 persistently screamed from her room over a 21-minute interval, and staff attempted three times to redirect her screaming behaviors. Continued observation revealed R2's persistent screaming disrupted a bingo activity for 16 residents.
On 10/03/22 at 01:52 PM, Certified Medication Aide (CMA) R stated R2 had screaming behaviors every day that disrupted other residents' meals, activities, and sleep. CMA R stated staff were not able to prevent or redirect R2's screaming and yelling behaviors.
On 10/03/22 at 02:57 PM, R64 stated R2's yelling often disrupts meals and activities, and he has reported complaints about the resident's behaviors to multiple staff.
On 10/03/22 at 03:10 PM, R125 stated staff were aware R2's behaviors disrupt all the residents' lives on the unit and she has reported complaints to the administrative staff.
On 10/03/22 at 03:18 PM, R48 stated staff were not able to control R2's yelling, and R2's yelling about her dirty diapers during mealtime was very unpleasant. R48 stated he has individually and with a group of resident reported complaints about R2's disruptive behaviors.
On 10/03/22 at 03:25 PM, R26 stated he has observed R2's persistent yelling make other residents in the dining room uncomfortable, and he has reported R2's behaviors to multiple staff.
On 10/03/22 at 03:48 PM, R27 stated R2's persistent yelling disrupts meals and activities, and he has complained to staff about not being able to sleep or watch TV due to R2's behaviors.
On 10/04/22 at 11:30 AM, R32 stated R2's screaming ruined the bingo activity for residents today, and he does not appreciate hearing about R2's nasty diapers during mealtime. R32 stated he has compassion for the residents who are unable to voice complaints, and he has reported complaints about R2 to administrative staff many times. R32 stated, outside the facility, R2's behaviors would be against the law and neighbors would call the police.
On 10/04/22 at 11:30 AM, R51 stated she keeps her room door closed due to R2's frequent yelling, and she still has difficulty sleeping and watching TV. R51 stated she has complained to staff many times about R2's behaviors.
On 10/04/22 at 01:27 PM, R44 stated R2's screaming frequently disrupts his sleep and watching TV, and he had reported R2's behaviors to staff many times.
On 10/04/22 at 02:10 PM, Licensed Nurse (LN) H stated R2 had frequent disruptive behaviors that agitated other residents, was difficult to redirect and staff should record and monitor the resident's behaviors. LN G stated R2 spent most of her time in her room in bed, and when R2 had behaviors outside her room other residents often confronted her with angry comments.
On 10/05/22 at 07:56 AM, R30 stated he spends most of the time in bed due to pain, and R2's yelling often disrupts his sleep and watching TV. R2 stated his family told him to call the police on R2 or ask the facility to move to a different room away from R2. R30 stated he has complained to multiple staff about R2's behaviors, and nothing happens.
On 10/05/22 at 08:51 AM, Social Service Staff X verified the facility had no grievances concerning R2's behaviors and staff should assist residents with the grievance process if the resident reports concerns.
On 10/05/22 at 09:27 AM, Administrative Nurse D stated grievance forms were available at the nurse station on each unit and staff should assist the resident with the grievance form when the resident reports concerns. Administrative Nurse D verified a problem with the grievance system since no grievances were filed concerning R2's behaviors.
The facility's Resident Rights Policy, dated 10/04/16, directed staff to provide an environment that enhances quality of life and residents have the right to report grievances in the facility.
The facility failed to provide a system for residents to file grievances. This placed residents at risk for unresolved concerns.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
The facility had a census of 79 residents. Based on observation, record review, and interviews, the facility failed to serve food in a safe and sanitary manner for two of the five kitchenettes in the ...
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The facility had a census of 79 residents. Based on observation, record review, and interviews, the facility failed to serve food in a safe and sanitary manner for two of the five kitchenettes in the facility. This placed the affected residents at risk for food-borne illness.
Findings Included:
- On 10/03/22 at 08:30 AM, during tour of the facility kitchenette, observation of the temperature logs of [NAME] one and Maple two daily food temperature logs lacked evidence staff assessed temperature of the following meals:
Willow one:
Review of the weekly unit temperature logs from September 25 until October 1, 2022 revealed the 09/26/22 supper meal lacked documented temperatures.
Review of the weekly unit temperature logs form August 28 until September 3, 2022 revealed the 09/28/22 supper meal lacked documented temperatures.
