MATTHEWS MEMORIAL HEALTH CARE CENTER
For profit - Limited Liability company
124 Beds
THE BEEBE FAMILY
Data: November 2025
Trust Grade
35/100
#142 of 264 in LA
Photo by Matthews Memorial Health Care
Photo by Matthews Memorial Health Care
Photo by Matthews Memorial Health Care
1 / 5 photos
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Matthews Memorial Health Care Center has received a Trust Grade of F, indicating poor quality with significant concerns regarding care. It ranks #142 of 264 facilities in Louisiana, placing it in the bottom half, and #4 of 9 in Rapides County, meaning there are only three local options that are better. While the facility is showing signs of improvement, reducing issues from 16 in 2023 to 11 in 2024, its staffing is a concern with a 61% turnover rate, higher than the state average. Specific incidents have raised alarms, such as a resident who fell from a shower chair due to inadequate safety measures, requiring emergency treatment and surgery, and failures to manage residents' pain and diabetes-related conditions. Although the nursing home has average RN coverage, the overall situation reflects serious weaknesses alongside minimal strengths.
- Trust Score
- F
- In Louisiana
- #142/264
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $36,140 in fines. Higher than 87% of Louisiana facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 15 minutes of Registered Nurse (RN) attention daily — below average for Louisiana. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 47%
Needs review
16 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 16 issues
2024: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Near Louisiana average (2.4)
Below average - review inspection findings carefully
Staff Turnover: 61%
15pts above Louisiana avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $36,140
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: THE BEEBE FAMILY
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Louisiana average of 48%
The Ugly 35 deficiencies on record
1 actual harm
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately inform the resident, consult the resident's physician; a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to immediately inform the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) resident records reviewed for falls.
Findings:
Review of a facility policy with a revision date of 09/2017 and titled Change in Resident Medical Status revealed the following in part . A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include: a fall and/or injury . A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is - 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention.
Review of Resident #2's Electronic Health Record revealed an admit date of 11/08/2024. Resident #2 had the following diagnoses including: Unspecified Severe Protein-Calorie Malnutrition, Functional Quadriplegia; and Pain, Unspecified.
Review of Resident #2's 11/2024 Physician Orders revealed the following including:
11/08/2024 - DNR
11/08/2024 - Admit to [NAME] Memorial for long term care
11/15/2024 - Lorazepam 2 mg/ml give 0.25 ml SL q 4 hours prn agitation r/t pain
11/15/2024 - MS 20 mg/ml give 0.25 ml po q 4 hours prn pain or SOB
11/15/2024 - Admit to Guardian Hospice with terminal diagnosis Severe Protein Caloric Malnutrition.
Review of Resident #2's 11/2024 Nurse Notes revealed the following including:
11/10/2024 at 2:15 a.m. - Upon making rounds, noticed resident not in his bed, found on floor lying on his back on left side of bed. Resident reported he wanted to try to get up, and stated, I didn't realize how weak I am. Denied hitting his head and denies any pain at this time. Performed full ROM, moving all extremities x 4 without any difficulties or complaints of pain. Obtained VS - BP-147/82, P-77, R-20, T-97.4, SaO2-97% on room air. Initiated neuro checks and all WNL, bilateral weakness to extremities noted. Resident had a BM noted, and staff cleaned and changed resident prior to assisting him back to bed. Notified MD via fax at this time. Side rails up x 2, bed in lowest position, and call light within reach. Implemented resident safety education on importance of using call light for assistance before attempting to get out of bed/transfer, resident verbalized understanding at this time. Will continue to monitor.
11/10/2024 at 10:55 a.m. - 97.2 temporal,67-22-112/72-O2 sat 98% room air - Resident's family member to nurse's station - states resident said he fell in the middle of the night-requesting x-ray to be done due to Left and Right pelvis fractures prior to admit- resident denies pain or discomfort at this time- Physician notified with new order for stat x-ray of pelvic area; imaging company informed of x-ray order -family members in room-informed of new order.
11/10/2024 at 12:15 p.m. - stat x-ray of pelvic done at this time per imaging company
11/10/2024 at 1:10 p.m. - received stat x-ray result: acute right pubic fractures - On call Physician notified - states ok-inform Primary Physician on Monday-results faxed to Primary Physician office at this time-RP informed of results and md notification - states ok- I'm glad he's okay.
Telephone interview was conducted on 11/19/2024 at 8:58 a.m. with Resident #2's RP who reported the facility did not notify her of the resident's fall on 11/10/2024. Resident #2's RP stated during a visit to Resident #2 on 11/10/2024, he told her he fell. She stated she asked the nurse and was told he did have a fall. Resident #2's RP stated that an x-ray was not done after the fall and she ask for one to be done. Resident #2's RP stated she was unsure of the x-ray results, but stated that he received the hip fractures he was admitted with about 3 weeks ago from a fall at his apartment in Texas.
Interview on 11/19/2024 at 10:30 a.m. with S1 DON and S2 Corporate Nurse revealed that Resident #2's family/RP should have been notified of the fall at the time of the incident and should not have been told by the resident during a visit later that day.
Interview on 11/19/2024 at 12:05 p.m. with S1 DON revealed S3 LPN had been suspended following the event. Review of S3 LPN's Employee Warning Report dated 11/12/2024 revealed the type of violation as failure to notify RP of fall with an action of immediate suspension noted.
Sept 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#2 and #82) of 2 (#2 and #82) Residents reviewed for ADL's. The facility failed to ensure Resident's (#2 and #82) were shaved.
Findings:
Review of the facility's policy with a revision date of 08/24, titled Resident Quality of Care revealed the following: . 2. The policy of the facility is to establish a minimum acceptable level of daily care which shall include and involve the maximum utilization of the resident's capabilities; while providing the necessary assistance to accomplish the following: .C. At the time of the bath, all residents shall also receive .nail care .shave .
Resident #2
Record review revealed Resident #2 was admitted to the facility on [DATE] with the following diagnosis that included Cerebral Infarction Unspecified, Paraplegia, Cognitive Communication Deficit, Bed Confinement Status, and Other Lack of Coordination.
Review of the Quarterly MDS with ARD of 07/02/2024 revealed Resident #2 had a BIMS of 3 indicating severe cognitive impairment, and is dependent on staff for personal hygiene and bathing.
Review of the CNA Task Schedule for September 2024 revealed no documentation of Resident #2 received a bath in September, and the CNA Task Schedule indicated that personal hygiene was provided on 09/05/2024 and 09/09/2024.
Review of Resident #2's care plan with a target date of 10/08/2024 revealed ADLS: Self care deficit: Res requires substantial/max assist with meals. Dependent assistance with bed mobility, UB dressing and personal hygiene, bathing .
Observations on 09/09/2024 at 9:00 a.m. revealed Resident #2 sitting in his Geri-Chair in the Rehab Therapy room. He was observed to have approximately 1/16th inch long facial hair covering his face and neck. Resident #2 was not interviewable.
Observation on 09/09/2024 at 1:11 p.m. accompanied by S4 ADON revealed Resident #2 had facial hair on his face and neck. S4 ADON reported that Resident #2 needs to be shaven and could not shave his self.
Resident #82
Record review revealed Resident #82 was admitted to the facility on [DATE] with the following diagnosis that included Other Sequelae of Cerebral Infarction, Unspecified Age Related Cataract, Muscle Weakness, and Dysphagia Following Cerebral Infarction.
Review of the admission MDS with ARD of 06/25/2024 revealed Resident #82 had a BIMS of 9 indicating moderate cognitive impairment, and requires substantial and/or maximum assistance for bathing.
