Salem Springlake Health & Rehabilitation Center
For profit - Corporation
75 Beds
ATRIUM CENTERS
Data: November 2025
Trust Grade
45/100
#132 of 266 in KY
Photo by Emma Deckert (Belle)
Photo by Emma Deckert (Belle)
Photo by Emma Deckert (Belle)
1 / 5 photos
Last Inspection: December 2023
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Salem Springlake Health & Rehabilitation Center has a Trust Grade of D, indicating below-average performance with some concerns about care quality. Ranked #132 out of 266 facilities in Kentucky, they are in the top half, but they are the only option in Livingston County. The facility shows an improving trend, with issues decreasing from 7 in 2021 to 6 in 2023, and it has good staffing with a 4 out of 5 rating and a turnover rate of 37%, lower than the state average. However, there have been serious incidents, such as failing to consult a physician for a resident with significant changes in health and not providing timely treatment for urinary issues, which led to hospitalization for some residents. While there are strengths in staffing and the absence of fines, the facility's overall quality of care raises concerns for families considering placement.
- Trust Score
- D
- In Kentucky
- #132/266
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 37% turnover. Near Kentucky's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Kentucky facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Kentucky. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Top 49%
Review needed
7 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2021: 7 issues
2023: 6 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Kentucky average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Kentucky average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 37%
Near Kentucky avg (46%)
Typical for the industry
Chain: ATRIUM CENTERS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
3 actual harm
Dec 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy, it was determined the facility failed to treat each resident with...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy, it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. for five (5) of fourteen (14) sampled residents(Resident #8, Resident #23, Resident #38, Resident #42 and Resident #203).
Observation of a dinner meal in the dining room, on 12/04/2023, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance. Additionally, observations of Resident's #42, #23, #38, and #203, revealed staff failed to ensure the resident's bare bodies were not exposed to others.
The findings include:
Review of the facility's policy, Resident Rights, updated 09/20/2022, revealed it was the policy of the facility to ensure residents had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility.
Review of the facility's policy, Privacy, Dignity, and Confidentiality, dated 01/2011 and reviewed 01/2022, revealed residents had the right to privacy with whomever the resident desires. The resident had the right to personal privacy, which included accommodations, medical treatment, written and telephone communication, personal care, visits, and meetings of the family and resident groups.
1. Review of Resident #42's admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction.
Review of Resident #42's admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment.
Observation of Resident #42 on 12/05/2023 at 11:18 AM, revealed his/her door was open, and he/she was laying in bed and had no sheet or blanket covering him/her. Resident #42's legs were exposed. Further observation revealed Resident #42's gown was not in place causing his/her brief to be visible to others.
During an interview with Certified Nurse Aide (CNA) #3 on 12/06/2023 at 10:40 AM, she stated Resident #42 would often remove his sheet or blanket. She stated they usually kept the door pulled closed. CNA #3 further stated it could be a dignity issue if a resident was exposed.
2. Review of Resident #8's admission Record revealed the facility admitted the resident on on 05/28/2021 with diagnoses which included Alzheimer's, Dementia, and Hypertension.
Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 11/03/2023, revealed a the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating that Resident #8 was unable to complete the assessment. Further view of the MDS assessment, Section GG, revealed Resident #8 was a dependent dinner.
Observation of a dinner meal in the dining room, on 12/04/2023 at 5:15 PM, revealed Unit Manager #1 was standing over Resident #8 as she provided feeding assistance to the resident, while he/she was seated.
In an interview with the Unit Manager #1 on 12/06/2023 at 10:28 AM. she stated she was not aware that standing while feeding a resident was a dignity issue. She stated she was in a standing position so that she could observe the other residents in the dining room.
3. Review of Resident #38's admission Record revealed the facility admitted the resident on 10/27/2022, with diagnoses which included Diabetes Mellitus, Atrial Fibrillation, and Depression.
Review of Resident #38's Annual Minimum Data Sets (MDS) Assessment, dated 2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) of fifteen (15), which indicated the resident was interviewable.
Observation of Resident #38 on 11/29/2023 at 2:20 PM, revealed his/her door was open, and he/she was lying in bed with no clothing or blanket covering his/her body.
4. Review of Resident #23's admission Record revealed the facility admitted the resident on 11/23/2018 with diagnoses which included Gastroesophageal Reflux Disease (GERD), Dementia, and Depression,
Review of Resident #23's Quarterly Minimum Data Sets (MDS) Assessment, dated 11/01/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) of fifteen (15), which indicated severe cognitive impairment.
Observation of lunch meal pass, on 12/05/2023 at 12:05 PM, revealed Certified Nurse Aide (CNA) #3, and CNA #2 passing lunch meal trays to resident's rooms. Further observation revealed Resident #23 who had a BIMS of two (2) and required feeding assistance, had his/her meal tray left on the bedside table while staff continued to pass other residents' food trays.
In an interview with CNA #3, on 12/05/23 at 12:10 PM, she stated it had been normal practice for Resident #23's meal tray to be left on bedside table until assistance was provided. She stated had not been aware that the meal tray should be left on the enclosed cart until staff were ready to assist the resident.
In an interview with CNA #2, on 12/05/23 at 12:15 PM, she stated she not aware the tray should not be left on the food cart to keep it warm until staff were ready to assist the resident. She further stated she would ensure that did not happened again.
5. Review of Resident #203's admission Record revealed the facility readmitted the resident on 07/18/2023, with diagnoses which included Unspecified Dementia, Psychotic Disturbance, and Anxiety.
Review of Resident #203's Quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15) indicating the resident was not interviewable.
Observation on 12/05/2023 at 11:01 AM and 12/07/2023 at 11:54 AM, revealed Resident #203's door was open, the resident was laying in bed asleep. Resident #203 was wearing a T-shirt and a brief, with only a sheet covering his/her feet, leaving his/her body exposed to others.
During an interview with Registered Nurse (RN) #5 on 12/06/2023 at 12:12 PM, she stated residents should be covered in a dignified way at all times and if she saw a resident with a body part exposed, she would ask the resident if she could cover them with a blanket or close their door.
In an interview with the Director of Nursing ( DON), on 12/08/023 at 3:50 PM, she stated staff were expected to cover residents with a blanket, or ask to pull the curtain, and check room temperatures, prior to exiting the resident's room, if they were exposed to others. She further stated staff could only close the door if residents had permitted them to close it. The DON stated staff should assist resident's with their meal trays timely.
In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated staff were expected to honor resident rights and dignity always. She further stated if a Residen were uncovered, she would expect staff to cover the resident or at least pull the curtain to ensure they were not exposed. Additionally, the Administrator stated all residents should be served at the same table at the same time, and no meal tray should be dropped off in resident's room until staff were ready to assist them with the meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to revise the care plan following a significant weight change for four (4) of fourteen (14) sampled residents (Resident #22, Resident #42, Resident #18 and Resident #203).
Review of Resident #22's, #42's, #28's, and #203's care plans revealed the care plans were not revised to include interventions for weight loss and supplements.
The findings include:
Review of the facility policy titled, Resident Assessment Comprehensive Care Plans, updated on 05/24/2022, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a residents medical, nursing and mental and psychosocial needs, that were identified in the comprehensive assessment. Continued review revealed that the comprehensive care plan must describe the residents medical, nursing, physical, mental and psychosocial needs and preferences on how the facility would assist in meeting those needs and preferences. The care plan must reflect interventions to enable each resident to meet their objectives. The care plan must reflect changes in the residence preferences and goals as they change throughout their stay. Further review revealed that updates would be made to the Comprehensive Care Plan as needed.
1. Review Resident #18's admission Record revealed the facility admitted the resident on 06/04/2018 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus and Adult failure to Thrive.
Review of Resident #18's Significant Change in Status Minimum Data Set (MDS) Assessment, dated 11/16/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating the resident had moderate cognitive impairment.
Review of Resident #18's weight June 2023 through December 2023 revealed that on 06/14/2023, Resident #18 weighed one hundred twenty six (126) pounds (lbs) and on 12/05/2023, Resident #18 weighed one hundred two point eight (102.8) lbs. On 12/07/2023 the Surveyor requested and observed staff as Resident #18's weight was obtained at 98.8 lbs. This reflected a significant weight loss of twenty one point five percent (21.5 %) in one hundred eighty (180) days.
Review of Resident #18 Comprehensive Care Plan dated 06/05/2018, revealed a focus problem of Nutritional Status, that indicated Resident #18 was at risk related to lack of coordination, type 2 diabetes mellitus, essential hypertension, atherosclerotic heart disease, schizophrenia, altered texture diet, thickened liquids, and pour intakes. Continued review revealed that the Comprehensive Care Plan was last reviewed and revised on 11/22/2023 by the MDS Coordinator. However, further review revealed no new interventions had been added to the care plan since 01/23/2023.
Review of care plan approaches revealed the following; diet per physician orders, med pass supplement as ordered, encourage resident to eat meals in the dining room for increased socialization and pleasant dining experience, encourage increased intake of meals, provide cues as needed, assist with meals as needed, encourage fluids per physician order, honor likes and dislikes and medications as ordered to increase appetite.
2. Review of Resident #22's admission Record revealed the facility admitted the resident on 02/17/2023 with diagnoses which included Congestive Heart Failure, Cognitive Communication Deficit, and Personal History of Transient Ischemic Attack.
Review of Resident #22's Quarterly Minimum Data Set MDS) Assessment, dated 10/16/2023, revealed the resident assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), indicating the resident had severe cognitive impairment.
Review of Resident #22's Physician orders revealed a diet order of Puree diet with Magic Cup (supplement) as an evening snack. Further, Resident #22 received Remeron seven point five milligrams (7.5mg) at bedtime for appetite stimulant
Review of Resident #22's Comprehensive Care Plan for Nutritional Status dated 02/18/2023, revealed that the resident was at risk for altered nutritional status related to, congested heart failure, hyperglycemia, anemia, diuretic use, and edema. Further review revealed interventions dated 02/18/2023, included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for labs as needed, monitor meal intake and record, monitor tolerance to diet texture, offer substitutes if consumes less than 50% of meals, therapy or restorative screen and treat as needed, weigh every month or as needed, notify physician of significant change. The care plan did not reflect that Resident #22 was receiving supplements (health shakes) or that weekly weights were being obtained.
3. Review of Resident #42's admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction.
Review of Resident #42's admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment.
Review of Resident #42's Comprehensive Care Plan dated 09/02/2023, revealed that Resident #42 was at risk for Nutritional Status related to diabetes mellitus, obesity, history of stroke, hypertension, and chronic kidney disease. Continued review of the care plan revealed, interventions, dated 09/02/2023, included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, monitor meal intake and record, monitor tolerance to diet texture and adjust as needed, offer substitutes if consumes less than 50% of meals, therapy, restorative, screen and treat as needed. weight every month and or as needed, notify physician if significant change.
In an interview with Unit Manager (UM) #1, on 12/08/2023 at 3:30 PM, she stated CNAs would report to her if there were concerns with residents not consuming meals and had potential weight loss. She stated she would notify would report to an RN or the ADON if available and then either she or another nursing staff member would contact the physician for orders. She stated weight loss would be recognized as a change of condition. She stated she recalled all nursing staff being allowed to make changes on resident care plans, but she stated she had not made those changes without consulting with her superiors or the physician and being given consent.
In an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated she does not usually do anything with the care plan, but she probably could update it, she stated the MDS or DON would be responsible for updating a care plan. The RN stated if a resident had a change in condition or a new intervention was added, she would notify the oncoming shift and/or CNA's verbally either during the current shift or at change of shift.
In an interview with the Minimum Data Set (MDS) Coordinator on 12/08/2023, at 2:20 PM, she stated she had been at the facility for two (2) years. She stated the purpose of the care plan was to guide care. She stated information came from resident interviews, staff interviews, the clinical record, and observations. The MDS coordinator stated she was responsible for updating all areas of the Comprehensive Care Plan. She stated the Registered Dietitian initiated the nutrition care plan, but she was responsible for doing any updates. She stated that weight loss, could be addressed on the nutrition care plan, or a resident may have a specific care plan for weight loss. The MDS nurse stated care plans were reviewed and revised quarterly or with a significant change of status.
4) Review of Resident #203's admission Record revealed the facility readmitted the resident on 07/18/2023, with diagnoses which included Unspecified Dementia, Psychotic Disturbance, and Anxiety.
Review of Resident #203's Quarterly Minimum Data Sets (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15) indicating the resident was not interviewable.
Review of Resident #203's Weight Record revealed on 07/25/2023, the resident weighed 178.8 pounds and on 11/28/2023 he/she weighed 140 pounds indicating a -21.70% loss for the one hundred and eighty (180) day period. On 10/25/2023 the resident weighed 157 pounds and on 11/28/2023 he/she weighed 140 pounds indicating a -10.83% loss for thirty (30) days.
Review of Resident #203's Comprehensive Care Plan for nutritional status revealed it was implemented on 01/14/2023. However there were no revisions to address the resident's documented weight loss.
During an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated she usually does not have any responsibilities related to a care plan but she could probably update it if needed. RN #1 stated the MDS coordinator or the DON would be responsible for updating a care plan. She stated if a resident had a change in condition or a new intervention was added, she would notify the oncoming shift verbally.
During an interview with the Director of Nursing (DON) on 12/08/2023 at 3:52 PM, she stated the MDS coordinator was responsible for implementing a care plan but any nurse could also do that. The DON stated she expected floor nurses, the MDS or herself to ensure the resident's care plans were updated and revised.
During an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated the resident's care plans were the facility's guide to providing care and if something was not added to the care plan then staff would not be aware of what needed to be done. The Administrator stated the Care Plan had to be updated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight ...
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Based on observation, interviews, record review and review of facility policy, it was determined the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible, for two (2) of fourteen (14) sampled residents (Resident #22 and Resident #42).