Review of the weekly temperature logs from August 14 -20, 2022 revealed the 08/17/22 supper meal lacked documented temperatures.
Maple two:
Review of the weekly temperature logs from July 20-30, 2022 lacked temperatures of the lunch meal on 07/24/22 and the supper meals on 07/24/22, 07/25/22 and 07/29/22 lacked documented temperatures.
Review of the weekly temperature logs from July 31 -August 06, 2022 lacked documentation of temperatures on 08/01/22, and 08/06/22 for the supper meals.
Review of the weekly temperature logs from August 7-13, 2022 lacked documented temperatures on 08/07/22, 08/10/22 and 08/12/22 for the supper meals.
Review of the weekly temperature logs from August 14 -20, 2022 revealed no documented temperatures for the supper meals on 08/15/22 and 08/18/22.
Review of the weekly temperature logs from August 21-27,2022 revealed no documented temperatures for the supper meals on 08/23/22, 0825/22, and 08/27/22.
Review of the weekly temperature logs from September 04 -10, 2022 revealed the 09/04/22 and 09/06/22 supper meals lacked documented temperatures. 09/01/22 lacked documented temperatures for the breakfast and lunch meal.
Continued review of the kitchenette temperature logs revealed no evidence staff assessed food temperatures from the two kitchenettes at the facility from September 2021 until July 2022. Dietary Staff BB verified she started work at the facility one month ago and was unable to find the logs for the past temperatures.
On 10/05/22 at 09:30 AM, Dietary Staff BB stated staff should assess and document the food temperature before serving the residents their meals with each meal served.
The facility's General Food Handling/Storage/Prepare policy, dated 2021, (no month identified) recorded it is the policy of the facility to provide safe and sanitary storage, handling, and consumption of all food including food and fluids brought to residents by family and other visitors. Additionally, the facility procures food from sources approved or considered satisfactory by federal, state or local authorities. This includes the storage, preparations, distributing, and serving food in accordance with professional standards for food service safety. Overview of food safety practices the Long-Term Care facility follows to ensure resident safety are to cook foods to the appropriate temperature to kill microorganisms and keep food hot at 135 degrees and cold foods at 41 degrees. Take food temperatures during and after cooking and keep temperature logs, food safety monitoring software can help ensure compliance.
The facility failed to serve food in a safe manner when staff failed to assess and log food temperatures for each meal, placing the residents at risk for food borne illnesses.
May 2021
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had census of 75 residents. The sample included 19 residents. Based on observation, record review, and interview, t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had census of 75 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to accommodate one of 19 sampled residents' needs, Resident (R) 60, who's audio device had dead batteries, making her unable to hear her scriptures that brought her comfort.
Findings included:
- R60's admission Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing and personal hygiene. The assessment documented it was very important to the resident to take part in religious programs
The Mood Care Plan, dated 04/26/21, directed staff to assist the resident with a program of activities that were meaningful and of interest, and wanted scripture played on her audio device.
On 05/11/21 11:45 AM, observation revealed the resident in a Broda chair (positioning chair), the resident's Faith Comes by Hearing bible audio device was not playing, and the red light was on.
On 05/11/21 at 12:00 PM, Licensed Nurse (LN) G stated the resident listened to bible podcasts but right now her audio device did not work because the batteries were dead. LN G stated the facility did not provide the batteries, the family did.
05/11/21 at 1:30 PM, observation revealed the resident's door was closed and the resident was hollering.
05/12/21 at 10:41 AM, observation revealed the resident's audio device sat on the resident's nightstand and was not turned on.
05/12/21 at 01:15 PM, observation revealed the resident's television was on and played an old western show. The resident was lying in bed and hollered, hey, hey continuously. Continued observation revealed the resident's audio device sat on her nightstand and a faint static sound could be heard.
On 05/13/21 at 08:30 AM, observation revealed the resident lying in bed, not hollering, and the audio device played bible scripture.
On 05/12/21 at 01:20 PM, LN G stated the device was staticky because the batteries were going dead and was not sure when family would be in to visit and replace the batteries.
On 05/12/21 at 01:45 PM, Administrative Nurse D stated the family brought in the device because the resident was very religious, and she liked to listen to hymns. Administrative Nurse D further stated the resident hollered, the family did not want the resident over sedated with medication, and the facility provided batteries for the device if the family did not bring batteries when visiting.