Review of Resident #82's care plan with a target date of 09/19/2024 revealed Resident needs assistance with ADL's Resident will be assisted with ADLs while promoting max level of independence .
Observations on 09/08/2024 at 11:20 a.m. revealed Resident #82 in his room lying down. He was observed to have facial hair approximately 1/16th inches long on his face and neck. During that time Resident #82 stated that someone usually shaved him and indicated he thought the person that shaved him was not here today.
On 09/09/2024 at 1:09 p.m. an observation of Resident #82 was made with S4 ADON. S4 ADON verified that Resident #82 had facial hair and needed to be shaved. At that time, Resident #82 requested to be shaved and stated he would like to keep his mustache. S4 ADON verified that Resident #82 required assistance with personal hygiene and could not shave himself.
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 record review, observation, and interview the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of pr...
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Based on record review, observation, and interview the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and to prevent infection for 1 (#188) of 2 (#2, #188) residents reviewed for pressure ulcers. The facility failed to ensure Resident #188's wounds were accurately assessed and documented weekly.
Findings:
Review of the facility's policy titled Pressure Ulcer Prevention and Treatment Interventions Guidelines last revised on 10/2022 revealed in part .
1.
Weekly body audits are to be performed by a Licensed Nurse on designated day.
2.
If a pressure ulcer is present initiate the weekly documentation.
Review of Resident #188's medical record revealed an admit date of 11/03/2021 with diagnoses that included .Paraplegia, Pressure Ulcer of Sacral Region, Pressure Ulcer of Left Buttock-stage 4, Pressure Ulcer of Right Buttock-Stage 4, and Acquired Absence of Right Leg above Knee.
Review of Resident #188's Quarterly MDS with an ARD of 05/06/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #188 required partial/moderate assistance with eating and dependent with rolling left and right and chair/bed to chair transferring.
Review of Resident #188's current physician's orders revealed in part the following:
09/06/2024: Apply 5% Lidocaine ointment to stage 4 sacrum wound. Cleanse wound with wound cleanser, apply skin prep to periwound, apply silver alginate, cover with ABD pad and secure with tape every other day until resolved.
09/06/2024: Apply 5% lidocaine ointment to Stage 4 left buttock wound. Cleanse wound with wound cleanser. Apply skin prep to periwound. Apply silver alginate, cover with ABD pad and secure with tape every other day until resolved.
09/06/2024: Apply 5% lidocaine ointment to stage 4 right buttock wound. Cleanse wound with wound cleanser. Apply skin prep to periwound. Apply silver alginate, cover with ABD pad and secure with tape every other day until resolved.
Review of Resident #188's medical record revealed the resident was care planned for:
Resident has an open area to sacrum. Interventions included record percentage of meals eaten, dietary consult as needed, labs as ordered, treatment as ordered, pressure reducing device for bed and chair, and turning and repositioning program.
Resident has a Pressure ulcer to right buttock, stage 4. Interventions included: Turn and reposition resident per schedule, observe skin daily w/ adl care or bath and report any problems to nurse, weekly body audit, and labs as ordered.
At risk for infection related to diagnosis of stage 4 pressure ulcer to left buttocks; Onset 12/24/2021. Interventions included: 12/24/2022-stage 4 right buttock-turn and reposition resident per schedule, pressure reducing mattress to bed and cushion to wheelchair, observe skin daily w/ adl care or bath and report any problems to nurse, weekly body audit, Dietary consult prn, labs as ordered; observe current treatment for effectiveness; Enhanced Barrier Precautions (wounds) - gloves and gown to be worn during high contact resident care.
In an observation and interview on 09/09/2024 at 3:39 p.m., Resident #188 was lying in bed on his back. His positioning wedge was lying on the resident's wheelchair across the room. Resident #188 stated he had been on his back with no wedge since after finishing lunch. He said staff don't turn or reposition him every 2 hours. Resident #188 stated the CNAs come in and tell him they would have to find help, but never come back.
In an interview on 09/10/2024 at 12:24 p.m., S2 DON stated Resident #188 doesn't have a sacral pressure ulcer, but a shearing to his sacrum and that his sacral pressure ulcer healed a long time ago. S2 DON stated she did not know why the resident had treatment orders for a Stage 4 pressure ulcer. This surveyor requested the wound assessments for the sacrum and the pressure ulcers to the left and right buttocks from 08/01/2024 to present date. Wound assessments were provided for 08/13/2024 and 08/27/2024 for the left and right buttocks only. S2 DON confirmed there were no wound assessments completed from 08/01/2024 through 08/12/2024 and no wound assessments completed since 08/28/2024 to present. S2 DON stated they had not had a wound care nurse since around June 2024. S2 DON acknowledged the resident's wounds should be assessed weekly by a nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #54) of 1 sampled residents reviewed for respir...
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Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #54) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly labeled and stored.
Findings:
Review of Resident #54's Clinical Record revealed an admit date of 02/01/2024 with diagnoses that included in part .Hypertensive Heart Failure with Heart Failure, Gastrostomy Status, and Chronic Respiratory Failure with Hypoxia.
Review of Resident #54's Care Plan with a Review date of 10/01/2024 revealed in part .At risk for Shortness of Breath, Resident has a diagnosis of Acute Respiratory Failure, with interventions that included: Oxygen as ordered.
Observation and interview on 09/08/2024 at 11:12 a.m. revealed Resident #54's Nebulizer mask was uncovered and undated lying on his over bed table. Resident #54's oxygen tubing was uncovered and undated lying on top of the oxygen concentrator beside his bed. Resident #54 revealed he wore oxygen daily and received nebulizer treatments daily.
Observation on 09/09/2024 at 8:52 a.m. revealed Resident #54 lying in bed with oxygen per nasal cannula in place. Oxygen tubing was undated.
Observation and Interview on 09/09/2024 at 9:33 a.m. of Resident #54 with S2 DON in attendance revealed Resident #54's oxygen tubing was undated. S2 DON confirmed Resident #54's oxygen tubing was undated and if oxygen equipment is not in use it should be covered and changed out every 7 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #27 and Resident #64...
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Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #27 and Resident #64) of 29 sampled residents reviewed for quality of care.
Findings:
Patient #27
Review of Resident #27's Electronic Health Record revealed an admit date of 07/03/2024 with the following diagnoses including Type 2 DM with Neuropathy and long term use of Insulin.
Review of Resident #27's 09/2024 Physician Orders revealed the following including:
07/03/2024 - Insulin Glargine Soln Pen-Injector 100U/ml inject 15U q HS
07/03/2024 - HGBA1C q 3 months (Sept, Dec, Mar, June)
07/18/2024 - Accuchecks BID notify MD if CBG <60 or >300
Review of Resident #27's 09/2024 Electronic Medication Administration Record revealed Capillary Blood Sugars above 300 on the following dates and times:
09/05/2024 at 6:00 a.m. - 301
09/06/2024 at 6:00 a.m. - 330
09/08/2024 at 6:00 a.m. - 324
Review of Resident #27's 09/2024 Nurse Notes revealed no documentation that the Physician was notified concerning capillary blood sugar results greater than 300.
Interview on 09/10/2024 at 10:10 a.m. with S3 Corporate RN confirmed there was no documentation that Resident #27's physician was notified concerning capillary blood sugar results over 300 and there should be.
Resident #64
Review of Resident #64's medical record revealed an admit date of 02/23/2024 with diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety, Muscle Weakness, and Moderate Protein-Calorie Malnutrition.