1. Review of Resident #42's weight beginning 09/04/2023, revealed an admission weight of 233.5 pounds (lbs). On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in ninety (90) days.
2. Review of recorded weights for Resident #22 revealed that on 06/14/2023, the resident weighed 131.4 lbs. On 12/08/2023 at 10:00 AM, the Surveyor requested and observed staff obtain Resident #22's weight and the weight was one hundred eight point six (108.6) lbs, indicating Resident #22 had a significant weight loss of seventeen point four percent (17.4%) in one-hundred an eighty (180) days.
The findings include:
Review of facility policy titled, Residents at Nutritional Risk, revised 08/2023, revealed any resident identified as being at nutritional risk would have a problem of, Alteration in Nutrition, identified on the care plan. The physician would be informed, and a dietary consultation requested. Continued review revealed criteria to help identify nutritionally at risk residents included, a resident consistently refuses twenty-five (25%) percent or more of a meal, undesirable weight loss or gain of three (3) pounds (lbs.) if under one hundred lbs., and five (5) lbs., if over one hundred (100) lbs. or more in one month. Progressive weight loss ten percent (10%) in six (6) months or gain over several months, difficulties in swallowing or chewing. Non compliance with diet order. Further, based on nutritional assessment, many nutrition assessment section. If a resident score is less than nine, would indicate a risk or is malnourished. Timely assessment and implementation of a plan was crucial in proper care of the resident at risk.
Review of facility policy titled, Weight Monitoring, dated 01/2019 and reviewed 01/2022, revealed all residents height and weight would be determined by the appropriate method and recorded within twenty four (24) hours of admission. Weight would be measured monthly and weight changes of all residents would be monitored. Percentage weight changes would be determined for a 30 day, 90 day and a 180 day. Continued review revealed residents that triggered for a significant weight loss, more than 5% from the previous month, would be placed on weekly weights and each resident would be reviewed by the interdisciplinary team (IDT) committee and appropriate interventions would be put in place.
1. Review of Resident #42's admission Record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction.
Review of Resident #42's admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment.
Review of Resident #42's Physician orders revealed that Resident #42 received a Regular diet with sugar substitutes and sugar free health shakes four times a day.
Review of Resident #42's Weight Record revealed an admission weight of 233.5 lbs on 09/04/2023. Continued review revealed on 10/09/2023, weight was 217 lbs., on 11/08/2023, weight was 189 lbs., on 11/30/2023, Resident #42 returned from the hospital and weight was recorded at 212 lbs. Additionally, weight on 12/05/2023, was 191 lbs.
On 12/06/2023 at 10:30 AM, the Surveyor requested and observed staff obtain Resident #42's weight using a mechanical lift scale and weight was observed to be 187 lbs. This reflected a significant weight loss of 19.91% in 90 days.
Review of Resident #42's meal intakes for December 1st through December the 6th, revealed there was an opportunity for eighteen (18) meals. Resident #42 had one meal where 26 to 50% of the meal was consumed, eight (8) meals that 1-25% was consumed and there were seven (7) meals that were documented as not taken. Further, there were two (2) meals that no documentation was available
Review of the Initial Nutritional assessment dated , 08/31/2023, and signed by the Registered Dietician (RD), revealed the resident had a history that included stroke, diabetes, and hypertension. Resident triggers for nutrition risk related to obesity, decreased meal intake. Weekly weights for four (4) weeks, then monthly if stable.
Review of Nutrition Note dated, 11/11/2023 and signed by the RD, revealed Resident #42 received a regular diet with finger foods, and a sugar free health shake daily. Resident #42 triggered for nutrition risk related to obesity. Decreased intake and recent weight loss of 12.9% in 30 days. Recommend continuing weekly weights then monthly of stable. Also recommend adding an additional sugar free shake daily at lunch. Current intakes average 25%.
Review of Interdisciplinary Team (IDT) Note dated 11/15/2023 and signed by the Administrator, revealed that Resident #42 continued with weekly weights and weight was stable.
Review of Resident #42's Comprehensive Care Plan dated 09/02/2023, revealed the resident was at risk for Nutritional Status related to diabetes mellitus, obesity, history of stroke, hypertension, and chronic kidney disease. Continued review of the care plan revealed, interventions included, assist with meals as needed, diet per order, encourage fluids, honor likes and dislikes, medications as ordered, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, monitor meal intake and record, monitor tolerance to diet texture and adjust as needed, offer substitutes if consumes less than 50% of meals, therapy, restorative, screen and treat as needed. weight every month and or as needed, notify physician if significant change.
Observation on 12/05/2023 at 12:27 PM, Kentucky Medication Aide (KMA) #10 was observed exiting Resident #42's room with lunch tray and the surveyor asked to see what was consumed. KMA #10 removed lid and Resident #42's food looked to be untouched.
In an interview during observation with KMA #10 on 12/05/2023 at 12:27 PM, she stated Resident #42 was independent with eating after set up. She stated Resident #42 ate the cookie and drunk the tea. KMA #10 stated she did not offer Resident #42 anything else to eat. She stated she would inform the nurse of Resident #42's not eating. She further stated she would document that Resident #42 ate 0-25% of the meal.
Observation on 12/06/2023, at 9:20 AM, revealed Resident #42 was awake with head of bed elevated Surveyor entered room and noted breakfast tray remains at bedside. The breakfast meal consisted of scrambled eggs, biscuit and gravy, oatmeal and 1/2 glass of liquid. There are no condiments (butter, sugar, salt pepper) or finger foods on the tray and the meal is untouched as the utensils are unused. Resident #42 was a dependent diner and no staff were present. Unit Manager entered room, saw Resident #42 had not eaten and offered him/her a peanut butter and jelly sandwich to which he refused. Further the Unit Manager made no attempt to assist Resident #42 with his/her meal.
2. Review of Resident #22's admission Record revealed the facility admitted the resident on 02/17/2023 with diagnoses which included Congestive Heart Failure, Cognitive Communication Deficit, and Personal History of Transient Ischemic Attack.
Review of Resident #22's Quarterly Minimum Data Set MDS) Assessment, dated 10/16/2023, revealed the resident assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), indicating the resident had severe cognitive impairment.
Review of Resident #22's Weight Record revealed the resident weighed 131.4 lbs on 06/14/2023. Continued review revealed that on 07/07/2023, the resident weighed 111.2 lbs., a significant weight loss of 15.37% in 30 days. Further weights were recorded on 08/08/2023, at 108 lbs., on 09/05/2023, 111 lbs., on 10/03/2023, 109.6 lbs., and on 11/08/2023, Resident #22 weighed 108.2 lbs.
On 12/08/2023 at 10:00 AM, the Surveyor requested and observed staff obtain Resident #22's weight and the weight was one hundred eight point six (108.6) lbs, indicating Resident #22 had a significant weight loss of seventeen point four percent (17.4%) in 180 days.
Review of Resident #22's Physician orders revealed a diet order of Puree diet with Magic Cup (supplement) as an evening snack. Further, Resident #22 received Remeron seven point five milligrams (7.5mg) at bedtime for appetite stimulant
Review of record revealed no documentation of Interdisciplinary Team (IDT) or Nutrition notes could be located for June or July 2023, when Resident #22 was first noted with a significant weight loss.
Review of a Nutrition Note dated 08/01/2023, and signed by the RD, revealed Resident #22 received a Puree diet with snacks twice a day. Average meal intake was 76%. Weight on 07/11/2023 was 111 lbs, and indicated a loss of 15.4% in 30 days, and 11.3% in 90 days. Resident was placed on weekly weights for 4 weeks to monitor, recommend adding magic cups for added calories.
In an interview with the Certified Dietary Manager (CDM) on 12/07/2023, at 4:07 PM, she stated she had been the CDM for five years. The CDM stated she attended care plan meetings and the weekly IDT meetings. She stated she updated the care plan if needed. She further stated she made the RD aware if a resident was having weight loss. She stated residents having weight loss were discussed in the weekly IDT meeting and notes were made.
In an interview with Certified Nurse Aide (CNA) #6 on 12/08/2023 at 9:00 AM, he stated if a resident was not eating he would report it to the charge nurse. He further stated he would let the kitchen know and get a sandwich. He stated he was not aware of anything the kitchen offered other than sandwiches.
In an interview with Certified Nurse Aide (CNA) #8 on 12/08/2023 at 9:33 AM, she stated she had been at the facility for eight (8) years. and normally works 400,500 and 600 halls. She stated if a residents appetite changed and the resident was not eating she would notify the nurse. She stated residents with weight loss received shakes or magic cups. She stated there were limited options when residents did not like or want what was served. She stated the kitchen would serve left overs or sandwiches.
In an interview with the Registered Dietician (RD) (contract) on 12/08/2023 at 10:18 AM, she stated she came to the facility weekly on Saturday. She stated the Certified Dietary Manager (CDM), leaves her a list of things she needs to look at. She reviews residents on weekly weights and residents being followed in the weekly meeting. She stated the menus came from corporate and there was no alternative menu or an always available menu. She stated she did not know what was available to the residents as she was only at the facility once a week.
In an interview with Kentucky Medication Aide (KMA) #10 on 12/08/2023 at 3:10 PM, she stated CNAs would report to her if they had concerns with resident weight loss or not eating meals. She stated she would notify the Unit Manager (UM) or charge nurse about the concerns. She stated weight loss would be considered a change of condition and the charge nurse or UM on duty would notify the physician. She further stated she was not been involved with care plans.
In an interview with Unit Manager (UM) #1 on 12/08/2023 at 3:30 PM, she stated CNA's would report to her if there were concerns with residents not consuming meals and had potential weight loss. She stated she would notify would report to an RN or the Assistant Director of Nursing (ADON) if available and then either she or another nursing staff member would contact the physician for orders. She stated weight loss would be recognized as a change of condition. She stated she recalled all nursing staff being allowed to make changes on resident care plans, but she stated she had not made those changes without consulting with her superiors or the physician and being given consent.
During an interview with Registered Nurse (RN) #1 on 12/08/2023 at 3:20 PM, she stated the Certified Nursing Assistant (CNA) would notify her if meal intakes were less than fifty percent (50%). She stated weights were reported to the MDS nurse. She also stated that if a resident was not consuming at least 50% of meals, that would be a decline and a significant change in condition and should be reported to the physician; She stated the DON was responsible for notifying the doctor. RN #1 stated she would notify the residents provider and DON within two days if a resident continued not to consume their meals.
In an interview with the Director of Nursing (DON) on 12/08/2023 at 3:50 PM, she stated with weight loss and feeding, the guidelines were listed on the resident care guide. She stated she expected the CNA or KMA to report to the nurse if a resident was not eating. She further stated the NP or physician should be made aware. She stated the MDS Coordinator and the CDM followed resident weights and that the Dietician also followed residents with weight loss. She further stated, residents with weight loss were placed on weekly weights and followed weekly until stable.
In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated she was part of the IDT team. She stated the IDT team followed residents with weight loss weekly by making notes in the chart. The Administrator stated the facility did not offer a second options for meals but soup and sandwiches were always available to residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility document review, it was determined the facility failed to ensure services were provided by sufficient competent staff, including but not limited to licensed nurses and nurse aides, on a 24-hour basis to provide nursing and related services to residents for four (4) of fourteen (14) sampled residents (Resident's #4, #6, #16, and #26).
Interviews revealed nursing staff was slow to answer resident call lights.
The findings include:
Review of the Facility Assessment Tool, revised 10/23/2023, revealed the facility staffing plan was based on resident population and their identified needs for care and support. The facility determined the following approach to staffing to ensure that the facility had sufficient staff to meet the needs of the residents at any given time. The facility completed an evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. Continued review revealed that the total number of full-time equivalents needed on a daily basis for nursing, based on a twelve (12) hour shift was, Licensed Nurses, four to five (4-5) staff per twelve (12) hour shifts, Certified Nurse Aides (CNAs), six to eight (6-8) staff per twelve (12) hour shifts.
Review of the facility policy titled, Standards of Nursing Practices, revised 05/2018, revealed residents requiring help with meals would be provided the necessary needed help. Further review revealed staff would respond to residents request for assistance by answering call lights within a reasonable amount of time, per policy, was no longer than a ten (10) minute period of time.
1. Review of Resident #26's admission Record revealed the facility readmitted the resident on 02/23/2022 with diagnoses which included Hypertension, Dementia, and Arthritis.
Review of Resident #26's Quarterly Minimum Data Set (MDS) Assessment, dated 09/25/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) which indicated severe cognitive impairment.
In an interview with Resident #26, on 12/05/2023 at 10:02 AM, he/she stated the call lights were not always answered timely especially during meal times. He/she stated staff had provided good care as best as they could. He/she stated he/she could ambulate on his/her own, but getting into his/her wheelchair required at least one staff member to be with him/her. (Resident #26 had a low BIMS score but demonstrated knowledge regarding his/her care)
2. Review of Resident #16's admission Record revealed the facility readmitted the resident on 12/18/2021 with diagnoses which included Atrial Fibrillation, Anxiety Disorder, and Asthma.
Review of Resident #26's Quarterly Minimum Data Set(MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) which indicated the resident was interviewable.
In an interview with Resident #16, on 12/05/2023 at 10:30 AM, he/she stated staff had not always answered call lights timely when assistance was needed. Resident #16 had pressed call light and after ten (10) minutes staff had not come to assist him/her.
On 12/05/23 at 10:42 AM, State Surveyor (SS) had gone to the nurse station to interview to why the call light for Resident #16 had not been answered and observed no staff at the nurse station. Observation of Certified Nurse Aide (CNA)#3, who arrived to answer call light for Resident #16 after fifteen (15) minutes was informed that Resident #16's call light was a test call.