Upon request, the facility did not provide a policy for accommodation of needs.
The facility failed to provide R60 an audio device with working batteries, placing the resident at risk for anxiety and discomfort.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 75 residents. The sample included 19 residents with one resident reviewed for communication. Based ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 75 residents. The sample included 19 residents with one resident reviewed for communication. Based on observation, record review, and interview, the facility failed to provide communication tools for a non-English speaking resident, Resident (4).
Findings included:
- R4's Physician Order Sheet (POS), dated 03/16/21, documented diagnoses of type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), peripheral vascular disease (abnormal condition affecting the blood vessels), hemiplegia (paralysis of one side of the body ) and hemiparesis (muscular weakness of one half of the body ) following cerebral infarction (CVA (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) affecting left non-dominant side, dysphagia (swallowing difficulty) hypertension, history of sudden cardiac arrest, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness).
The Annual Minimum Data Set (MDS), dated [DATE], documented the resident was Asian, needed or wanted an interpreter to communicate with a doctor or health care staff, preferred language of Vietnamese, had unclear speech, sometimes understood, and sometimes understands. Staff assessed the resident with severe cognitive impairment, he required extensive assistance with activities of daily living, had physical and verbal behaviors directed toward others, had an indwelling urinary catheter and feeding tube.
The Communication Care Area Assessment (CAA), dated 08/06/20, documented the resident as sometimes understood, not able to speak clearly, had difficulty understanding what is said to him, had a cerebral vascular accident (CVA) with dysphagia with left sided weakness, and these factors impeded his ability to verbally communicate as well as to understand complex ideas.
The Quarterly MDS dated 04/24/21, documented the resident as Asian, needed or wanted an interpreter to communicate with a doctor or health care staff, preferred language was Vietnamese, had unclear speech, sometimes understood, and understands, had severe cognitive impairment. The MDS further documented R4 required extensive assistance with activities of daily living, an indwelling urinary catheter, feeding tube, received occupational and physical therapy.
The Communication Care Plan, dated 04/04/21, directed staff to provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out a staff member when agitated. The care plan further directed staff to make sure the resident was safe when overly agitated and attempt approaching the resident at a later time, if appropriate.
The Social Service Summary Progress Note, dated 04/24/21, documented staff assessments were completed by staff, due to R4 unable to participate, being non-English speaking, and noting he had some confusion. R4 could not effectively make his needs known, therefore staff tried to anticipate and provide his needs. He could be resistive to cares at times, call out, yell out, and spit at staff.
On 05/11/21 at 12:30 PM, observation revealed staff fed R4 his midday meal. The resident repeated the same non-English words. The resident stated I'm full.
On 05/13/21 at 08:29 AM, observation revealed nursing staff in R4's room to flush his feeding tube, the resident began to holler out what sounded like I don't want and hurt.
On 05/11/21 at 12:33 PM, Certified Nurse Aid (CNA) N stated she did not understand what R4 was trying to say as he yelled out.
On 05/12/21 at 08:26 PM, Certified Medication Aid (CMA) R stated the resident did not speak English and does not understand what the resident says or means.
On 05/12/21 at 08:40 AM, CNA O stated the resident did not speak English and when R4 began to yell she went to the room and tried to communicate by pointing at things, she adjusted pillows, and/or she repositioned, and moved things he may have needed to be near him.
On 05/13/21 at 08:29 AM, Licensed Nurse (LN) H stated the resident could say a few English phrases like thank you and hello, and she could not always understand what he needed.
On 05/13/21 at 08:04 AM, Administrative Nurse E stated staff would call R4's family if they needed interpretation of language. The resident's wife did not speak much English, but his children were fluent in English. Administrative Nurse E verified the care plan lacked interventions the resident and staff could utilize for his language barrier.
The facility's Quality of Life, Non-English Communication policy, dated October 2007, stated that all residents who are non-English speaking will be able to communicate their needs as desired by the resident. The facility will identify the language or tool needed for interpreter services and contact appropriate agency who can interpret. The policy further stated the facility will supple resident, family, staff members with the use of a communication board/binder/signage that has universal known drawing, whenever desired.