Review of Resident #64's Significant Change MDS with an ARD of 06/12/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #64 required supervision with eating, substantial/maximal assistance with toilet hygiene and chair/bed to chair transferring, and partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing.
Review of Resident #64's current physician's orders revealed the following orders:
09/06/2024: Tresiba FlexTouch Subcutaneous solution pen injector 100 units/ml-inject 15 units subcutaneously at HS.
07/29/2024: Humalog Kwikpen subcutaneous Solution Pen-injector 100 unit/ml-inject subcutaneously before meals and at bedtime related to type 2 meals. Inject as per SS:
If 60-180=0 notify MD if less than 60.
181-250=3
251-300=6
301-350=9
351-400=12
401-9999=15;
Administer 15 units and notify MD if greater than 400, subcutaneously before meals and at bedtime r/t Type 2 DM w/ hyperglycemia;
Review of Resident #64's medical record revealed the following capillary blood sugars:
08/01/2024 at 10:44 p.m.: 539
08/01/2024 at 10:45 p.m.: 499
08/08/2024 at 5:18 p.m.: 497
08/09/2024 at 5:21 p.m.: 570
09/04/2024 at 5:50 p.m.: 450
Review of the nurses' notes revealed no documentation of reporting these capillary blood sugars greater than 400 to the physician, as ordered.
In an interview at 10:16 a.m. on 09/10/2024, S3 Corporate RN confirmed there was no documentation the nurse reported Resident #64's capillary blood sugars greater than 400 to the physician and acknowledged it should have been reported.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comp...
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Based on record review and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#4, #64) of 2 residents reviewed for pain. The facility failed to ensure Resident #4 and #64, who reported pain, received medication or interventions to alleviate pain.
Findings:
Review of the facility's policy titled Pain Screen and Management with a revision date of 12/2023 revealed in part .
1. All residents have the right to treatment for pain.
2. The resident's statements are the most valid measurement of pain.
3. A pain scale is used whereby the resident describes his/her pain and amount of pain relief.
Chronic Pain Management:
Documentation requirements for Chronic Pain Management focus on the following:
E-MAR documentation
Use of as needed (PRN) medication
Review and revision of care plan as appropriate
Resident #4
Resident #4's medical record revealed an admit date of 05/31/2017 with diagnoses that included .Chronic Pain Syndrome, Chronic Kidney Disease, Multiple Sclerosis, Localized Edema, and Unspecified Convulsions.
Review of Resident #4's Quarterly MDS with an ARD of 06/01/2024 revealed Resident #4 had a BIMS score of 15 indicating intact cognition. Review of the MDS revealed Resident #4 required supervision with eating, dependent with toilet hygiene and bathing, and transfers. Review of the MDS revealed Resident #4 had a pain assessment interview and received PRN pain medication.
Review of Resident #4's Care Plan with a review date of 07/16/2024 revealed in part .Resident has pain related to Multiple Sclerosis and Chronic Pain Syndrome with interventions that included: Administer medications as ordered, Observe onset, location, severity and duration of pain.
Observation and interview on 09/08/2024 at 10:05 a.m. revealed Resident #4 in bed. Resident #4 revealed she had not received her pain medication as requested and she was hurting. Resident #4 stated she had Multiple Sclerosis and her legs were hurting (10/10 on a pain scale). Resident #4 revealed she received oxycodone every 4 hours as needed for pain. Resident #4 revealed on 09/07/2024 she had called for the nurse twice between 1:00 a.m. and 5:00 a.m. Resident #4 revealed the nurse never came to her room all night and she never received any pain medication.
Review of Resident #4's Physician's orders for September 2024 revealed an order for Oxycodone 10 MG by mouth every 4 hours as needed for pain related to Chronic Pain Syndrome.
Interview on 09/09/2024 at 9:00 a.m. with Resident #4 revealed she received pain medication on 09/08/2024 at approximately 10:30 a.m. Resident stated she was not able to attend the Resident Council Meeting held on 09/08/2024 due to pain.
Telephone Interview with S8 CNA revealed on 09/07/2024 Resident #4 had called for the nurse twice for pain medication between 1:00 a.m. and 5:00 a.m. S8 CNA stated she had looked for Resident #4's nurse and had paged her, but she never came.
Interview on 09/09/2024 at 1:15 p.m. with S9 Agency LPN revealed she was the nurse for Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m. S9 Agency LPN revealed she did not provide any care for Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m. S9 Agency LPN stated I never laid eyes on Resident #4, my whole shift. S9 Agency LPN confirmed she did not administer any pain medication to Resident #4 on 09/07/2024 from 11:00 p.m. to 7:00 a.m.
Resident #64
Resident #64's medical record revealed an admit date of 02/23/2024 with diagnoses that included Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety, Muscle Weakness, and Moderate Protein-Calorie Malnutrition.
Review of Resident #64's Significant Change MDS with an ARD of 06/12/2024 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #64 required supervision with eating, substantial/maximal assistance with toilet hygiene and chair/bed to chair transferring, and partial/moderate assistance with rolling left and right, sitting to lying, lying to sitting, and sitting to standing.
In an interview on 09/08/2024 at 12:57 p.m., Resident #64 stated he hurts all the time because he has problems with his back. He stated the facility doesn't give him anything for pain, not even Tylenol or Ibuprofen.
Review of Resident #64's September 2024 MAR revealed the following pain levels entered by S5 LPN:
09/09/2024-6 at 10:02 a.m.
09/06/2024-7 at 9:55 a.m.
09/05/2024-7 at 9:09 a.m.
09/04/2024-6 at 11:04 a.m.
09/03/2024-6 at 9:54 a.m.
Review of the September 2024 MAR revealed no pain medication had been given to Resident #64.
Review of Resident #64's medical record revealed he was currently care planned for being at risk for pain. Interventions included Administer medications as ordered, Notify MD of any unrelieved pain, Reposition for comfort as needed, Observe onset, location, severity and duration of pain, and Observe effectiveness of medication.
In an interview on 09/09/2024 at 10:41 a.m., S5 LPN stated Resident #64 hadn't complained of pain to her today but may have complained of pain to her last week. S5 LPN stated Resident #64 doesn't have anything ordered for pain and the ASA 81 mg he received was ordered related to hemiplegia. S5 LPN stated she could have contacted his doctor last week to report his pain but did not.
In an interview on 09/10/2024 at 10:16 a.m., S3 Corporate RN reviewed Resident #64's MAR and the documentation by nursing staff of the resident's pain levels of 6 and 7 this month. S3 Corporate RN acknowledged the nurse should have called the doctor to report the resident's pain. S3 Corporate RN stated if she was the nurse she would have called the doctor to report the pain since he didn't have anything ordered for pain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the Facility failed to provide pharmaceutical services that assure the accurate reconciliation of controlled medications to meet the needs of each Resident by fai...
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Based on interview and record review, the Facility failed to provide pharmaceutical services that assure the accurate reconciliation of controlled medications to meet the needs of each Resident by failing to ensure at each shift change a physical inventory of controlled medications were conducted by two licensed clinicians.
Findings:
Review of the Facility's policy and procedure titled Controlled Substances with a revision date of 11/2017, read in part .A controlled drug count is to be done at the beginning of each shift by the outgoing and the on-coming medication nurses.
Telephone Interview on 09/09/2024 at 11:00 a.m. with S10 Agency LPN revealed on 09/08/2024 she reported to work for 7:00 a.m. S10 Agency LPN confirmed she did not reconcile narcotics with the off going nurse or any other nurse and she should have.