In an interview with Licensed Practical Nurse (LPN), Unit Manager (UM) #1, on 12/05/23 at 11:08 AM, she stated to her knowledge, fifteen (15) minutes was the state maximum wait time for call lights to be answered, but residents had not typically waited that long to get assistance. LPN/UM #1 further stated she didn't believed the facility was short staffed because resident's received good care.
3. Review of Resident #4's admission Record revealed the facility readmitted the resident on 08/09/2016 with diagnoses which included Heart Failure, Diabetes Mellitis, and Depression.
Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) of fifteen (15), which indicated severe cognitive impairment.
In an interview with Family Member #3, on 12/06/2023 at 9:25 AM, he stated he had visited Resident #4 everyday and only lived about a block away from the facility. He stated if he had not been close enough to visit daily, Resident #4 would not be in that facility. He stated Resident #4 stated to him that call lights were not answered timely and stated staff were unable to assist all residents appropriately. He stated Resident #4 had called him when he/she needed something and if staff had not answered his/her call light, he had come to the facility to assist Resident #4. Resident #4 had stated to him the wait time to get assistance going to the bathroom had sometimes been an hour or an hour and a half, but noted unsure if Resident #4's perception of time was exact. He stated Resident #4 was unable to walk and was fully dependent on staff to assist him/her to the wheelchair and then assist him/her onto the toilet.
In an interview with Certified Nurse Aide (CNA) #3, on 12/05/2023 at 10:00 AM, she stated that staffing had been okay most days, but they had a staff member quit recently and weekends were about the same. CNA #3 stated she had worked on both sides of the facility, depending on where she had been assigned, but had been able to complete her assigned tasks during her shift.
4. Review of Resident #6's admission Record revealed the facility readmitted the resident on 07/05/2018 with diagnoses which included Hyperlipidemia, Heart Failure, and Depression.
Review of Resident #6's Quarterly Minimum Data Sets (MDS) Assessment, dated 10/31/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15) which indicated no cognitive impairment.
In an interview with Resident #6, on 12/08/23 at 11:26 AM, he/she stated that breakfast was normally good and most of the time, he/she had been able to feed him/herself. Resident #6 stated it had taken him/her a long time to eat without assistance, and he/she had trouble with eating sausage sometimes. Resident #6 stated that staff had not always assisted him/her with meals. He/she stated sometimes they had come to assist after passing all other trays. and other times staff would be busy picking up trays and at those times he/she had no assistance with feeding at all. Resident #6 further stated he/she was able to press the call light button and it was in reach, but stated staff had not always answered the call light timely. He/she felt there was not enough staff available at times because the call lights weren't answered timely.
In an interview with Assistant Director of Nursing (ADON), on 12/01/2023 at 2:53 PM, she stated call lights should be answered within five (5) minutes, but no later then ten (10) unless there was an emergency, and she would typically let residents know why there was a delay.
In an interview with Director of Nursing (DON), on 12/08/023 at 3:50 PM, she stated staff expectations for answering call lights timely was less than fifteen (15) minutes.
In an interview with the Administrator, on 12/08/2023 at 4:15 PM, she stated call lights should be answered as soon as staff were physically able to get out of the room noting staff may be tied up in another room. She stated facility policy stated ten (10) minutes to answer resident's call lights, but she stated that was a little harsh. The Administrator stated expectations were that staff would at least acknowledge the light and tell the resident they would be back as soon as possible. Further, she stated staff should acknowledge the light is on then to get to it as soon as they can. Additionally, she stated all staff had worked together, and sometimes staff were pulled from other areas of the facility if necessary to provide the best care for residents. She stated when staff had called out and the facility required other staff to come in, staff members were responsible to assist with filling their positions for that shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to ...
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Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of fourteen (14) sampled residents (Resident #42).
Observation on 12/06/2023 at 10:20 AM, revealed Certified Nursing Assistant (CNA) #3 failed to remove her soiled gloves prior to picking up and offering Resident #42 a glass of water.
The findings include:
Review of the facility policy titled, Infection Control Program, reviewed on 03/20/2023, revealed the major purpose of infection control program in the nursing facility were to minimize the effects of infections on residents and employees and to educate the staff.
Review of Resident #42's admission record revealed the facility admitted Resident #42 on 08/31/2023 with diagnoses which included Cerebral Infarction due to Unspecified Occlusion of the Cerebral Artery, Aphasia, and Hemiplegia/Hemiparesis following Cerebral Infarction.
Review of Resident #42's admission Minimum Data Set (MDS) Assessment, dated 09/05/2023 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) of fifteen (15), indicating Resident #42 had severe cognitive impairment.
During observation of care on 12/06/2023 at 10:20 AM, Certified Nursing Assistant (CNA) #3 and Unit Manager (UM) were providing incontinent care to Resident #42. CNA #3 and the UM washed their hands and donned gloves prior to care. However, following care, CNA #3 moved Resident #42's bedside table closer to the resident, picked up the glass of water and offered the resident a drink. CNA #3 had not removed her soiled gloves or washed her hands prior to offering Resident #42 a drink of water.
In an interview with CNA #3 at the time of observation, on 12/06/2023 at 10:20 AM, she stated she should have removed her gloves and washed her hands prior to giving Resident #42 a drink of water.
In an interview with the Director of Nursing/Infection Preventionist on 12/08/2023 at 3:50 PM, she stated her expectations on hand hygiene following incontinent was for staff to remove gloves and wash their hands. She stated potential outcomes could be spreading infection to themselves or other residents.
During an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated staff should always remove gloves and do hand hygiene following any care with a Resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if ...
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Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment for one (1) of fourteen (14) sampled residents (Resident #42).
Observation of Resident #42's bed on 12/07/2023, revealed there was a large gap between the side rails and bed mattress.
The findings include:
Review of the facility policy titled, Bed/Side Rail Use, dated 04/2018 and reviewed on 01/2022, revealed the facility would attempt to use appropriate alternatives prior to installing a bed rail or side rail. If a bed or side rail was used, the facility would ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements, assess the resident for risk of entrapment from bedside rail prior to installation, review the risk and benefits of bedrails with the resident or resident representative, and obtain informed consent prior to installation, ensure that the beds dimensions were appropriate for the resident size and weight and follow the manufacturers recommendation and specification for installing and maintaining bed rails.
During observation of care on 12/07/2023 at 10:55 AM, revealed Resident #42 had ¼ rails on his/her bed with a large gap between the right rail and the mattress. The Maintenance Director measured the right-side rail and it was five point five (5.5) inches from the mattress. The left-side rail measured three point seven five (3.75) inches from the mattress. Further observation revealed the mattress was too small for the bed frame.
In an interview with Maintenance Director at time of observation revealed,, he stated the bed frame was adjustable and he would adjust the frame. He stated he does nothing to the beds except add rails when he was asked.
In an interview with Unit Manager #1 on 12/07/2023 at 10:15 AM, she stated assessments were completed when a resident used a bed rail as an enabler. She stated she was unaware of what maintenance did with beds.
In an interview with the Maintenance Supervisor on 12/07/2023 at 10:55 AM, he stated he was not aware of any assessments or inspections he was supposed to be doing on beds, mattresses, or rails. He stated he does not do anything with the beds except put rails on when asked. He stated Resident #42's bed frame was adjustable and he adjusted the frame on 12/07/2023.
During an interview with the Director of Nursing (DON) on 12/08/2023 at 3:52 PM, she stated she thought maintenance was supposed to inspect the beds. She stated nursing checked that beds were functioning, such as a broken rails. The DON stated a device assessment was completed when resident required or requested rails as enablers.
In an interview with the Administrator on 12/08/2023 at 4:13 PM, she stated the Maintenance Supervisor had just completed training as of 12/07/2023 on bed assessments, to include rails and mattresses's. She stated going forward when residents were admitted , the facility would inspect beds and mattresses to ensure guidelines were being followed. The Administrator further stated a monthly audits would be completed.
Apr 2021
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality, for two (2) of twelve (12) sampled residents (Residents #11 and #14).
Staff failed to close the blinds/curtain when providing a skin assessment for Resident #11, leaving the resident's buttocks exposed to anyone who could have looked in the window. In addition, staff placed Resident #14's medication in his/her mouth with her bare hand and the resident stated it made him/her feel like a child.
The findings include:
Review of the facility's policy titled, Dignity, not dated, revealed the policy of the facility is to care for residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life, dignity, and respect in full recognition of his or her individuality. Dignity means that in their interactions with residents, staff carries out activities that assist the Resident to maintain and enhance his/her self-esteem and self worth.
1. Record review revealed the facility admitted Resident #11 on 11/17/2015 with diagnoses which included Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Diabetes Type 2, Hypertension, Tracheostomy, Gastrostomy, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood.
Observation of Resident #11's skin assessment, on 03/30/2021 at 1:20 PM, performed by Registered Nurse (RN) #1 and State Registered Nurse Aide (SRNA) #1, revealed the staff failed to close the privacy curtain and window blinds. Further observation revealed the resident's buttocks were exposed to the window and could be viewed from the outside. In addition, observation revealed a staff member entered Resident #11's room while the skin assessment was being conducted although staff at the bedside stated, resident care.
Interview with SRNA #1 on 03/30/2021 at 1:30 PM, revealed the window blinds and privacy curtains should be closed before providing resident care to ensure the resident's privacy and dignity.
Interview with RN #1 on 03/30/2021 at 1:30 PM, revealed she expected staff to ensure each resident's privacy when care was provided. RN #1 stated she and SRNA #1 should have closed Resident #11's window blinds and privacy curtain although they failed to do so. She states, We just got in a hurry.
2. Record review revealed the facility admitted Resident #14 on 08/09/2017 with diagnoses which included Amyotrophic Lateral Sclerosis (ALS), Myotonic Muscular Dystrophy, Quadriplegia, Idiopathic Scoliosis, Osteoporosis, Pathological Fracture Left Femur, Flaccid Neuropathic Bladder, and Bipolar Disorder. Review of the Quarterly MDS assessment, dated 03/12/2021, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable.
Observation on 03/30/2021 at 9:40 AM, revealed Resident #14 received Percocet (pain medication) and Toprol XL (hypertension) by mouth which was administered by the Assistant Director of Nursing (ADON). The ADON was observed to remove both pills from the medicine cup with her bare hand and place them in the resident's mouth.
Interview with Resident #14 on 03/31/2021 at 1:05 PM, revealed the ADON was the only staff that administered his/her medications with bare hands. Resident #14 stated, Although she washes her hands, it makes me feel like a child when she put the pills in my mouth bare handed.
Interview with the ADON on 04/01/2021 at 2:05 PM, revealed Resident #14 asked her one (1) time to wear gloves when administering his/her medication although he/she did not say why. The ADON further revealed she gave the resident's medication either bare handed or with a spoon. She stated, I am not the only nurse that gave the resident medication bare handed.
Interview with the Director of Nursing (DON) on 04/01/2021 at 2:40 PM, revealed staff should ensure privacy when resident care was provided. She stated, privacy was provided when privacy curtain and window blinds are closed. Further interview revealed Resident #14 preferred his/her medications to be given with a spoon. She stated, I would expect staff to administer )(his/her medications with a spoon or gloved hand, not bare handed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for two (2) of twelve (12) sampled residents, (Residents #11 and #29), related to oxygen administration, and stoma/suctioning.
Resident #11 was care planned for oxygen at 2 Liters per trach mask at 35% humidified oxygen air. However, observations on 03/30/2021 revealed Resident #11's oxygen humidification container was empty and the oxygen was not humidified at 35%, per the care plan.
In addition, Resident #29 was admitted on oxygen; however, review of the comprehensive care plan revealed the facility failed to develop a care plan to address the resident being on oxygen.
The findings include:
Review of the facility's policy titled, Resident Assessment Comprehensive Care Plans, dated 11/28/2017, revealed the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10 (c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.
1. Record review revealed the facility admitted Resident #11 on 11/17/2015 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Tracheostomy, Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Diabetes Type 2, Hypertension, and Gastrostomy. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood.
Review of Resident #11's Comprehensive Care Plan titled, Potential for Complications related to History of Pneumonia and Compromised Respiratory System related to Tracheostomy dated 11/30/2015, revealed an intervention for oxygen at 2 Liters per trach mask at 35% humidified oxygen air. However, observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11 was receiving oxygen at two (2) liters per trach mask collar and the humidification container was empty and was not providing humidified oxygen as care planned.
Interview with Registered Nurse (RN) #1, on 03/31/2021 at 1:30 PM, revealed Resident #11 was care planned for humidified oxygen. RN #1 stated humidification container should not be empty and the licensed staff was responsible to ensure the resident's oxygen was humidified with an oxygen saturation greater than 92%. She stated without oxygen humidification the resident was at risk for alteration in his/her respiratory status and decrease in his/her oxygen saturation.
Interview with the Director of Nursing (DON), on 04/01/2021 at 2:05 PM, revealed she expected Resident #11's oxygen to be humidified as care planned.
2. Record review revealed the facility admitted Resident #29 on 02/05/2021 with diagnoses which included Encounter for attention to tracheostomy-trach has been removed, Hypoxemia, Chronic Obstructive Pulmonary Disease, Encounter for attention to other artificial openings of digestive tract J tube, History of Malignant Neoplasm Pharynx.
Review of the admission MDS Assessment, dated 02/10/2021, revealed the facility assessed Resident #29's cognition as intact with a BIMS score of 14 which indicated the resident was interviewable. Further review of the MDS revealed Resident #29 had a tracheostomy, but it did not indicate suctioning.
Review of a Physician's Order, dated 02/05/2021 revealed an order that stated, May use Yankauer suctioning as needed, may keep at bedside. In addition, observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM and 03/30/21 at 3:30 PM revealed there was an uncovered suction machine on Resident #29's bedside table and the canister was dated 02/25/2021. Continued observation revealed liquid contents in the canister. However, review of Resident #29 Comprehensive Care Plan, dated 02/05/2021- 03/03/2021 revealed there was no care plan to address Resident #29's tracheostomy and the use of suction equipment.