The facility failed to provide the resident with necessary communication tools of R4's non-English speaking status, placing the resident at risk for lack of informed care and services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 75 residents. The sample included 19 residents, with three reviewed for activities of daily living ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 75 residents. The sample included 19 residents, with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing and nail care for one of three sampled residents, Resident (R) 60.
Findings included:
- R60's admission Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of two staff for personal hygiene. The assessment documented bathing did not occur during the seven day look back period.
The ADL Care Plan, dated 04/26/21, documented the resident required total staff assistance for bathing and one staff assistance for personal hygiene.
The April 2021 Bathing Record documented the resident received a bed bath on the following days:
04/12/21
04/27/21(14 days without a bath).
On 05/12/21 at 10:41 AM, observation revealed the resident's toenails were brown, jagged, and overgrown past the tip of the toes.
On 05/12/21 at 01:15 PM, observation revealed the resident's toenails continued to be long and jagged, and the resident's mattress contained had a large amount of dry skin flakes from the resident's feet because the resident's feet were dry and flaky.
On 0/5/12/21 at 10:41 AM, Certified Nurse Aide (CNA) P stated she did not know why the resident's toenails were not cut.
On 05/12/21 at 01:15 PM, Licensed Nurse (LN) G stated staff applied lotion to the resident's legs and feet often, but did not know anything about the resident's toenails.
On 05/12/21 at 01:45 PM, Administrative Nurse D stated staff applied lotion to the resident's legs and feet all the time and verified the resident's toenails needed clipped.
On 05/13/21 at 11:30 AM, Administrative Nurse D stated staff documented the resident's bed baths on paper and in the computer, and verified staff had not given R60 a bed bath for two weeks.
The facility's ADL Services policy, dated November 2007, documented the residents are given the appropriate treatment and services to maintain or improve his/her abilities and residents who are unable to carry out ADL's received services to maintain good nutrition, grooming, personal hygiene and oral hygiene.
The facility's Nail Care policy, dated November 2007, documented the facility promoted cleanliness, the safety and neat appearance of residents, staff observe for ingrown nails, corns calluses or infections, trim nails straight across and even with end of finger or toe, round the edges with a nail file or emery board, and smooth the rough edges on toenails
The facility failed to provide R60 bathing services and nail care as care planned, placing the resident at risk for poor hygiene.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 40 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $28,558 in fines. Higher than 94% of Kansas facilities, suggesting repeated compliance issues.
- • Grade F (30/100). Below average facility with significant concerns.
- • 59% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Shawnee Post Acute Rehabilitation Center's CMS Rating?
CMS assigns SHAWNEE POST ACUTE REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Kansas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Shawnee Post Acute Rehabilitation Center Staffed?
CMS rates SHAWNEE POST ACUTE REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 59%, which is 13 percentage points above the Kansas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Shawnee Post Acute Rehabilitation Center?
State health inspectors documented 40 deficiencies at SHAWNEE POST ACUTE REHABILITATION CENTER during 2021 to 2024. These included: 2 that caused actual resident harm and 38 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Shawnee Post Acute Rehabilitation Center?
SHAWNEE POST ACUTE REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 101 certified beds and approximately 78 residents (about 77% occupancy), it is a mid-sized facility located in OVERLAND PARK, Kansas.
How Does Shawnee Post Acute Rehabilitation Center Compare to Other Kansas Nursing Homes?
Compared to the 100 nursing homes in Kansas, SHAWNEE POST ACUTE REHABILITATION CENTER's overall rating (2 stars) is below the state average of 2.9, staff turnover (59%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Shawnee Post Acute Rehabilitation Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Shawnee Post Acute Rehabilitation Center Safe?
Based on CMS inspection data, SHAWNEE POST ACUTE REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Kansas. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Shawnee Post Acute Rehabilitation Center Stick Around?
Staff turnover at SHAWNEE POST ACUTE REHABILITATION CENTER is high. At 59%, the facility is 13 percentage points above the Kansas average of 46%. Registered Nurse turnover is particularly concerning at 80%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Shawnee Post Acute Rehabilitation Center Ever Fined?
SHAWNEE POST ACUTE REHABILITATION CENTER has been fined $28,558 across 1 penalty action. This is below the Kansas average of $33,364. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Shawnee Post Acute Rehabilitation Center on Any Federal Watch List?
SHAWNEE POST ACUTE REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.