Interview on 09/09/2024 at 1:15 p.m. with S9 Agency LPN revealed she worked the 11:00 p.m. to 7:00 a.m. shift on 09/07/2024. S9 Agency LPN revealed S10 Agency LPN was the on-coming nurse for 7:00 a.m. on 09/08/2024. S9 Agency LPN confirmed she did not reconcile medications with S10 Agency LPN and she should have.
Interview with S2 DON on 09/09/2024 at 2:10 p.m. revealed all controlled substances should be counted at the beginning and at the end of each shift, by the on-coming and off going nurse.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure snacks are served at times in accordance with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure snacks are served at times in accordance with resident's needs, preferences and requests. The facility failed to provide snacks for residents outside of scheduled meal service times. The facility failed to ensure that Residents meals were distributed in a timely manner.
Findings.
Interviews on 09/08/2024 at 2:00 p.m. with residents during the Resident Council meeting revealed snacks were not being provided and were not available at all times. Residents in the council meeting stated they would ask for snacks and the nurse would tell them dietary did not leave any out for them. Residents stated snacks were labeled with residents names on them, and if your name was not on a snack you did not get a snack.
Observation on 09/08/2024 at 9:44 a.m. of meal service on Hall X revealed staff were distributing breakfast trays.
Interview on 09/08/2024 at 10:35 a.m. with Resident #236 revealed he was admitted to the facility on [DATE]. Resident #236 revealed he did not receive breakfast this morning. Resident #236 revealed he had not eaten since supper on 09/07/2024 at 5:30 p.m. and had not received any snacks.
Interview on 09/08/2024 at 10:38 a.m. with S1 Administrator revealed she was unaware that a resident had been admitted on yesterday (09/07/2024), and that he had not received his breakfast.
Observation on 09/08/2024 at 11:30 a.m. revealed Resident #236 received his breakfast at this time.
Interview on 09/08/2024 at 12:48 p.m. with Resident #64 (BIMS score of 15 indicating intact cognition), revealed he was always hungry and his blood sugar dropped at night. Resident #64 revealed he did not get a snack in the evening like other residents. Resident #64 revealed he told the nurse he wanted a snack or orange juice and he did not receive it.
Interview on 09/09/2024 at 7:52 a.m. with Resident #27 revealed he ate supper at 5:30 p.m. on 09/08/2024, and did not receive a snack that night. Resident #27 revealed he had not had breakfast and was hungry.
Interview on 09/09/2024 at 8:15 a.m. with Resident #64 revealed he did not receive a snack last night (09/08/2024
.
Observation on 09/09/2024 at 9:06 a.m. revealed staff distributing breakfast trays on Hall Y.
Review of posted meal times revealed in part .
Breakfast from 7:30 a.m. -8:00 a.m.
Lunch from 12:00 p.m.-12:30 p.m.
Dinner from 5:00 p.m.-5:30 p.m.
Interview on 09/09/2024 at 9:40 a.m. with S2 DON and S7 Dietary Manager revealed only residents with a doctor's order received snacks at 10:00 a.m. and 2:00 p.m. S2 DON and S7 Dietary Manager revealed bed time snacks were left at the nurse's station and if a resident wanted a snack they had to go to the nurse's station and ask for it. S2 DON acknowledged residents who could not go to the nurse's station and ask for a snack were not provided with a snack.
Interview on 09/10/2024 at 10:30 a.m. with S1 Administrator and S7 Dietary Manager acknowledged they were aware of meal service times being longer than 14 hours from dinner to breakfast at times, and snacks not being provided/offered to all residents.
May 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 Resident (#3) of 3 sampled Residents (#1, #2, and #3). The facility failed to ensure that Resident #3 was safely secured in a shower chair prior to showering.
This deficient practice resulted in an actual harm for Resident #3 on 04/19/2024 at approximately 7:30 p.m., when Resident #3 was placed in a shower chair that was not equipped with a safety belt. Resident #3 fell from the shower chair to the floor, after being showered by S5 CNA. Resident #3 was transferred to the emergency room and diagnosed with a Displaced Left Intertrochanteric Femur Fracture. Resident #3 required surgical intervention of an Intramedullary Nail placement, Left Intertrochanteric Femur Fracture, on 04/21/2024.
Findings:
Review of the facility's policy and procedure titled Bathing, with a revision date of 01/2024, read in part .
Shower - Dependent Resident
2. When using the shower chair, always apply the safety belt.
Review of Resident #3's EHR revealed an admission date of 04/11/2022, with admitting diagnoses that included: Endocarditis, End Stage Renal Disease, Acute Kidney Failure with Tubular Necrosis, Benign Prostatic Hyperplasia, and Thoracic Aortic Aneurysm.
Review of Resident #3's Annual MDS with an ARD of 02/29/2024, revealed a BIMS score of 15 (intact cognition). The MDS revealed Resident #3 required substantial/maximal assistance x1 with shower/bathe, and partial/moderate assistance x1 with sit to standing, transfer from chair/bed-to-chair, toilet transfer, and tub/shower transfer. Resident #3 had impairment on one side to the upper/lower extremities, and used a motorized wheelchair for mobility.
Review of Resident #3's Comprehensive Care Plan with a target date of 06/04/2024, revealed in part .
1. Resident required Restorative Nursing Program for transfers, with a problem onset of 10/04/2022. Resident needs staff assistance with ADLs and transfers. Approaches included in part .Assist with transfers
2. Resident has Hx. of falls with potential for fall impaired mobility, has unstable balance, has motorized wheelchair, and 04/19/2024 fall with injury. Approaches included in part .assist with ADLs.
Review of the Post-Incident Actions notes dated 04/19/2024 at 7:30 p.m., read as follows in part . S6 CNA called S4 LPN to the shower room. Resident #3 was sitting on the wet floor on his buttocks - slid from the shower chair. Resident c/o severe pain to left leg and hip. Assisted Resident to wheelchair with lift, and placed in bed. Resident's pain = 10. Resident #3's physician was notified with orders given to transfer to ER for evaluation and treatment.
Review of the Radiology Interpretation dated 04/19/2024 revealed in part . There is a Basicervical Left Proximal Femoral Fracture.
Review of the hospital Discharge Summary read in part .Resident #3 was admitted to the hospital on [DATE], with a diagnosis of Status Post Fall with Left-Sided Hip Fracture. The course of hospital treatment included: Surgical repair of the left hip with preoperative diagnosis of Displaced Left Intertrochanteric Femur Fracture, with PT and OT. Resident #3 was discharged back to the facility on [DATE]. Discharge instructions included: Continue PT and OT at the facility, and recommend to follow-up with primary care provider within 7 days.
Interview on 04/30/2024 at 2:00 p.m. with S1 Administrator, revealed Resident #3 was transferred and admitted the hospital with a fractured left femoral, after sliding from the shower chair while in the shower on 04/19/2024. S1 Administrator stated Resident #3 required surgery in order to repair the left femoral fracture, and was scheduled to be discharged back to the facility this evening.
Telephone interview on 05/01/2024 at 4:23 p.m. with S5 CNA, revealed she worked on 04/19/2024 from 3:00 p.m. - 11:00 p.m., and was assigned to Resident #3. S5 CNA stated on 04/19/2024, Resident #3 went into the shower room and transferred from the motorized wheelchair to the shower chair using his walker. S5 CNA stated there is a floor threshold before entering the shower stall, and while standing in front of Resident#3, she tried to pull the shower chair over the threshold, and Resident #3 fell forward. S5 CNA stated she tried to push the resident back onto the chair, but because he was heavier than her, the resident went down to the floor. S5 CNA stated on the day that Resident #3 fell out of the shower chair, there was no safety belt attached to the chair. S5 CNA stated the shower chair had been without a safety belt for a while (unable to recall how long). S5 CNA stated that she never reported the shower chair being without a safety belt, because she thought that the issue had already been reported by the day shift. S5 CNA stated this was not the first time she had used the shower chair without a safety belt, and never had any problems.