Interview with the DON on 03/31/2021 at 2:15 PM revealed care plans were printed from the Matrix following the MDS assessment period. The DON stated the care plans were kept in a binder at the desk for updating changes. She revealed Resident #29 should have had a Respiratory care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to update and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to update and revise the comprehensive nursing care plan for one (1) of (12) sampled residents (Resident #34)
Resident #34 was readmitted to the facility on [DATE] with a new indwelling urinary catheter and was on oxygen therapy. However, review of Resident #34's Comprehensive Care Plan revealed the facility failed to revise the care plan to reflect the use and/or care of the indwelling urinary catheter and oxygen.
The findings include:
Review of the facility's policy, titled Resident Assessment Care Plan Development, effective 11/28/2017 revealed a comprehensive care plan must be reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions
Record review revealed the facility admitted Resident #34 on 02/25/2021 with diagnoses which included Acute Kidney Failure, Urinary Tract Infection (UTI), Dyspnea, Hypoxemia and Pneumonia.
Review of the admission Minimum Data Set (MDS) assessment, dated 03/02/2021, revealed Resident #34 had an indwelling urinary catheter present on admission. However, review of Physician's Orders revealed the catheter was removed at the facility on 03/03/2021. Review of Progress Notes dated 03/18/2021, revealed Resident #34 was sent to an acute care facility and returned on 03/26/2021 with oxygen and an indwelling catheter in place.
Observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM and 03/30/2021 at 3:30 PM, revealed Resident #34 had a indwelling urinary catheter and was receiving oxygen via nasal cannula at 2 liters. However, review of Resident #34's Comprehensive Care Plan dated 02/25/2021-03/19/2021 revealed there was no care plan to address the resident's use of an indwelling urinary catheter or oxygen.
Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021. RN #1 stated Resident #34 had a catheter and was using oxygen. The RN further stated usually two (2) nurses completed admissions, one to complete the assessment and the other nurse to enter Physician's Orders. She stated she did not enter Resident #34's orders.
Interview with the Director of Nursing (DON) on 03/31/2021 at 230 PM, revealed she expected the resident's care plan to include the catheter and oxygen. She further stated the care plan should be updated and revised when a resident returned from the hospital to reflect their true status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined two (2) residents in the selected ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined two (2) residents in the selected sample of twelve (12) were identified on the facility's Census and Condition to have a urinary catheters. The facility failed to have an effective system in place to ensure appropriate treatment and services was provided to one (1) of twelve (12) sampled residents (Resident #34).
Resident #34 was readmitted to the facility on [DATE] with an indwelling urinary catheter in place. However, the facility failed to ensure the resident had a valid justification for use, a Physician's Order for the use of the catheter, interventions in place to address the care of the catheter, and appropriate care and services to prevent infections was provided.
The findings include:
Review of the facility's policy, titled Urinary Catheters, dated January 2019, revealed a Physician's Order for a catheter must be obtained with a medical justification.
Review of the facility's policy, titled Resident Assessment Care Plan Development, effective 11/28/2017 revealed a comprehensive care plan must be reviewed and revised based on changing goals, preferences and needs of the resident and in response to current interventions
Record review revealed the facility admitted Resident #34 on 02/25/2021 and discharged the resident to hospital on [DATE]. Further review revealed the facility readmitted him/her on 03/26/2021 with diagnoses of Pneumonia. However, there were no diagnoses to support the use of a catheter, per facility policy.
Review of the admission Minimum Data Set (MDS) assessment, dated 03/02/2021, revealed Resident #34 was rarely/never understood. Further review revealed Resident #34 required total care with the assistance of two (2) for toileting and the extensive assistance of one (1) for hygiene.
Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021 and Resident #34 had a catheter.
Review of Resident #34's, 03/26/2021 readmission Orders, March 2021 Treatment Administration Record (TAR), and Comprehensive Care Plan, dated 02/25/2021 - 03/19/2021, revealed there was no documented evidence the resident had an indwelling catheter and what care staff had to provide related to the catheter, per facility policy.
Observations on 03/29/2021 at 11:10 AM, 03/30/2021 at 9:20 AM, and 03/30/2021 at 3:30 PM, revealed Resident #34 was in bed and had an indwelling urinary catheter. Further observation revealed the urinary catheter bag was lying on the floor.
Interview with State Registered Nurse Aide (SRNA) #3,who was assigned to Resident #34, on 03/31/2021 at 1:27 PM, revealed the resident did not have a catheter when he/she went to hospital. SRNA stated she did not recall noticing the position of the bedside drainage bag or if it was on the floor.
Interview with Registered Nurse (RN) #1 on 03/31/2021 at 1:47 PM, revealed she had completed Resident #34's readmission assessment on 03/26/2021 and Resident #34 had a catheter. She revealed two (2) nurses completed admissions, one to complete the assessment and the other nurse to enter Physician's Orders. RN #1 stated she did not enter Resident #34's orders and was not sure why the catheter order was not placed on his/her care plan. She stated she was not aware Resident #34's catheter drainage bag was on the floor. The RN stated she would expect staff to ensure drainage bags were kept off the floor at all times.
Interview with the Director of Nursing (DON) on 03/31/2021 at 230 PM, revealed she expected Resident #34's care plan to include the catheter. The DON stated the care plan should be updated and revised when a resident returned from the hospital to reflect their true status. She stated she was responsible for entering Resident #34's admission orders and she failed to include the catheter order. The DON further stated catheter bags should be kept off the floor to prevent infection control issues.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an eff...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure oxygen therapy was provided according to the Physician's Order and care plan for one (1) of twelve (12) sampled residents (Resident #11).
Observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11's oxygen humidification container was empty and not dated.
The findings include:
Interview with the Director of Nursing (DON), on 03/30/2021 revealed the facility did not have a policy for oxygen humidification. However, the facility referenced the Lippincott Manual of Nursing Practices procedures in providing nursing care for residents with a tracheostomy.
Review of the Lippincott Manual of Nursing Practices 11th Edition, dated 2018, Nursing Care for Residents with Artificial Airways revealed to ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation as indicated. Assess breath sounds every two (2) hours, note evidence of ineffective secretion clearance (rhonchi, crackles), which suggest need for suctioning. Provide adequate humidity when the natural humidifying pathway of the oropharanyx is bypassed.
Record review revealed the facility admitted Resident #11 on 11/17/2015 with diagnoses which included Traumatic Subarachnoid Hemorrhage with Loss of Consciousness, Diabetes Type 2, Hypertension, Tracheostomy, Gastrostomy, and Chronic Obstructive Pulmonary Disease (COPD).
Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident was rarely/never understood.
Review of Resident #11's Physician Orders, dated 12/30/2019, revealed an order to administer oxygen per Tracheostomy Mask 35% humidified air to keep saturation greater than 92% every shift.
Review of Resident #11's Comprehensive Care Plan titled,Potential for Complications related to History of Pneumonia and Compromised Respiratory System related to Tracheostomy dated 11/30/2015, revealed a goal: resident will not exhibit signs of pneumonia or complications from respiratory compromise. Further review revealed an intervention for oxygen at 2 Liters per tracheostomy mask at 35% humidified oxygen air.
Observations on 03/30/2021 at 10:08 AM, 11:30 AM, and 1:20 PM revealed Resident #11 received oxygen at two (2) liters per tracheostomy mask collar. However, the oxygen humidification container was empty and humidified oxygen was not provided, as ordered.
Interview with Registered Nurse (RN) #1, on 03/31/2021 at 1:30 PM, revealed Resident #11 had humidified oxygen ordered. RN #1 stated the humidification container should not be empty and the licensed staff was responsible to ensure the resident's oxygen was humidified with an oxygen saturation greater than 92%. She stated without oxygen humidification, the resident was at risk for alteration in his/her respiratory status and decrease in his/her oxygen saturation.
Interview with the Director of Nursing (DON), on 04/01/2021 at 2:05 PM, revealed Resident #11's oxygen should always be humidified as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordanc...
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Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable.
Observation on 03/30/2021 revealed there were two (2) expired medications stored in the facility's medication refrigerator.
The findings include:
Review of the facility's policy, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, last revised 10/28/2019, revealed the facility should ensure medications and biologicals have an expired date on the label; have been retained no longer than recommended by the manufacturer or supplier's guidelines; or if contaminated or deteriorated were stored separate from other medications until destroyed or returned to the pharmacy.
Observation of the one (1) medication refrigerator on 03/31/2021 at 10:25 AM, revealed one (1) unopened, expired vial of PrevNar 13 (Pneumonia Vaccine) with an expiration date of September 2020; and an opened bottle of Magic Mouthwash with an expiration date of 03/05/2021.
Interview with Registered Nurse (RN#1) on 03/31/2021 at 10:40 AM revealed expired drugs should be removed from cart or refrigerator.
Interview with the Director of Nursing (DON) on 03/31/2021 at 10:50 AM revealed nurses and medication techs should remove expired medications from the medication cart/refrigerator. She stated the nightshift nurses should check the medication room refrigerator weekly on Sundays, but she had no tracking system to ensure this had been done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) and Prevention guidelines, it was determined the facility failed to ensure staff followed s...
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Based on observation, interview, facility policy review, and review of the Centers for Disease Control (CDC) and Prevention guidelines, it was determined the facility failed to ensure staff followed standard and transmission-based precautions to prevent the spread of infections; and, hand hygiene procedures when involved in direct resident contact.
Resident #34 was on contact and droplet precautions due to being readmitted to the facility from hospital, however, observation revealed staff provided incontinent care to the resident without wearing a gown and shield. In addition, licensed staff placed Resident #14's medication in his/her mouth with her bare hand.
The findings include:
Review of the facility's policy on 2019 Novel Coronavirus (COVID19), last revised March 2021 under Transmission and Control Strategies revealed a health care provider (HCP) should wear a face mask at all times while they are in the facility. Further review revealed all newly admitted residents should be placed in Standard, Contact, and Droplet precautions; and be closely monitored in a private room, if possible.
Review of the guidance from the Centers for Disease Control (CDC) Prevention revealed Standard Precautions were used for all patient care. They are based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Further review revealed Contact Precautions requires the use of Personal Protective Equipment (PPE), including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Wear PPE upon room entry and properly discard before exiting. Droplet Precautions requires the use of a mask upon entry into the patient room or patient space.
1. Record review revealed the facility readmitted Resident #34 on 03/26/2021 with diagnoses which included Acute Kidney Failure, Urinary Tract Infection (UTI), Dyspnea, Hypoxemia and Pneumonia.
Observation on 03/29/2021 at 10:15 AM revealed Resident #34 had an isolation cart outside the door of his/her room with no visible signage indicating precautions were in place, and there were no receptacles for trash or soiled linens in the room. Further observation on 03/29/2021 at 2:30 PM revealed there were signs for contact precautions visible at door, and trash and linen receptacles were inside the doorway.
Observation on 03/30/2021 at 9:30 AM revealed State Registered Nurse Aide (SRNA) #3 entered Resident #34's room and closed the door. Further observation revealed SRNA #3 was not wearing a gown or face shield. She proceeded to provide incontinent care and reposition the resident.
Interview with SRNA #3 outside Resident #34's room on 03/30/2021 at 9:40 AM, related to the signage on the wall, she stated, I should have used a gown. SRNA #3 stated Resident #34 was not there the last time she worked. She further revealed new admissions/readmissions were placed in isolation and staff should wear PPE in those rooms when providing direct care.
Interview with the Director of Nursing (DON), on 03/31/2021 at 2:28 PM revealed new admissions and re-admissions were placed on the observation unit. The DON stated residents should have isolation carts outside the door, signs that tell what type of precaution, and containers in the room for soiled linens and trash. She further revealed Personal Protective Equipment should be worn as long as a resident was on isolation. She stated the facility's policy mimicked the CDC guidelines
2. Record review revealed the facility admitted Resident #14 on 08/09/2017. Review of the Quarterly MDS assessment, dated 03/12/2021, revealed the facility assessed Resident #14's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable.
Observation on 03/30/2021 at 9:40 AM, revealed the Assistant Director of Nursing administered Resident #14 Percocet (pain medication) and Toprol XL (hypertension) by removing both pills from the medicine cup with her bare hand and placing them in the resident's mouth.
Interview with the Assistant Director of Nursing (DON) on 04/01/2021 at 2:05 PM, revealed Resident #14 asked her one (1) time to wear gloves when administering his/her medication although he/she did not say why. The DON stated she gave the resident's medication either bare handed or with a spoon.
Interview with the Director of Nursing (ADON) on 04/01/2021 at 2:40 PM, revealed she stated, I would expect staff to administer his/her medications with a spoon or gloved hand, not bare handed due to infection control.
Jan 2019
10 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to consult with the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to consult with the resident's physician when there was a significant change and a need to alter treatment significantly for one (1) of eighteen (18) sampled residents (Resident #35).
Resident #35 refused breakfast and lunch on 10/14/18, 10/15/18, 10/17/18 and 10/18/18 and only ate twenty-five (25) percent at supper; and his/her twenty-four (24) hour intake totaled 600 milliliters (mL) 10/14/18; 580 mL on 10/15/18; 600 mL on 10/16/18; and, 420 mL on 10/17/18 and 10/18/18; however, the facility failed to make the Physician/APRN aware of the resident's continued refusals of meals and decrease in fluid intake per facility policy. On 10/18/18 at 8:09 AM, Resident #35 experienced an episode of vomiting, he/she did not eat or drink at breakfast and would not take his/her morning medications. At 9:44 AM on 10/18/18, the resident experienced another episode of vomiting. Additionally, the resident's blood pressure was low, and a urinalysis (UA) was ordered on 10/16/18 but was not obtained prior to the resident's transport to the emergency room on [DATE]. However, there was no documented evidence of Physician/APRN notification of the resident's continued vomiting on 10/18/19, low blood pressure, or that staff were unable to obtain the 10/16/18 ordered UA, so treatment could be altered; per facility policy.
The findings included:
Review of facility policy titled Nonfiction of Change, dated July 2017, revealed the residents' physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death. The facility has adopted the current INTERACT Tools Change in Condition: When to report to the Physician, Physician Assistant (PA) or Advanced Practice Registered Nurse (APRN). The program is an evidence based program that may be utilized by the nurse when needed and does not supersede the clinical judgement of the licensed nurse.
Review of the INTERACT Version 4.0 Tool, updated June, 2018, revealed the Physician, PA or APRN should be notified immediately for any symptom, sign or apparent discomfort that is acute or sudden in onset; and a marked change in relation to usual symptoms and signs; or unrelieved by measures already prescribed. Non-immediate notification would be for new or worsening symptoms that do not meet the above criteria. Additional review revealed a listed sign or symptom to report included diminished appetite, with immediate notification for no oral intake two (2) consecutive meals; and non-immediate notification would be for significant decline in food and fluid intake in the resident with marginal hydration and nutritional status. A second listed symptom to report was vomiting with immediate notification if persistent or recurrent (two [2] or more within twelve [12] hour) vomiting, with or without abdominal pain, bleeding, distention/fever; and non-immediate notification would be for intermittent recurrent vomiting without immediate notification criteria met.
Record review revealed the facility admitted Resident #35 on 03/09/18 with diagnoses which included Cerebral Palsy, unspecified; and Other Seizures. Review of the Quarterly Minimum Data Set, dated [DATE], revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder.
Review of the Intake and Output Record for October, 2018, revealed Resident #35 had refused breakfast and lunch on 10/14/18, 10/15/18, 10/17/18 and 10/18/18 and only ate twenty-five (25) percent at supper on each of these days. On 10/16/18, the resident ate fifty (50) percent of breakfast and twenty-five (25) percent of lunch and dinner. Further review revealed the resident's fluid intake was poor. On 10/14/18, twenty-four (24) hour intake totaled 600 milliliters (mL); on 10/15/18: 580 mL; on 10/16/18: 600 mL; and, on 10/17/18 and 10/18/18: 420 mL for each day. The resident's usual average fluid intake for twenty-four (24) hours was 1000 ml per day.
Review of the Nurse's Progress Notes dated 10/17/18 at 4:14 PM revealed RN #1 was alerted Resident #35 wasn't acting right. Vital signs were, blood pressure 102/48 (base line 128/68), temperature 103.3 degrees Fahrenheit, heart rate 120 (base line 65), resident awake and alert, grinding teeth at times. At 4:37 PM, RN #1 telephoned the Physician's Assistant (PA) (who was back-up call for the Advanced Practice Registered Nurse {APRN}) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature; and a UA per in and out catheterization.
Further review of the Nurse's Progress Notes revealed an in and out catheterization (cath) was not attempted until 10/17/18 at 9:00 PM by RN #3 , almost five (5) hours after the order was received. The attempt was unsuccessful due to only a scant amount of urine obtained. Further review revealed there were two (2) other entries made in the Nurse's Progress Notes, on 10/17/18 at 6:26 PM and on 10/18/18 at 9:44 AM by RN #1 revealing the resident had incontinent episodes and staff were unable to obtain a urine specimen.
Review of the Nurse's Progress Notes, dated 10/18/18 at 8:09 AM, by Registered Nurse (RN) # 1 revealed Resident #35 did not eat any breakfast this morning or drink any fluid. He/she would not take morning medications with liquids or food. The RN documented she was informed by a nurse assistant that the resident has vomited greenish fluid earlier that morning. and the resident's temperature was 99.1 degrees Fahrenheit. Further review of the Nurse's Progress Notes, dated 10/18/18 at 9:44 AM, by RN #1, revealed Resident #35 vomited greenish bile fluid, approximately 100 milliliters (mL).
However, further clinical record review revealed there was no documented evidence the Physician, PA, or APRN was notified of the severe decrease in food or fluid intake; that the resident had two (2) episodes of vomiting on 10/18/18 at 8:09 AM and 9:44 AM; or that the staff had not obtained the UA ordered on 10/16/18.
Review of the Clinical Situation, Background, Assessment and Review (SBAR) Form for Resident #35, dated 10/18/18 at 4:30 PM, (almost seven (7) hours after the last documented emesis) completed by RN #1, revealed under 'Situation', 'The change in condition, symptoms, or signs I am calling about is/are', Resident has been vomiting green bile looking fluid X 3 over 2 days; just not acting right in general; not eating or drinking; was given an enema earlier today due to constipation and temp of as high as 103.3 however now is 99.2. The APRN was notified and orders received to notify the resident's family and let them decide if they want the resident sent to the emergency room (ER) for evaluation.
Review of the Nurse's Progress Notes dated 10/18/18 at 6:57 PM, by RN #1, revealed Resident #35 was transported, by family in a private vehicle, to the ER. Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with diagnoses of Urosepsis, Acute Renal Failure Syndrome, Abdominal Pain, and Fecal Impaction. Review of the Discharge Physician's Note revealed, on admission, the resident was also hemoconcentrated initially and with hydration, labs improved. After treatment, the resident was discharged from the hospital on [DATE].
Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she worked day shift on 10/17/18 and 10/18/18. RN #1 stated she had not been monitoring the Intake and Output sheets as she did not know where they were located and no one had told her she needed to do so.
Interview (Post Survey) with the APRN on 01/25/19 at 9:33 AM revealed she knew Resident #35 had been having some vomiting because she ordered Zofran on 10/16/18, however, she was not aware the resident had vomited two (2) times on 10/18/18 (8:09 AM and 9:44 AM). The APRN further stated she was aware the resident had not been eating well, however, she was not made aware of how poor the resident's food and fluid intake had been. Additionally, the APRN stated had she been made aware of the severity of the resident's illness (more vomiting, severity of lack of food and fluid intake, and low blood pressure) she would have initiated intravenous fluids or sent the resident to the ER sooner. The APRN further stated had she been contacted by the facility, it probably would have made a difference in the severity of the resident's illness and the outcome as well.
Interview (Post Survey) with the Director of Nursing (DON) on 01/24/19 at 8:52 AM revealed she felt like RN #1 completed a full assessment and she trusted the RN nursing judgment on when to notify or not notify the physician.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the residents r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice to prevent hospitalization for one (1) of eighteen (18) sampled residents (Resident #35).
Record review revealed Resident #35 had a decline in intake, episodes of vomiting from 10/14/18-10/16/18, and constipation. The Advanced Practice Nurse Practitioner (APRN) saw Resident #35 on 10/16/18 and ordered a stool softener for constipation and an antiemetic for nausea and vomiting. On 10/17/18 at 4:14 PM, the resident had symptoms of temperature of a 103.3 degrees Fahrenheit, heart rate 120 (base line 65), blood pressure 102/48 (base line 128/68) and was grinding his/her teeth at times. The Physician Assistant and APRN were contacted with orders received for labs and Tylenol. However ,further record review revealed there was no evidence a complete nursing assessment was completed per facility policy when the resident's change in condition was first identified on 10/16/18 and no evidence ongoing assessments were completed per policy due to the resident's continued refusal of meals, vomiting, and lack of bowel movements. The resident was hospitalized [DATE] to 10/22/18 with diagnoses of Sepsis, Acute Renal Failure Syndrome, Abdominal Pain and Fecal Impaction.
The findings included:
Review of the facility policy titled, Standard of Nursing Practice, last revised May 2018, revealed residents having any change in condition will have a complete nursing assessment performed and documented. A complete nursing assessment may include but is not limited to: vital signs with temperature, bowel sounds, lung sounds, oxygen saturation level, skin appearance, mental status, review of meal intakes over a twenty-four hour period, and review of bowel elimination record over the last three (3) days. On-going monitoring may be required to identify the resident's response to clinical interventions and if resolution is achieved. The resident's response will determine the frequency of the assessment. Reasons to assess the resident's condition more frequently include vomiting and/or diarrhea, new onset or increased complaints of pain, increased confusion. Monitoring a change in condition requires the nurse to include an entry in the progress notes. Communication to the physician will require completion of a SBAR (Situation, Background, Assessment, Recommendation) tool. Monitoring a resident's condition may have multiple entries in the resident's medical record and include progress notes, observations, and assessment tools.
Record review revealed the facility admitted Resident #35 on 03/09/18 with diagnoses which included Cerebral Palsy, unspecified; and Other Seizures. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/07/19, revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder.
Review of the Intake and Output Record for October, 2018, revealed Resident #35 started having a decreased intake of food and fluid on 10/14/18. On 10/14/18 and 10/15/18, the resident refused breakfast (prior average intake 40%), only had bites for lunch (prior average intake 50%), and only ate twenty-five (25) percent for supper (prior average intake 35%), each day. The resident drank 120 milliliters (mL) of fluid for each of the six (6) meals on these two (2) days (average prior fluid intake was 240 mL each meal). On 10/16/18, the resident ate fifty (50) percent of breakfast, and twenty-five (25) percent for lunch and supper; and, drank 120 ml fluid with each meal. Further review of the Intake and Output Record revealed the resident had one (1) small bowel movement on 10/14/18, none on 10/15/18 and one (1) small on 10/16/18.
Review of the Nursing Progress Notes dated 10/14/18-10/16/18 revealed there was no documented evidence the resident was assessed related to having any decline in his/her food and fluid intake, being constipated, or having nausea/vomiting peer facility policy. However, further review of the Nurse's Progress Notes revealed on 10/16/18 at 10:57 AM, the APRN assessed Resident #35 and ordered Colace (stool softener) two times a day for constipation and Zofran (antiemetic) 4 milligrams (mg) every four (4) hours as needed for nausea and vomiting. In addition, there was no evidence a SBAR was completed per facility policy to ensure the Nurse Practitioner had all the information of an assessment.
Review of the APRN's Progress Note dated 10/16/18 revealed nursing staff stated Resident #35 had only two (2) bowel movements in the last fourteen (14) days and was also having some issues with occasional vomiting. On physical exam, the APRN assessed the resident to have pale, warm and dry skin; bowel sounds present, abdomen was soft, round and nontender. Orders were given for Docusate Sodium ten (10) mL orally two (2) times per day and Zofran ODT four (4) mg every six (6) hours as needed.
Interview with Registered Nurse (RN) #4 on 01/23/19 at 6:33 PM, revealed she worked on 10/15/18, day shift. RN #4 did not recall why the Docusate was increased or why Zofran was ordered on 10/16/18. The RN stated she thought the resident had a history of constipation. Additionally, the RN could not recall if anyone had alerted her of the resident's decreased food and fluid intake.
Interview (Post Survey) with RN #2 on 01/24/19 at 9:03 AM, revealed she documented the APRN's visit on 10/16/18 at 10:57 AM. She stated she did not recall the reason for the increase in Docusate or the new order for Zofran. RN #2 further stated if the Docusate was increased, the resident was probably having problems with constipation. The RN did not recall if the resident was having nausea or vomiting at that time.
Further review of the Intake and Output Record for October, 2018 revealed on 10/17/18 the resident refused food and fluid for both breakfast and lunch and ate fifty percent of supper on 10/17/18. His/her fluid continued to decline with daily, twenty-four (24) hour, fluid intake total of 420 mL (normal fluid intake averaged one-thousand [1000] mL per day or more). In addition, the resident had one (1) medium bowel movement on 10/17/18.
Review of the Nursing Notes dated 10/17/18 at 3:21 AM revealed Resident #35 was tolerating the increase in Docusate without adverse effects and the resident did not request Zofran this shift. Further review revealed there was no documented evidence the resident was assessed again due to the resident refusal of both breakfast and lunch, and decline in fluid intake per facility policy. On 10/17/18 at 4:14 PM (approximately thirteen (13) hours after last assessment), the nurse was alerted the resident wasn't acting right and the resident's vital signs were blood pressure: 102/48 (base line 128/68), temperature: 103.3 degrees Fahrenheit, heart rate: 120 (base line 65), with resident awake and alert, and grinding teeth at times. Registered Nurse (RN) #1 attempted to contact the APRN two (2) times and text her as well with no response. RN #1 telephoned the Physician's Assistant (PA) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature and a UA per in and out catheterization. Tylenol was given at that time. Further review of the Nursing Notes revealed on 10/17/18 at 4:46 PM, the APRN returned telephone calls with orders for a CBC, CMP, and to check bowel sounds. Temperature at that time was 102.3 degrees Fahrenheit and bowel sounds were positive in all four (4) abdominal quadrants.
Review of the Nurse's Progress Notes revealed Resident #35 had emesis of greenish fluid, did not eat any breakfast or drink any fluid, and would not take his/her morning medications with food or fluid on 10/18/18 at 8:09 AM, and was given an enema at 9:12 AM with only small results. At 9:44 AM, the resident had emesis of green fluid again. Further review of the Intake and Output Record for October, 2018 revealed on 10/18/18 the resident refused food and fluid for lunch. Further review of the Nursing Notes revealed there was no documentation of the resident's condition or of ongoing assessments per facility policy from 10/18/18 at 9:44 AM to 2:37 PM. On 10/18/18 at 2:37 PM vital signs were: blood pressure 92/42, heart rate 109, respirations 22 and temperature 99.8 degrees Fahrenheit
Review of the facility's Observation Detail List Report (Situation, Background, Assessment, Recommendation, SBAR) completed on 10/18/18 at 5:10 PM by RN #1 revealed the ARPN was notified on 10/18/18 at 4:30 PM regarding Resident #35's condition. The report revealed the resident's symptoms started on 10/17/18 and it was reported to the ARPN the resident had vomited green bile three (3) times over two (2) days; the resident had not been acting right in general; the resident was not eating or drinking; and, was having fever and had been given Tylenol Suppositories two (2) times. Vital signs were blood pressure 94/68; heart rate 109; respirations 18; and temperature 99.3 degrees Fahrenheit. The SBAR indicated there were no gastrointestinal/abdomen or gastrourinary changes and revealed the resident was not having pain. The APRN gave an order to let the family decide if they wanted the resident sent to the ER. Review of the Nurse's Notes, revealed RN #1 spoke to Resident #35's brother on 10/18/18 at 5:52 PM and at 6:27 PM, Resident #35 was in stable condition and was transported to the hospital ER in a private vehicle by his/her brother.