Telephone interview on 05/02/2024 at 8:50 a.m. with S6 CNA, revealed S5 CNA called her cellphone, and asked that she come to the shower room, and get the nurse because Resident #3 had fallen. S6 CNA stated she went to get S4 LPN and reported to her that Resident #3 had fallen in the shower. S6 CNA stated when she entered the shower room, Resident #3 was sitting straight up on his buttocks, and S5 CNA was standing up holding the resident's back. S6 CNA stated she assisted with transferring Resident #3 from the shower floor into his motorized wheelchair using the lift, along with assistance from S4 LPN, S5 CNA, and S7 CNA. S6 CNA stated she didn't see a safety belt on the shower chair on the day that Resident #3 fell (04/19/2024), and she was aware that the shower chair should have had a safety belt attached to it.
Interview on 05/02/2024 at 9:40 a.m. with S8 CNA, revealed she was aware that the shower chairs were supposed to have safety belts, but they didn't always because the belts would break, and/or wouldn't snap close, and they would not be replaced. S8 CNA stated it was not usual for the shower chairs to be without safety belts. S8 CNA stated she was unable to recall the exact length of time that the shower chairs had been without safety belts, or if she had ever logged in the maintenance log book that the shower chairs needed safety belts. S8 CNA stated safety belts were attached to all shower chairs after Resident #3 fell on [DATE].
Interview on 05/02/2024 at 9:42 a.m. with S9 CNA, revealed she last used the shower chair in Shower Room B about 1 week before Resident #3 fell, and there was no safety belt on it at that time. S9 CNA stated she was aware at the time that she last used the shower chair, that it was supposed to have a safety belt on it. S9 CNA stated there were 2 shower chairs in Shower Room B, neither one had a safety belt on it, and that she used one of the shower chairs anyway. S9 CNA stated it was not until after Resident #3 fell last month that safety belts were attached to the shower chairs.
Interview on 05/02/2024 at 10:00 a.m. with Resident #3, revealed he fell from the shower chair on 04/19/2024, as S5 CNA was trying to get him out of the shower stall. Resident #3 stated S5 CNA pulled him forward after she showered him, and while trying to get him out of the shower stall, he fell out of the shower chair. Resident #3 stated he was not strapped in the shower chair, and was not able to recall if the shower chair had a strap or not. Resident #3 stated his legs felt as if they had buckled underneath him and the chair came from under him as S5 CNA was pulling the shower chair forward. Resident #3 stated S4 LPN examined him, and his pain level at that time was a 10. Resident #3 stated he was transferred to the hospital, admitted on [DATE] with a fractured left hip, and had surgery on 04/21/2024.
Telephone interview on 05/02/2024 at 11:30 a.m. with S4 LPN, revealed on 04/19/2024 Resident #3 fell out of a shower chair in the shower, and sustained a fractured left hip. S4 LPN stated when she arrived in shower room B, Resident #3 was seated on the shower floor in front of the threshold, and S5 CNA was bent over holding the resident up. S4 LPN stated S5 CNA told her that Resident #3 slipped out of the shower chair while she was trying to pull him over the threshold, and she was not able to stop his fall. S4 LPN stated she asked S5 CNA if she had used the safety belt to strap Resident #3 in, and S5 CNA answered, No ma'am, the shower chair had no safety belt on it. S4 LPN stated she checked the shower chair at that time, and there was no safety belt attached.
Telephone interview on 05/02/2024 at 1:00 p.m. with S7 CNA revealed she assisted with transferring Resident #3 from off floor in the shower room using the lift, to his motorized wheelchair. S7 CNA stated when she entered the shower room, Resident #3 was sitting on the floor on his buttocks. S7 CNA stated there was no safety belt on the shower chair, and there should have been.
Interview on 05/02/2024 at 2:10 p.m. with S11 Maintenance Supervisor revealed if there were problems with any of the shower chairs, whether it be a missing safety belt, brakes or anything, the staff would personally tell him, and/or write it in the maintenance log, at which time he would address it. S11 Maintenance Supervisor stated the logs are kept at each nurse's station, and he checked them daily. After checking each maintenance log with surveyor present, S11 Maintenance Supervisor confirmed there was nothing in the logs in regards to shower chairs.
Interview on 05/02/2024 at 2:35 p.m. with S1 Administrator confirmed that the shower chair in use for Resident #3 when he fell on [DATE], did not have a safety belt, and stated that all shower chairs should have safety belts attached for residents' safety.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to immediately consult with the physician, and notify the resident's representative when a resident experienced a fall for 1 Resident (#1) of 3...
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Based on interview and record review the facility failed to immediately consult with the physician, and notify the resident's representative when a resident experienced a fall for 1 Resident (#1) of 3 (Resident#1, Resident #2, Resident #3) sampled residents.
Findings:
Review of the Facility's Policy titled Change in Resident Medical Status with a revision date of 09/17 read in part:
A change in medical status is defined as physical, psychological and/or medical deviation as compared to the resident's status as noted on the initial assessment. These changes may include: a fall and/or injury .
A facility must immediately inform the resident; consult with the resident's physician; and or notify, consistent with his or her authority, the resident representative(s), when there is
1. An accident involving the resident which results in injury and has the potential for requiring physician intervention.
Review of the facility's incident report dated 04/05/2024, revealed action taken: On 04/05/2024 at 9:15 p.m., Resident #1's physician was contacted. The report revealed the name of Resident #1's RP, with the time of contact was not documented.
Review of the nurse's progress notes dated 04/05/2023, and documented at 10:12 p.m. by S3 LPN, revealed in part .on 04/05/2024 at approximately 9:12 p.m., Resident #1 slid out of bed, and onto the floor. Assessed with no injury noted and or c/o pain. Resident #1 was assisted back to bed, instructed to use the call light, and bed in low position. There was no documentation that the RP and/or the physician had been notified of Resident #1's fall.
Review of the nurse's progress notes dated 04/05/2024, and documented at 9:19 p.m. by S12 LPN, revealed on 04/06/2024 at 9:19 p.m., while assisting Resident #1 to undress, the CNA noted swelling of the resident's right upper arm with greenish colored bruises. Resident #1 complained of right ribcage and back pain. The physician was notified with an order for stat x-ray of the right arm, ribcage and back. Resident #1's RP was notified.
Review of the X-ray impression dated 04/06/2024 read in part .Acute fracture of the right 6th rib.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve a grievance filed by a resident's Responsible Party, for 1 (Resident #1) of 3 (R...
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Based on interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve a grievance filed by a resident's Responsible Party, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.
Findings:
Review of the facility's policy/procedure titled, Grievances-Residents, last revised in 10/2023, revealed, in part .
The facility shall make prompt efforts to resolve the grievances.
The Administrator and his/her designees will conduct an impartial investigation of the allegations .will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant.
Review of an electronic grievance complaint dated 04/08/2024, revealed an electronic complaint was registered by the DON. Resident #1's RP stated she was not notified of a fall that Resident #1 sustained on 04/05/2024. Findings of conclusion: Resident did in fact have a fall on 04/05/2024, and S3 LPN did not notify the RP of the fall. Corrective action taken: DON verbally counseled S3 LPN regarding policy to notify RP in the event of a fall.