Review of the Hospital Labs obtained at the hospital dated 10/18/18 revealed Resident #35's Blood Urea Nitrogen (BUN) was 38 (7-25); Creatinine 2.9 (0.6-1.2); and [NAME] Blood Cells (WBC) 33.9 (4.0-10.0); and review of the UA results revealed the urine was dark yellow, cloudy with moderate amount of blood, with 3+ Bacteria (normal is none). Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with diagnoses of Urosepsis, Acute Renal Failure Syndrome, Abdominal Pain, and Fecal Impaction. Review of the Discharge Physician's Note revealed, on admission, the resident was also hemoconcentrated initially and with hydration, labs improved. After treatment, the resident was discharged from the hospital on [DATE].
Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she worked day shift on 10/17/18 and 10/18/18. RN #1 stated Resident #35 was one to get constipated very easily, but she was not sure exactly the circumstances surrounding the increase in the Colace or the Zofran because she had only recently started working at the facility. RN #1 revealed she could not recall if the resident was having bowel movements at the time she administered the enema on 10/18/18 at 9:12 AM. Additionally, RN #1 stated she was not made aware of the resident being constipated or that the resident had decreased food and fluid intake. RN #1 stated she had not been monitoring the Intake and Output sheets as she did not know where they were located and no one had told her she needed to do so.
Interview (Post survey) with RN #3 on 01/24/18 at 8:07 AM, revealed she worked 10/16/18 through 10/18/18, night shift. RN #3 stated she does not recall why the Docusate was increased nor did she have to give Resident #35 Zofran for nausea or vomiting. RN #3 further stated she could not recall if anyone alerted her to the resident's decreased food and fluid intake, however, she monitored the Intake and Output sheets as often as she could. Additionally, RN #3 stated a small bowel movement was normal for the resident.
Interview with the Physician's Assistant (PA) on 1/11/19 at 2:08 PM revealed a reasonable time to obtain a straight cath UA would have been two (2) to four (4) hours.
Interview with the APRN on 01/11/19 at 2:41 PM revealed she would have expected the UA and the results to be called back her within three (3) to four (4) hours after the UA was ordered, and if the UA could not be obtained, she would have expected the facility to notify her. The APRN further stated if the UA had been obtained quicker with the results called to her, she would have ordered intravenous fluids and antibiotics and possibly avoided hospitalization. She revealed she always tries to treat the residents at the facility first before sending out.
Further interview (Post Survey) with the APRN on 01/25/19 at 9:33 AM revealed she knew Resident #35 had been having some vomiting because she ordered Zofran on 10/16/18, however, she was not aware the resident had vomited two (2) times on 10/18/18 (8:09 AM and 9:44 AM). The APRN further stated she was aware the resident had not been eating well, however, she was not made aware of how poor the resident's food and fluid intake had been. Additionally, the APRN stated had she been made aware of the severity of the resident's illness (vomiting, poor food and fluid intake, and low blood pressure) she would have initiated intravenous fluids or sent the resident to the ER sooner. The APRN further stated had she been contacted by the facility, it probably would have made a difference in the severity of the resident's illness and the outcome as well.
Interview with the Director of Nursing (DON) on 01/11/19 at 11:33 AM and on 01/24/19 (Post Survey) at 8:52 AM revealed Resident #35 was having, what staff thought was, regular bowel movements, but after talking with the family, discovered the resident normally had extra large bowel movements. The DON stated RN #1 completed a full assessment of Resident #35 on 10/17/18 at 4:14 PM when the change occurred. The DON stated that RN #1 documented an assessment in the progress notes and notified the physician but failed to complete a SBAR per policy. The DON stated the expectation would have been for RN #1 to complete a SBAR per policy. Additionally, the DON stated that a full assessment was completed on 10/18/18 at 4:30 PM and a SBAR was completed but not documented in the nurse's notes. She would have expected the assessment to be documented in the nurse's progress notes as well as on the SBAR.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Incontinence Care
(Tag F0690)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for two (2) of eighteen (18) sampled residents (Resident #44 and #35).
On 10/17/18 at 4:37 PM the Physician's Assistant was contacted regarding Resident #35's change in condition. An order for a Urinalysis (UA) via in and out catheterization was obtained. However, a urine specimen was not obtained for over twenty-four (24) hours. On 10/18/18, the resident was hospitalized with diagnoses which included Urosepsis and Acute Renal Failure Syndrome.
In addition, observation of incontinent care on 01/10/19 for Resident #44 revealed the Certified Nurse Aide (CNA) failed to wash the buttocks and rectal area and, also, did not change gloves or wash her hands when going from a dirty to clean area.
The findings include:
Review of the facility policy titled Standard of Nursing Practice, last revised May 2018, revealed the licensed nurse that receives an order and notes the order is responsible to carry the order through by placing in the achieve Matrix, on the [Medication Administration Record or Treatment Administration Record] MAR or TAR, and communicating order specifics to appropriate departments.
Review of the facility policy titled Laboratory Test, dated 06/2008, revealed the licensed nurse receiving the order for any laboratory test will document the order on the appropriate Physician's order form, transcribe the order onto the the tracking log, include the type of laboratory test to be done; the licensed nurse working night shift will review the log for all labs to be done; once the lab is completed, the licensed nurse on duty will enter the date the lab was obtained onto the tracking log. The licensed nurse receiving the lab results will complete the tracking form by entering the date the lab result was received and physician notification.
Record review revealed the facility admitted Resident #35 on 03/09/18 with diagnoses which included Cerebral Palsy, unspecified; and Other Seizures. Review of the Quarterly Minimum Data Set, dated [DATE], revealed the facility assessed Resident #35's cognition as severely impaired as the resident was unable to complete a Brief Interview of Mental Status (BIMS) exam indicating the resident was not interviewable. Further review of the Quarterly MDS revealed Resident #35 required total care with all activities of daily living (ADL's); and the resident was incontinent of bowel and bladder.
Review of the Nurse's Progress Notes dated 10/17/18 at 4:14 PM revealed Registered Nurse (RN) #1 was alerted Resident #35 wasn't acting right. Vital signs were, blood pressure 102/48 (base line 128/68), temperature 103.3 degrees Fahrenheit, heart rate 120 (base line 65), resident awake and alert, grinding teeth at times. At 4:46 PM, RN #1 telephoned the Physician's Assistant (PA) (who was back-up call for the Advanced Practice Registered Nurse {APRN}) and received orders for Tylenol 650 mg suppository to be given then and every six (6) hours as needed for elevated temperature; and a UA per in and out catheterization.
Review of the facility Lab Tracking Form dated 10/18/18 revealed an entry for Resident #35 with ordered tests of CBC and CMP, and was collected at 2:02 AM; however, there was no entry for the UA order or collection per facility policy.
Further review of the Nurse's Progress Notes revealed an in and out catheterization (cath) was not attempted until 10/17/18 at 9:00 PM by RN #3 , almost five (5) hours after the order was received. The attempt was unsuccessfully due to only a scant amount of urine obtained. Further review revealed there were two (2) other entries made in the Nurse's Progress Notes, on 10/17/18 at 6:26 PM and on 10/18/18 at 9:44 AM by RN #1 revealing the resident had incontinent episodes and staff were unable to obtain a urine specimen. However, there was no documented evidence staff attempted to conduct an in and out cath from 10/17/18 at 9:00 PM until 10/18/18 at 6:27 PM, after the order was obtained and prior to going to the hospital.
Review of the facility's Observation Detail List Report (Situation, Background, Assessment, Recommendation, SBAR) completed on 10/18/18 at 5:10 PM by RN #1 revealed the resident's symptoms started on 10/17/18 and it was reported to the ARPN the resident had vomited green bile three (3) times over two (2) days; the resident had not been acting right in general; the resident was not eating or drinking; and, was having fever and had been given Tylenol Suppositories two (2) times. Vital signs were blood pressure 94/68; heart rate 109; respirations 18; and temperature 99.3 degrees Fahrenheit. The APRN gave an order to let the family decide if they wanted the resident sent to the ER. Review of the Nurse's Notes, revealed RN #1 spoke to Resident #35's brother on 10/18/18 at 5:52 PM and at 6:27 PM, Resident #35 was in stable condition and was transported to the hospital ER in a private vehicle by his/her brother.
Review of the Hospital laboratory results dated [DATE] for a Complete Blood Count (CBC), Comprehensive Metabolic Profile (CMP) and a Urinalysis (UA) revealed the resident's BUN was 38 (7-25); Creatinine was 2.9 (0.6-1.2); WBC was 33.9 (4.0-10.0); and the UA results indicated the urine was dark yellow, cloudy with moderate amount of blood, with 3+ Bacteria (normal is None).
Review of the Hospital Discharge Summary revealed Resident #35 was admitted to the hospital on [DATE] at 9:00 PM with diagnoses of Urosepsis, Acute Renal Failure Syndrome, Abdominal Pain, and Fecal Impaction. After treatment, the resident was discharged from the hospital back to the nursing home on [DATE].
Interview (Post Survey) with RN #3 on 01/24/18 at 8:07 AM, revealed she worked 10/16/18 through 10/18/18, night shift. The RN stated she attempted to obtain a urine specimen on 10/17/18 at 9:00 PM, but was unsuccessful because the resident was always incontinent of urine and there was no urine in the bladder. The RN stated she did not make another attempt to obtain the specimen.
Interview with RN #1 on 01/11/18 at 2:22 PM and on 01/23/19 at 11:41 AM (Post Survey) revealed she was not aware of the lab process according to policy, and could only report what she had done when she received the order for the UA. RN #1 stated when she received orders, I can hope that I get to it and if not, I pass it to the next shift. RN #1 stated she received the order for the UA on 10/17/18 at 4:46 PM, but did not attempt to obtain the UA that day and reported the need to get the UA to the oncoming RN (RN #3). RN #1 further stated she did not know why she did not obtain the specimen at that time. RN #1 revealed on 10/18/18 she attempted to get the UA but was unsuccessful and when she removed the catheter, there was a mucous plug on end of of the catheter, so she completed the SBAR and called the APRN. She revealed she contacted Resident #35's brother per the APRN's directive. RN #1 stated she did not make another attempt to obtain a specimen before the resident went to the ER on [DATE] at 6:27 PM.
Interview with the Physician's Assistant (PA) on 1/11/19 at 2:08 PM revealed a reasonable time to obtain a straight cath UA would have been two (2) to four (4) hours.
Interview with the APRN on 01/11/19 at 2:41 PM revealed she would have expected the UA and the results to be called back her within three (3) to four (4) hours after the UA was ordered, and if the UA could not be obtained, she would have expected the facility to notify her. The APRN further stated if the UA had been obtained quicker with the results called to her, she would have ordered intravenous fluids and antibiotics and possibly avoided hospitalization. She stated she always tries to treat the residents at the facility first before sending out.
Interview with the Director of Nursing (DON) on 01/11/19 at 11:33 AM revealed she expected staff to obtain a straight cath UA in a timely manner and to keep the APRN or doctor informed if they were unable to obtain the specimen. The DON further stated the APRN should have been notified that they were unable to obtain the specimen.
2. Review of the facility Certified Nurse Aide (CNA) form titled Perineal Male Care Competency, not dated, revealed:
9. Expose perineum only.
10. Retract foreskin if resident uncircumcised, grasp penis, cleaning tip, using circular motion, using water and soapy washcloth. Starting at meatus of the urethra and working outward.
11. Rinse the area with another washcloth, using the same circular motion.
12. Return foreskin to its natural position immediately after rinsing.
13. Clean shaft of penis. Rinse and dry the area.
14. Assist the resident to flex knees and spread legs as much as possible. Clean the scrotum. Rinse well pat dry.
15. Assist resident to turn side to side, away from the CNA.
16. With a new soapy washcloth, clean rectal area.
17. Using washcloth clean from scrotum to rectal area in a single stroke, using clean area of washcloth with each stroke.
Record review revealed the facility admitted Resident #4 on 01/03/18 with diagnoses which included Unspecified Sequelea of Cerebral Infarction, Vascular Dementia with behavioral disturbance, Hemiplegia and Hemiparesis. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/15/18 revealed the facility assessed the resident was unable to complete a Brief Interview for Mental Status (BIMS) which indicated the resident's cognition was severely impaired and he/she was not interviewable. Further review of the MDS revealed the resident required extensive assist of two (2) for toileting and extensive assist of one (1) with hygiene.
Observation on 01/10/19 at 4:40 PM revealed CNA #2 performed peri care and she was accompanied by the Unit Manager and Registered Nurse (RN) #2. Further observation revealed each of the staff washed their hands, applied gloves, and CNA #2 cleaned the peri area per protocol and policy, but failed to wash the buttocks and rectal area. In addition, observation revealed when cleaning of the peri area was completed, CNA #2 did not wash her hands or change gloves but continued with applying the resident's brief, clothing, and assisted him/her out of bed without ever washing her hands or changing gloves.
Interview with CNA #2 on 01/11/19 at 5:41 PM revealed she realized after finishing, she failed to wash the rectal area, and also she knew to always wash her hands and change her gloves after completing the cleaning procedure but just forgot.
Interview with the Unit Manager on 01/11/19 at 5:45 PM revealed the CNA said she should have cleaned the buttocks area, washed hands and changed gloves when going from dirty to clean.
Interview with the DON, on 01/11/19 at 5:50 PM revealed she expected the nursing staff to follow policy and CNA competency check off list while providing incontinent care, and to wash the buttocks as well as the peri area. She stated staff should wash hands and change gloves after providing incontinent care, and before applying a clean brief, clothing, and bed linen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of eighteen sampled ...
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Based on observation, interview, record review and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of eighteen sampled (18) residents (Resident #22).
Observations on 01/09/19 revealed staff failed to implement Resident #22's care plan related to turning and repositioning every two hours and floating heels.
The findings include:
Review of facility policy titled, Resident Assessment Care Plan Development, dated 11/28/17 revealed the intent is to ensure the timeliness of each person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident's representative, if applicable, is involved in developing the care plan and making decision about his/her care.
Record review revealed the facility admitted Resident #22 on 10/09/16 with diagnoses which included Diabetes Mellitus, Altered Mental Status, a history of pressure wounds, and Rheumatoid Arthritis. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 11/09/18 revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable.
Review of Resident #22's Comprehensive Care Plan for potential for skin breakdown related to decreased mobility, Diabetes, Vascular Disease, and incontinence, dated 08/16/16 revealed interventions, dated 07/20/18, to float heels while in bed and encourage to turn and reposition upon rounds while in bed. However, observations on 01/09/19 at 8:30 AM, 10:09 AM, 11:33 AM, 12:07 PM, 3:00 PM, 3:35 PM, and 3:45 PM, revealed Resident #22 remained on his/her left side with no evidence of the resident being turned and repositioned; and heels being floated per care plan during this time. In addition, observation on 01/10/19 at 8:24 AM revealed Resident #22 being assisted with breakfast with heels noted to be flat on the bed.
Interview with Certified Nurse Aide (CNA) #6 on 01/09/19 at 4:30 PM revealed Resident #22 should be turned every two (2) hours from side to side. She stated she did turn the resident at 4:15 PM but she did not check to see if his/her heels were off the bed. She revealed she was not sure the last time the resident was turned and repositioned.
Interview with CNA #2 on 01/10/19 revealed Resident #22 should be turned from side to side every two (2) hours and feet floated. She stated the resident should only be on his/her back at meal time because of a wound to his/her bottom, but she had failed to ensure his/her heels were floating.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:38 PM revealed she expected staff to follow the care plan for each resident. She stated nursing staff should turn Resident #22 every two (2) hours due to a pressure wound to the coccyx, and float heels at all times while in bed as indicated on his/her care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and facility policy review, it was determined the facility failed to review and revise a Comprehensive Care Plan for one (1) of eighteen (18) sampled res...
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Based on observation, interview, record review and facility policy review, it was determined the facility failed to review and revise a Comprehensive Care Plan for one (1) of eighteen (18) sampled residents (Resident #43).
Observation of a skin assessment for Resident #43 on 01/09/19 revealed the resident was on pressure reducing mattress; however, review of the Comprehensive Care Plan revealed Resident #43 had a Low Air Loss(LAL) mattress in place. The care plan had not been revised when the Low Air Loss Mattress was discontinued.
The findings include:
Review of facility policy titled,Resident Assessment Care Plan Development, dated 11/28/17 revealed the intent is to ensure the timeliness of each person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident's representative, if applicable, is involved in developing the care plan and making decision about his/her care.
Record review revealed the facility admitted Resident #43 on 11/17/15 with diagnoses which included Traumatic Subarachnoid Hemorrhage with loss of consciousness of unspecified duration, and sequela related to trauma from a Motor Vehicle Accident (MVA). Review of the Annual Minimum Data Set (MDS) assessment, dated 10/30/18 revealed the facility assessed Resident #43's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was not interviewable.
Observation of Resident #43's skin assessment and treatment on 01/09/19 at 9:00 AM by Licensed Practical Nurse (LPN) #2, revealed Resident #43 was on a pressure reducing mattress, there was a healed pressure ulcer on right buttock, and a Stage II pressure ulcer to the left hip. However, review of the Comprehensive Care Plan for at risk for pain related to Diabetes, immobility, history from trauma from Motor Vehicle Accident (MVA), and resident has a history of pressure injury and remains at risk for reacquiring due to immobility and incontinence, dated 11/30/15, revealed the care plan had not been revised to include the pressure ulcer on the right hip was healed, a Stage II pressure ulcer had developed on the left hip, and the LAL mattress was discontinued.
Interview with LPN #2 on 01/09/19 at 10:00 AM revealed she was not aware of the new open area to the left buttock or the right buttock pressure ulcer had healed. She stated she was aware the LAL mattress was no longer in place.
Interview with the Minimum Data Set (MDS) Nurse, who is responsible for updating the care plan, on 01/11/19 at 3:24 PM, revealed she, at the time of the changes, was not reviewing Physician Orders every day and realized things were getting missed. She stated now all orders were reviewed at the morning meeting and care plans were updated daily.
Interview with the Director of Nursing (DON) on 01/11/19 at 3:35 PM revealed she expected all orders to be reviewed daily and care plans updated on a daily basis.
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
Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure two (2) of eighteen (18) sampled residents received necessary treatment and s...
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Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure two (2) of eighteen (18) sampled residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing (Residents #22 and #43).
Resident #22 was to be turned and repositioned from side to side and heels floated; however, observations on 01/09/19 throughout the day revealed staff failed to turn and reposition the resident and float heels per care plan as the resident remained on his/her left side and heels were not floated from 8:30 AM through 3:45 PM. Further observation on 01/09/19 revealed staff failed to change gloves and wash hands after removing a soiled dressing from Resident #22's pressure ulcer and before applying a new dressing per facility policy.
In addition, the facility failed to ensure Resident #43 was assessed when a new Pressure Ulcer was identified to his/her left hip, and failed to obtain treatment orders for the pressure ulcer per facility policy. Staff also continued to initial a Low Air Loss (LAL) mattress was in place after it was discontinued.
The findings include:
1. Record review revealed the facility admitted Resident #22 on 10/09/16 with diagnoses which included Diabetes Mellitus, Altered Mental Status, a history of pressure wounds, and Rheumatoid Arthritis.
Review of a Quarterly Minimum Data Set (MDS) assessment, dated 11/09/18 revealed the facility assessed Resident #22's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required total assist of two (2) with bed mobility.
Review of Resident #22's Comprehensive Care Plan for potential for skin breakdown related to decreased mobility, Diabetes, Vascular Disease, and incontinence, dated 08/16/16 revealed interventions, dated 07/20/18, to float heels while in bed and encourage to turn and reposition upon rounds while in bed.
Review of a Weekly Pressure Ulcer Progress Report for Resident #22 revealed a pressure wound was identified to the coccyx on 09/11/18 with treatment in place to clean the wound with Normal Saline (NS), apply collagen and cover with a dry dressing. Further review of the report revealed the wound was still open on 01/02/19.
Observations on 01/09/19 at 8:30 AM, 10:09 AM, 11:33 AM, 12:07 PM, 3:00 PM, 3:35 PM, and 3:45 PM revealed Resident #22 was lying on his/her left side with no evidence the resident was turned every two (2) hours; and, his/her heels were not floated throughout the observations. In addition, observation on 01/10/19 at 8:24 AM revealed Resident #22 being assisted with breakfast with heels noted to be flat on the bed.
Interview with Certified Nurse Aide (CNA) #6 on 01/09/19 at 4:30 PM revealed Resident #22 should be turned every two (2) hours from side to side. She stated she turned the resident at 4:15 PM but she did not check to see if his/her heels were off the bed, and was not sure the last time the resident was turned and repositioned.
Interview with CNA #2 on 01/10/19, revealed Resident #22 should be turned from side to side every two (2) hours and feet floated. She stated the resident should only be on his/her back at meal time because of a wound to his/her bottom, but she had failed to ensure his/her heels were floating.
In addition, observation of wound care for Resident #22 on 01/10/19 at 3:21 PM revealed Licensed Practical Nurse (LPN) #2 washed her hands, applied gloves, then removed the old soiled dressing. However, LPN #2 failed to wash her hands and change gloves before applying the clean dressing to the coccyx wound.
Interview with LPN #2 on 01/11/19 at 02:57 PM revealed she really did not remember if she washed her hands or changed gloves after removing the soiled dressing or not, but knew she should have.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:38 PM revealed she expected staff to turn Resident #22 every two (2) hours due to a pressure wound to the coccyx, and to float heels per care plan. She stated she also expected staff when doing a dressing change, to wash hands and change gloves after removing dirty dressing and before applying clean dressing.
2. Record review revealed the facility admitted Resident #43 on 11/17/15 with diagnoses which included Traumatic Subarachnoid Hemorrhage with loss of consciousness of unspecified duration, and sequela related to trauma from a Motor Vehicle Accident (MVA).
Review of the Annual MDS assessment, dated 10/30/18 revealed the facility assessed Resident #43's cognition as severely impaired with a BIMS score of 99 which indicated the resident was not interviewable. Further review of the MDS revealed the resident was totally dependent on two (2) staff for bed mobility.
Review of Resident #43's Comprehensive Care Plan for at risk for pain related to Diabetes, immobility, history from trauma from Motor Vehicle Accident (MVA), and resident has a history of pressure injury and remains at risk for reacquiring due to immobility and incontinence, dated 11/30/15, revealed an intervention for a LAL mattress for wound healing. Further review of care plan revealed an open area to right buttock, dated 12/11/18.
Review of Resident #43's Treatments Flowsheet dated January 2019 revealed an order for LAL mattress for wound healing, start date 06/29/17. Further review revealed licensed staff were initialing the LAL mattress was in place daily.
Observation of Resident #43's skin assessment and treatment by LPN #2 with assistance from CNA #1, and Treatment Nurse/Registered Nurse (RN) #2, on 01/09/19 at 9:00 AM revealed Resident #43 was not on a LAL mattress per care plan but was on a pressure relief mattress. Further observation revealed the pressure ulcer on the right buttock had healed but there was a dirty patch dressing on the left hip that was not dated or initialed. The new area under the dressing was described by staff to be a Stage II pressure ulcer which measured 1.5 centimeters (cm) x 1.5 cm X 0.1 cm, with a beefy red center; and peri-wound macerated related to frequent incontinence. At the time of the assessment, both nurses were not aware of the healed right buttock wound or the new wound to the left buttock.
Further review of the January 2019 Physician Orders, Treatment Flowsheet and Comprehensive Care Plan revealed no documented evidence an order had been obtained for the pressure ulcer on the left buttock, even though there was a dressing in place; and no evidence the pressure ulcer to the right buttock was healed.
Interview with LPN #2 on 01/09/19 at 10:00 AM revealed she was not aware of the new open area to the left buttock. She stated she was aware the LAL mattress was no longer in place but continued to sign the treatment record and realized she should have initialed and circled her initials indicating not in use.
Interview with the Director of Nursing (DON) on 01/11/19 at 3:35 PM revealed she was trying to track down the nurse who applied a treatment to the left buttock without order or documentation of the wound. She stated she expected all orders to be reviewed daily and care plans updated on a daily basis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of the facility policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently ac...
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Based on observation, interview, and review of the facility policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. Observation on 01/09/19 of two (2) of four (4) medication carts revealed a medication not dated when opened on the Six Hundred (600) medication cart.
The findings include:
Review of the facility policy titled, Storage and Expiration of Medications, Biological's, Syringes, and Needles, last revised 10/31/16, revealed once any medication or biological is opened, the facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened.
Observation of the 600 hall medication cart, on 01/09/19 at 11:05 AM, revealed one (1) vial of Humalog insulin was opened, however, it was not dated per facility policy.
Interview with Licensed Practical Nurse (LPN) #1 on 01/09/19 at 11:06 AM, revealed the insulin vials should be dated when opened because most insulin's expire after twenty-eight (28) days once opened. She stated it must have been overlooked.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:26 PM and post telephone interview on 01/25/19 at 10:25 AM, revealed she expected the nurses to date insulin vials when opened. She stated during orientation and training the nurses are informed of the facility policy on dating medications when opened.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, san...
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Based on observation, interview, and facility policy review, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of eighteen sampled residents (Resident #22) related to improper hand hygiene during wound care.
Observations of a medication pass on 01/10/19, revealed staff touched a medication with their bare hand.
The findings include:
Review of the facility's policy titled, General Dose Preparation and Medication Administration, last revised 01/01/13, revealed facility staff should comply with facility policy, applicable law and the State Operations Manual, when administering medications. The policy further revealed, facility staff should not touch the medication when opening a bottle or unit dose package.
Observation of a medication administration pass on 01/10/19 revealed Registered Nurse (RN) #1, removed a medication from a blister pack with her bare hand and placed the medication in a cup for administration.
Interview with RN #1 on 01/10/19 at 11:30 AM, revealed she should not have touched the medication with her bare hands because of contamination. She stated she was nervous and should have caught herself.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:26 PM, revealed she would expect nurses to pop medications into the medication cups and not use their bare hands. She stated nurses should waste medications that have touched unclean surfaces and not administer them.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure there was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure there was sufficient nursing staff to provide transfers timely and provide basic care needs and showers for three (3) of eighteen (18) sampled residents (Residents #4, #10, and #202).
The findings include:
Review of the facility policy titled Nursing Coverage, not dated, revealed it is the policy of this facility to ensure that the residents receive the appropriate and needed care and services at all times and that all nursing personnel are available to meet this need. The licensed practical nurses (LPN's) and registered nurses (RN's) are expected to provide direct care to our residents as the resident's need presents or at least four (4) hours per shift. This direct care includes but is not limited to transporting the resident to the bathroom, helping the resident meet their toileting needs, cleaning the resident; and providing activities of daily living (ADL) care to the resident. The facility nursing management team including the assistant director of nursing (ADON), unit manager, and minimum data set (MDS) nurses are expected to provide and help with direct care as needed. The facility nursing managers that are RN's are expected and required to provide supervisory roles and would be included in the required RN staffing hours. At least six (6) hours of their shift must be dedicated to assessment of the resident, developing critical decisions in regards to the resident care, supervising the LPN's and the nurse aides, and ensuring that the residents' plan of care is appropriate to meet the residents' needs as well as being carried out by the nursing staff.