Telephone interview on 05/01/2024 at 12:25 p.m. with Resident #1's RP, revealed that it was not until 04/06/2024 at about 9:30 p.m. that S12 LPN notified her that Resident #1 had fallen the night of 04/05/2024.
Interview on 05/01/2024 at 3:10 p.m. with S3 LPN revealed she had failed to notify Resident #1's RP on 04/05/2024 after the resident fell.
Interview on 05/02/2924 at 5:05 p.m., S1Administrator revealed a grievance had been initiated by the DON on 04/08/2024 in regards to Resident #1's RP not being notified until 04/06/2024, that the resident had fallen on 04/05/2024. S1 Administrator confirmed that the complaint had not been completed, and should have been.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure a resident received services in accordance with professional standards. The facility failed to ensure physician's orders were followe...
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Based on record review and interview the facility failed to ensure a resident received services in accordance with professional standards. The facility failed to ensure physician's orders were followed for wound care for 1 (#2) of 1 sampled resident reviewed for wound care.
Findings:
Review of the facility's Physician Orders policy read in part .
It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner.
Review of Resident #2's clinical record revealed an admit date of 01/27/2017 with diagnoses that included: Peripheral Vascular Disease, Lymphedema, Chronic Venous Hypertension with ulcers to bilateral lower extremities, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Unspecified Atherosclerosis of native arteries of extremities to bilateral legs.
Review of Resident #2's Quarterly MDS assessment with ARD of 09/14/2023 revealed Resident #2 had a BIMS score of 15, indicating cognitively intact.
Review of Resident #2's 10/2023 Physician's Orders read in part .
10/19/2023 -Bilateral lower extremities- Cleanse with Hibiclens, rinse with normal saline, apply abdominal pads, Wrap with kerlix, apply ace wrap 2 times a day at 10:00 a.m. and 3:00 p.m.
An interview on 10/23/2023 at 11:16 a.m. with Resident #2 revealed that he had not received wound care to his bilateral lower extremities over the weekend (10/21/2023 and 10/22/2023), and had last received wound care on Friday, 10/20/2023.
Review of the ETAR for 10/2023 revealed S1 Treatment Nurse signed off that she completed Resident #2's Bilateral lower extremities wound care for Saturday 10/21/2023 and Sunday 10/22/2023.
An interview on 10/23/2023 at 3:00 p.m. with S1 Treatment Nurse revealed she did not work on the weekend of 10/21/2023 through 10/22/2023. S1 Treatment Nurse confirmed that she clicked off Resident #2's wound care treatments for 10/21/2023 and 10/22/2023 to clear out her ETAR, and should not have because she did not provide the treatment for those days.
An interview on 10/23/2023 at 12:53 p.m. with S3 ADON revealed the facility's weekend RN typically provided wound care treatments on the weekends. S3 ADON revealed there were times that the weekend RN will help out on the floor, and the floor LPN's are responsible for providing wound care for the residents on their hall. S3 ADON revealed on the weekend of 10/21/2023-10/22/2023, she helped the CNAs out on the floor, so she did not perform wound care for any residents. S3 ADON stated she verbally notified each floor nurse and wrote it on the schedule that LPN's were to provide their own wound treatment for the weekend of 10/21/2023 through 10/22/2023.
A telephone interview on 10/24/2023 at 11:20 a.m. with S2 LPN revealed she worked a double weekend shift on Saturday 10/21/2023, and Sunday 10/22/2023 from 7:00 a.m. to 11:00 p.m., and was assigned Resident #2. S2 LPN confirmed she did not provide wound treatments for Resident #2 on Saturday 10/21/2023, or Sunday 10/22/2023 because she was not notified, and was unaware that she had to do so.
Oct 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (#3) of 2 (#3, #238) residents reviewed for hospice. The facility failed to collaborate with Resident #3's hospice provider in order to honor the resident's choices regarding end of life care.
Findings:
Resident #3
Review of Resident #3's medical record revealed an admit date of [DATE] with diagnoses that included, in part, Cerebral Infarction, Dysphagia, Dementia, and Epilepsy.
Review of Resident #3's physician's orders revealed an order dated [DATE] to admit to hospice. Review of the physician's orders for Resident #3 revealed an order dated [DATE] which read Full Code.
Review of Resident #3's admission MDS with an ARD of [DATE] revealed a BIMS score of 3 which indicated the resident had severe cognitive impairment. Review of the MDS revealed Resident #3 was totally dependent on two persons with transferring, totally dependent on one person with bed mobility and toilet use, and required limited assistance by one person with eating.
Review of Resident #3's care plan revealed the resident was care planned for Resident is a full code.
Review of Resident #3's medical chart located at the nurses' station revealed a binder which contained a bright green sticker near the front of the binder that read Full Code. The binder contained a tab titled Advance Directives near the back of the binder. Behind the Advance Directives tab was a page dated [DATE] titled Resident/Family Consent for Cardiopulmonary Resuscitation with a box initialed by Resident #3's responsible party that read I understand the CPR constitutes an extraordinary measure and SHOULD be done on this resident in the case of extreme emergency.
Review of the Hospice Binder for Resident #3, located at the nurses' station, contained a LaPOST dated [DATE] signed by Resident #3's responsible party with DNR/Do Not Attempt Resuscitation checked.
In an interview on [DATE] at 11:24 a.m., S3 LPN reported residents' code statuses were found on their physical charts, in physician orders, and on the electronic record in a spot designated for them. S3 LPN stated there was also a binder at the nurses' station with resident code statuses. S3 LPN checked Resident #3's code status on the electronic record by clicking on the designated spot for code status which indicated Resident #3 was coded as initiate CPR.
Review of the code status binder at the nurses' station revealed Resident #3's status was not listed in the binder.
In an interview on [DATE] at 2:02 p.m., S2 DON stated the facility's advance directives for Resident #3 were dated [DATE] and were newer than the LaPOST in Resident #3's hospice chart that was dated [DATE] therefore the facility's advance directives would be used.
In a telephone interview on [DATE] at 2:30 p.m., the RN Case Manager with Resident #3's Hospice provider stated Resident #3 was designated a DNR since they signed him on to hospice in [DATE]. She said she was unaware the nursing home had Resident #3's code status listed as full code. She said no one at the facility had communicated that tinformation to her.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 1 (Resident #57) of 1 sampled residents reviewe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 1 (Resident #57) of 1 sampled residents reviewed for pressure ulcers, received the necessary treatment and services to prevent and promote wound healing. The facility failed to ensure staff applied Resident #57's heel protectors as ordered. Findings:
Review of the facility policy titled: Prevention and Treatment of Skin Issues, revealed in part .
It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventive measures; and to provide appropriate treatment modalities for wounds according to industry standards of care.
The following may be utilized according to risk areas and resident need: pressure reducing/relieving/redistributing mattress to each resident bed in facility, pressure relieving devices in chair, bed rail, arm and leg protectors, positioning devices, moisture barriers, heel protectors or suspension boots, orthotics, splints, etc.
Review of Resident #57's clinical record revealed an admit date of 10/08/2021 with diagnosis that included pressure ulcer of sacral region stage 4; pressure ulcer of left buttock stage 3; moderate protein malnutrition; essential hypertension; pressure ulcer of right heel; unstageable, pressure ulcer of left heel; unstagable, and major depressive disorder.
Review of Resident #57's Care Plan with target date of 12/28/2023 revealed Resident #57 was at risk for further breakdown related to dependence with ADL needs. There were no care plan concerns noted related to refusal of care.