1. Record review revealed the facility admitted Resident #4 on 08/09/17 with diagnoses which included Amyotrophic lateral sclerosis, abnormal posture, other ideopathic scoliosis, muscular dystrophy, and quadriplegia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/10/18, revealed the facility assessed Resident #4's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident's was interviewable. Additionally, the Quarterly MDS revealed the resident required total care with one (1) to two (2) staff assists with all ADL's, specifically transfers with assistance of two (2) staff using a mechanical lift; and resident had functional limitations in range of motion to bilateral upper and lower extremities.
Interview with Resident #4 on 01/09/19 at 8:30 AM, revealed the facility had been having staffing problems for about three (3) months. The resident stated on one occasion, he/she asked to get up at approximately 7:30 AM but was not able to get up until approximately 12:30 PM. Additionally, the resident stated there are times when he/she would like to get up to go to the dining room for lunch but is not assisted up. The resident stated he/she has been told by staff because it takes two (2) staff to get him up, his care impedes on the care of other residents and he/she will be assisted up when all the other work is done.
Interview with Nurse Assistant (NA) #4 on 01/10/19 at 4:46 PM revealed she was working on the day Resident #4 requested to get up at 7:30 AM. NA #4 stated there were two (2) Certified Nurse Assistants (CNA's) and herself working that day. She stated she was assigned to Resident #4's side, another CNA was assigned to the other side, and a CNA floated between both sides (there were approximately twenty-five to thirty {25 to 30} residents on each side). NA #4 revealed Resident #4 required a mechanical lift and assistance of two (2) staff for transfers. The NA stated she asked the other CNA's to assist her but they were busy and could not help her with the transfer until approximately 12:30 PM.
2. Record review revealed the facility admitted Resident #202 on 12/21/18 with diagnoses which included other specified fracture of unspecified pubic, sequela; Unsteadiness on feet; other abnormalities of gait and mobility; and fracture of superior rim of unspecified pubis, sequela. Review of the admission MDS assessment, dated 01/01/19, revealed the facility assessed Resident #202's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Additionally, the admission MDS assessment revealed the resident required extensive assistance of one (1) staff for bathing, and required human assistance to stabilize when turning to face the other direction.
Review of the Intake & Output record for January, 2019, revealed between 01/01/19 and 01/11/19, Resident #202 received showers on 01/01/19, 01/08/19, and 01/15/19, three (3) showers in eleven (11) days.
Interview with Resident #202 on 01/08/19 at 3:02 PM revealed this place is understaffed and he/she cannot get a shower according to her preference. He/she stated sometimes when the staff come to assist him/her with a shower, he/she was in too much pain to get it at that time. He/she revealed the staff would never come back to assist him/her later; and if he/she asked for assistance later was told by the staff they did not have time to provide assistance.
Interview with Certified Nurse Aide (CNA) #1 on 01/11/19 at 9:22 AM revealed if a resident declines a shower, the nurse is notified. The CNA stated it is documented that the shower was declined at that time and passed on to the next shift; and sometimes they go back later and reoffer the shower but there is not always time to do that.
3. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses to include Heart Failure, Diabetes, and Hemiplegia. Review of the Quarterly MDS dated [DATE] assessed the resident to have a BIMS score of eight (8) and determined to be interviewable. The MDS further revealed he/she required total assist of one (1) with hygiene and bathing.
Interview with Resident #10's daughter on 01/10/19 at 2:45 PM revealed she had to complain constantly about her family member not getting a shower. She stated on Monday, her family member had laid two (2) hours in a dirty brief without getting changed. She revealed she felt a lot of resident's weren't getting their showers. She stated the facility frequently smelled of urine and feces, and she noted a resident urinated in the floor at one time and told the nurse who stated she knew, and was waiting on someone to clean it up. She further revealed her family member had told her about the showers and incontinent episode, and knew what he/she was talking about.
Review of Resident #10's December 2018-January 2019 shower sheet revealed he/she only received six (6) showers/bedbaths between 12/26/18 and 01/10/19.
Interview with CNA #6 and CNA #2 on 01/10/19 at 4:15 PM revealed there was not enough staff to get the job done. They stated on an average there is two (2) CNA's on each side with one nurse, and probable about one (1) day a week, only one (1) CNA per side and one (1) Nurse. The interview further revealed some of the nurses help out, others do not. They stated they are only able to get the essential care provided and have to leave the rest. They also revealed the facility had now changed the shower schedules to two (2) showers a week verses three (3) a week due to not enough staff. They stated if residents request a bed bath on the other days, they will receive one, if not they do not get one unless heavily wet or soiled.
Interview with NA #4 on 01/08/19 at 4:35 PM, during afternoon meal pass observation revealed there is not enough staff in the facility. She stated she was passing trays by herself because the other scheduled CNA was in the Dinning Room. She further revealed she is expected to pass all three (3) halls 400, 500 and 600, and feed the dependent residents in one and one-half (1.5) hours by herself. She also stated last Friday 01/04/19 she was the only one to work the shift. She stated she had worked six (6), twelve (12) hour shifts in a row because of lack of staff.
Interview with CNA #5 on 01/09/19 at 10:45 AM revealed there are usually three (3) CNA's scheduled on each side (unit). CNA #5 stated if someone called in, administration would try to call in staff, but if no one would come in, they work short.
Interview with CNA #7 on 01/09/19 at 10:35 AM revealed staffing is short once in a while. CNA #7 stated she usually works up front but was working the floor on this day because the facility was short staffed. CNA #7 further stated she does not get pulled to the floor very often.
Interview with Registered Nurse (RN ) #4 on 01/09/19 at 10:30 AM revealed CNA's are short today, there are two (2) CNA's for side one (1). RN #4 stated they try to have three (3) CNA's per side each day. She further stated adequate staffing is hit and miss.
Interview with RN #3 on 01/10/19 at 2:18 PM revealed staffing is not well, CNA's call in all the time. RN #3 stated there are usually two (2) CNA's scheduled for each side (unit) but at least one (1) CNA calls in every day. RN #3 revealed when this happens, there is one (1) CNA on each side and one (1) floats between the two (2) sides. RN #3 further stated this is not enough staff to meet the care needs of the residents; the most important care gets done such as rounds, incontinent care, turns, and fall prevention but baths do not always get done. She stated she tried to get the medications passed in a timely manner, but at times, they are late because she helps the CNA's. RN #3 stated the facility is short staffed about fifty (50) percent of the time, mainly due to call ins. Additionally, RN #3 stated she has talked to the Director of Nursing (DON) about the problem, but it continues and staff just try to provide care the best they can.
Interview (Post Survey ) with RN #2 on 02/23/10 at 2:37 PM, revealed she is the unit manager for both sides, the entire facility, and the Director of Nursing (DON) completes the daily schedule, however, the DON was not working on the day of the interview. RN #2 stated there is no one with the title staffing coordinator. RN #2 stated the usual staffing for day shift was five (5) certified nurse assistants (CNA's), two (2) nurses, and she and the DON are there during the week. Staffing for night shift was four (4) CNA's and two (2) nurses. RN #2 further stated sometimes it was difficult to replace a person should they call in and she was not aware of any shift working short staffed.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:30 PM revealed she is not aware of complaints or concerns related to staffing. The DON stated staff call in and we get the shift covered. She stated she feels there is adequate staffing based on the numbers. The DON further stated she expected all staff to come to her or other licensed staff if they cannot get assistance with a resident in a timely manner. Additionally, the DON stated she rarely had to come in on off shifts or weekends to cover a shift. The DON stated there should be two (2) CNA's on each side and one (1) CNA to float sides and one (1) licensed nurse on each side.
Interview with the Administrator on 01/11/19 at 4:23 PM, when told about staffing concerns stated well good, now maybe cooperate will let us get some more staff in here.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, pr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.
Observation of the kitchen, on 01/08/19, revealed food stored in the refrigerator and freezer were opened and not dated. Further observation of a dinner meal on 01/08/19, revealed staff did not remove soiled gloves and wash their hands after removing and replacing their eye glasses.
Review of the facility Census and Condition, daed 01/09/19, revealed fiftey-four (54) of fifty-five (55) residents received their meals from the kitchen.
The findings include:
1. Review of the facility policy titled, Storage Procedures, last revised November 2017, revealed food should be covered and dated. Further review revealed all foods in the freezer are to be labeled and dated with use-by dates clearly marked.
Observation of the freezer on 01/08/19 at 3:02 PM, revealed a box of donuts open and not dated. Further observation of the refrigerator revealed a cup of cottage cheese, not dated.
2. Review of facility policy titled Hand Washing from the Dietary Manual, Chapter 7.2-1 of 2, last revised July 2016 revealed:
Employees will use proper hand washing techniques to prevent the spread of infection.
1. Hand washing:
a. When entering the Dietary Department, after using the restroom, before starting to word.
b. Prior to handling raw meat, poultry, or seafood.
c. Touching hair, face, glasses, or body.
d. After taking out garbage, putting away stock, cleaning.
e. Sneezing, coughing or using a tissue.
f. Handling chemicals that might effect food safety, taking out garbage.
g. Eating, drinking, smoking, or chewing gum or tobacco.
h. Handling money
i. Cleaning tables or busing dirty dishes. Touching clothing or aprons.
j. Leaving and returning to the kitchen/prep area.
k. Touching anything else that may contaminate hands, such as dirty equipment, work surface, wash clothes.
Hand Antiseptic:
If passing trays to residents, hand antiseptic can be applied a minimum after every thirty resident. If direct contact with resident or any resident belonging's, then staff should wash hands.
Observation of a dinner meal, on 01/08/19 at 4:11 PM, revealed Dietary Aide #1 removed her glasses twice and placed them onto her face. Further observation revealed she did not wash her hands after removing and replacing her glasses and prior to touching the clean dishes.
Interview with Dietary Aide #1 on 01/09/19 at 3:34 PM, revealed she should have removed her gloves and washed her hands after removing her glasses and putting them on. She stated the glasses are considered unclean items and she should have realized it.
Interview with the Dietary Manager on 01/09/19 at 3:25 PM, revealed she expected all food items stored in the refrigerator and freezer to be dated when prepared or opened. She further stated she would have expected the cook to change her gloves after touching unclean items during meal pass.
3. Observation of a meal hall pass on 01/08/19 at 4:35 PM by Certified Nurse Aide (CNA) #4 revealed she passed, and set up trays on halls 400, 500, and 600 for the residents that did not go to the dining room to eat. The observation further revealed CNA #4 opened the food cart doors, then opened food in packaging without gloves (cornbread muffins and saltine crackers), removing them from the plastic wrapper with her bare hands. The observation also revealed the CNA picked at areas on her face, and pulled up her pants with her hands but continued to pass and touch food without washing her hands or using gloves to touch the food. Further observation revealed she was noted to remove a used wet wash cloth from the bed side tray in resident room [ROOM NUMBER], but did not wash hands prior to going to the next room. CNA #4 also picked up a plastic cup that had fallen off the resident's bedside tray; however, did not wash her hands or use hand gel and continued to pass meal trays.
Interview with CNA #4, on 01/08/19 at 6:00 PM revealed she was the only one to pass the trays on three halls, and was expected to pass the trays and feed the residents in one and one-half hours, so she forgot to wash her hands and wear gloves because she was in a hurry. She stated she realized she was to wash her hands or use hand gel, and touch food only with gloved hands, but just was not thinking.
Interview with the Director of Nursing (DON) on 01/11/19 at 5:52 PM, revealed she expected the CNA to wash or sanitize hands between each resident while passing trays and to never touch the food with bare hands. She stated the CNA was expected to use gloves.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Kentucky facilities.
- • 37% turnover. Below Kentucky's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 3 harm violation(s). Review inspection reports carefully.
- • 23 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Salem Springlake Health & Rehabilitation Center's CMS Rating?
CMS assigns Salem Springlake Health & Rehabilitation Center an overall rating of 3 out of 5 stars, which is considered average nationally. Within Kentucky, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Salem Springlake Health & Rehabilitation Center Staffed?
CMS rates Salem Springlake Health & Rehabilitation Center's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 37%, compared to the Kentucky average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Salem Springlake Health & Rehabilitation Center?
State health inspectors documented 23 deficiencies at Salem Springlake Health & Rehabilitation Center during 2019 to 2023. These included: 3 that caused actual resident harm and 20 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Salem Springlake Health & Rehabilitation Center?
Salem Springlake Health & 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 ATRIUM CENTERS, a chain that manages multiple nursing homes. With 75 certified beds and approximately 52 residents (about 69% occupancy), it is a smaller facility located in Salem, Kentucky.
How Does Salem Springlake Health & Rehabilitation Center Compare to Other Kentucky Nursing Homes?
Compared to the 100 nursing homes in Kentucky, Salem Springlake Health & Rehabilitation Center's overall rating (3 stars) is above the state average of 2.8, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Salem Springlake Health & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Salem Springlake Health & Rehabilitation Center Safe?
Based on CMS inspection data, Salem Springlake Health & 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 3-star overall rating and ranks #1 of 100 nursing homes in Kentucky. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Salem Springlake Health & Rehabilitation Center Stick Around?
Salem Springlake Health & Rehabilitation Center has a staff turnover rate of 37%, which is about average for Kentucky nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Salem Springlake Health & Rehabilitation Center Ever Fined?
Salem Springlake Health & Rehabilitation Center has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Salem Springlake Health & Rehabilitation Center on Any Federal Watch List?
Salem Springlake Health & 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.