Review of Resident #57's September 2023 and October 2023 nurses' notes revealed no documentation of refusals of care.
Review of Resident #57's September 2023 and October 2023 MAR's revealed orders dated 07/23/2023 stating, Heel protectors to bilateral feet while in bed.
Review of Resident #57's Braden Scale Risk assessment dated [DATE] revealed Resident #57 had a score of 14, indicating Moderate Risk for the development of pressure ulcers.
Review of Resident #57's October 2023 Treatment Administration Record revealed Resident #57 was receiving Betadine applications daily to scabbed areas on bilateral legs and feet as well as Zinc Oxide daily to his sacrum, as a preventive measure.
Observation on 10/02/2023 at 10:37 a.m. revealed Resident #57 lying on his back in bed. A turn schedule as well as signs stating Heel protectors to feet while in bed and Float Heels were observed on a bulletin board next to Resident #57's bed. Observation revealed a pair of blue heel protectors on the floor in the corner of Resident #57's room. Resident #57's heels also did not appear to be floated.
Interview with Resident #57 at the time of observation revealed he had wounds on his right hip and legs from an injury sustained about 2 years ago. Resident #57 also stated he had a bunch of sores on his feet and between his toes. Resident #57 stated he was supposed to be turned side to side but staff did not come in to turn him. Resident #57 stated he did not have on heel protectors nor were his feet elevated at the time of interview.
Observation on 10/03/2023 at 11:15 a.m. revealed Resident #57 awake in bed watching television. Resident #57 was positioned on his back, and bilateral feet did not appear elevated. A pair of blue heel protectors was observed on the floor in the corner of Resident #57's room. Interview with Resident #57 revealed staff did not elevate his feet.
Observation on 10/03/2023 at 11:44 a.m. of Resident #57 accompanied by S8 CNA revealed resident #57 did not have heel protectors on nor were Resident #57's heel floated.
Observation of Resident #57 accompanied by S3 LPN on 10/03/2023 at 11:55 a.m. revealed Resident #57 was not wearing heel protectors nor were his heels floated. Multiple scabbed over sores were noted to the top and undersides of Resident #57's bilateral feet.
Interview with S3 LPN at the time of observation revealed Resident #57's heel protectors were not on and should have been and Resident #57's heels should have been floated and were not.
Interview with Resident #57 on 10/03/2023 at 11:58 a.m. accompanied by S3 LPN revealed Resident #57 has never refused to wear his heel protectors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure resident's shower rooms were clean, sanitary, and in good repair ...
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Based on observation and interview the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure resident's shower rooms were clean, sanitary, and in good repair for 2 (Hall X and Hall Y) of 2 (Hall X and Hall Y) shower rooms observed. The facility failed to ensure medication carts were clean and sanitary for 2 of 3 medication carts observed for medication storage. The facility failed to ensure residents' assistive devices were maintained in good working condition for 1(Resident #19) of a sample size of 31 Residents. The facility failed to maintain the air conditioner units in sanitary condition in 2 (Room A and Room B) of 2 (Room A and Room B) rooms observed for air conditioner filter status. The facility failed to ensure that the designated smoking area was maintained in a clean, safe, and comfortable environment for all smokers in the facility.
Findings.
1.
Observation on 10/03/2023 at 7:55 a.m. of the shower room on Hall X revealed trash and debris scattered on the floor upon entry. An opened, cluttered cabinet containing trash and bath items was observed on the right side of the wall in front of the shower area. A towel was noted on the floor at the entrance of the shower and a washcloth with brown stains was observed on the floor of the shower stall. Water was observed running from a showerhead, lying on the floor of the shower stall.
Interview on 10/03/2023 at 7:58 a.m. with S1 Administrator confirmed the bathroom was not clean and there were dirty linens on the floor and there should not have been.
Observation on 10/04/2023 at 7:52 a.m. of the shower room on Hall Y accompanied by S6 CNA revealed a 20 inch by 20 inch hole in the ceiling over the shower stall with exposed insulation and pipes. Interview with S6 CNA at the time of observation revealed the open area had been there since last week and the shower was used to shower residents in the facility.
Interview on 10/04/2023 at 7:55 a.m. with S4 Corporate confirmed there was an opening in the ceiling above the shower on Hall Y.
Interview on 10/04/2023 at 8:00 a.m. with S7 Maintenance revealed the facility had a contractor come last week to give bids for a wall replacement in the shower room. S7 Maintenance stated a ceiling tile had been removed for the contractor to see where the pipes were and had not been replaced and should have been.
2.
Observation on 10/04/2023 at 11:45 a.m. of 2 facility medication carts which were used for Hall W, Hall X, Hall Y, and Hall Z during the medication storage task revealed the presence of debris, dirt, and stains around the bottom of the carts and on the bottom drawers of the carts.
Interview on 10/04/2023 at 11:48 a.m. with S3 LPN revealed she cleaned the top her cart, but she did not get down on her hands and knees and clean the drawers and shelf around the bottom of the cart. Interview at this time with S4 Corporate confirmed the medication carts were dirty and should not be.
Interview on 10/04/2023 at 12:13 p.m. with S4 Corporate revealed that S1 Administrator stated the Housekeeping Supervisor was responsible for cleaning the medication cart. S4 Corporate stated she told S1 Administrator that the medication carts were dirty and needed to be cleaned.
3.
#19
Observation on 10/02/2023 at 1:00 p.m. revealed Resident #19 sitting in a wheelchair on the patio smoking. Multiple tears were noted on the right and left armrests of Resident #19's wheelchair.
Observation on 10/03/2023 at 10:10 a.m. revealed Resident #19 in a wheel chair in his room, with multiple tears noted on the right and left armrests.
Observation on 10/03/2023 at 12:25 p.m. revealed Resident #19 in a wheel chair in his room, with multiple tears noted on the right and left armrests.
Observation of Resident #19 on 10/03/2023 at 12:30 p.m. accompanied by S5 ADON confirmed the presence of tears in the armrest of Resident #19's wheelchair. S5 ADON stated/or confirmed Resident #19's wheelchair was in need of repair and/or replacement.
4.
Observation of Room A on 10/02/2023 at 10:30 a.m. revealed a wall mounted air conditioner unit with a dark, black, thick substance on the air vents. Observation of the filter revealed a thick layer of gray matter.
Observation of Room A on 10/03/2023 at 2:05 p.m. revealed the air conditioner vents and filter had not been cleaned.
Observation of Room B on 10/02/2023 at 12:00 p.m. revealed a wall mounted air conditioner unit with dark, black, thick substance on the air vents. Observation of the filter revealed a thick layer of gray matter.
Observation of Room B on 10/03/2023 at 2:10 p.m. revealed the air conditioner vents and filter had not been cleaned.
Observation of Room A and Room B's air conditioner units on 10/03/2023 at 3:00 p.m. accompanied by S7 Maintenance, revealed the vents were covered in a dark, black, thick substance and filters were covered in a thick layer of gray matter. Interview with S7 Maintenance at the time of observation revealed the vents and filters needed to be removed and cleaned. S7 Maintenance stated housekeeping was responsible for removing the filters weekly and washing/ replacing the filters. S7 Maintenance stated he was responsible for removing the air conditioner units out and cleaning the vents as needed.
5.
Observation of the smoking patio adjacent to Hall X on 10/02/2023 at 1:00 p.m. revealed 2 open top metal cans approximately 8 inches tall and 6 inches in diameter containing ashes, cigarette butts and partially smoked cigarettes; 2 foot pedal operated top ashtrays approximately 4 inches tall and 4 inches in diameter containing cigarette butts only; and 1 empty small pail type ashtray. There were multiple cigarette butts and partially smoked cigarettes near the doorway of the facility, on the patio surface, and among the grass and rock beds surrounding the patio.
Observation of the smoking patio on 10/03/2023 at 12:50 p.m. accompanied by S1 Administrator confirmed the above information after inspecting the patio area. S1 Administrator stated This a constant battle trying to keep this area clean.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maint...
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Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving, and nail care to dependent residents for 4 (Resident #2, Resident #19, Resident #56 & Resident #78) of 31 sampled residents.
Findings:
Review of the facility policy titled: Quality of Care, revealed in part: Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical functional status as determined by the comprehensive assessment and person-centered plan of care. 2 b a full bath at least 3 times weekly. 2 c. all residents shall also receive if applicable; nail care, shave, and oral care.
Resident #2
Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 11/17/2021 with diagnoses which included Epileptic Seizure, Cerebral Vascular Accident, Chronic Obstructive Pulmonary Disease, Essential (primary) hypertension and Atherosclerosis Heart Disease.
Review of Care Plan revealed Resident #2 needed assistance with bathing/hygiene related to late effects of Cerebral Vascular Accident limited range of motion to right upper extremity, with a target date of 11/05/2023. Approaches included, staff to provide late ADL assistance, and bathe per schedule.
Review of Resident #2's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/27/2023 revealed a BIMS (Brief Interview for Mental Status) of 11 (moderately impaired cognition). Resident #2 required one person physical assist with personal hygiene, bathing and showering. Resident was not stable, only able to stabilize with staff assistance.
Observation of Resident #2 on 10/02/2023 at 10:30 a.m. revealed long, untrimmed fingernails. Interview with Resident#2 at the time of the observation, stated her fingernails were too long and she would like to have them trimmed.
Observation of Resident #2 on 10/03/2023 at 12:15 p.m. revealed her fingernails remained long and untrimmed. Interview with Resident #2 at the time of the observation, stated she was not certain the last time that her fingernails had been trimmed.
Observation of Resident #2 on 10/03/2023 at 12:20 p.m. accompanied by S2 DON confirmed the above findings. Interview with Resident #2 at that time revealed it had been a long time (unable to recall) since her fingernails had been trimmed. Resident #2 stated no one had offered to trim her fingernails. S2 DON confirmed the resident fingernails were long and should have been trimmed and were not.
Resident #19
Review of Resident #19's EHR revealed an admission date of 12/15/2021 with diagnoses which included Myocardial Infarction, CVA, and Essential (primary) hypertension.
Review of Care Plan revealed Resident #19 needed assist with ADLs, right side Hemiparesis related to late effects of Cerebral Vascular Accident limited range of motion to right extremity, required extensive assistance with dressing and bathing. Goal- Resident will be assisted with ADLs, with a target date of 01/30/2024. Approaches included: assist with upper/lower body dressing.
Review of the Care Plan for Resident #19 revealed he required assistance with Bathing/Hygiene related to Cerebral Vascular Accident, resident needed staff assistance with ADLs.
Review of Resident #19's Quarterly MDS with an ARD of 07/20/2023 revealed a BIMS of 9 (moderately impaired cognition). Resident #19 required one person physical total assist with personal hygiene.
Observation of Resident #19 on 10/02/2023 at 1:00 p.m. revealed he had thick, bushy facial hair and long untrimmed fingernails. Resident #19 was noted to be drooling and had a foul mouth odor.
Observation of Resident #19 on 10/03/2023 at 10:10 a.m. revealed thick, bushy facial hair and long untrimmed fingernails. Resident #19 was noted to have his mouth opened with a foul mouth odor.
Observation of Resident #19 on 10/03/2023 at 12:25 p.m. revealed he continued to have thick, bushy facial hair, long untrimmed fingernails and a foul mouth odor.
Observation of Resident #19 on 10/03/2023 at 12:30 p.m. accompanied by S5 ADON confirmed the above findings. S5 ADON confirmed the resident should have been shaved, fingernails trimmed and oral care performed and had not.
Resident #56
Review of Resident #56's EHR revealed an admission date of 11/17/2020 with diagnoses which included Bipolar Disorder, Major Depressive Disorder, Unspecified Dementia, Type 2 Diabetes Mellitus, Psychotic Disorder, and Essential (primary) hypertension.
Review of the Care Plan revealed Resident #56 had a Diagnosis of Dementia and required assistance with hygiene and dressing needs. Goal included, resident will be clean and free of body odor, and neatly dressed with a target date of 11/08/2023. Approaches included, assist resident in dressing needs, set up and assist with grooming needs, and encourage resident to actively participate in self-care.
Review of Resident #56's Quarterly MDS with an ARD of 09/28/2023 revealed a BIMS of 4 (Severely Impaired Cognition). Resident #56 required extensive one person physical assist with personal hygiene of bathing/showering and required one person assist to meet his ADLs needs.
Observation of Resident #56 on 10/02/2023 at 11:45 a.m. sitting at his bedside revealed he had a thick mustache, brittle stubby facial hair, and long untrimmed fingernails and toenails. Interview with Resident #56 during the observation revealed he was interviewable, and answered all questions asked with appropriate responses. Resident #56 stated he needed to be shaved and his fingernails/toenails were too long.
Observation of Resident #56 on 10/03/2023 at 9:40 a.m. revealed he continued to have a thick mustache, brittle stubby facial hair, and long untrimmed fingernails.
Observation of Resident #56 on 10/03/2023 at 11:50 a.m. in the dining room accompanied by S2 DON confirmed Resident #56 was in need of a shave and his fingernails needed to be trimmed and were not. S2 DON stated she would check Resident #56's toenails once he returned to his room.
Observation of Resident #56 on 10/03/2023 at 12:35 p.m. accompanied by S5 ADON confirmed Resident #56's toenails needed to be trimmed and were not.
Resident #78
Review of Resident #78's EHR revealed an admission date of 06/07/2023, with diagnoses which included Type 2 Diabetes Mellitus, Gastrostomy, Major Depressive Disorder, and Hypertensive Heart Disease.
Review of the Care Plan revealed Resident #78 required one person total assist with ADLs; total assist with bathing and oral care; and approaches included: RN clip nails
Review of Resident #78's Quarterly MDS with an ARD of 08/22/2023 revealed a BIMS of 13 (cognitively intact). Resident #78 required extensive one person physical assist with personal hygiene/bathing/showering, and required one person assist to meet his ADL needs.
Observation of Resident #78 on 10/02/2023 at 12:00 p.m. revealed Resident #78 was noted to have long brittle facial hair and long untrimmed fingernails. Interview with Resident #78 at the time of the observation stated he would like to be shaved and have his fingernails trimmed.
Observation of Resident #78 on 10/03/2023 at 10:00 a.m. and 12:05 p.m. revealed he had long brittle facial hair and long untrimmed fingernails.
Observation of Resident #78 on 10/03/2023 at 12:10 p.m. accompanied by S2 DON confirmed Resident #78 needed to be shaved and his fingernails needed to be trimmed and were not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and p...
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Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by:
1.
Failing to answer or respond to call light in a timely manner for 5 (#6, #9, #17, #18, #34) residents out of a total sample of 31,
2.
Failing to provide incontinent care for residents who require assistance in a timely manner for 2 (#17 and #42) out of a total sample of 31,
3.
Failing to honor resident's preferences for bedtime for 1 (#18) out of 31,
4.
Failing to bathe residents who require assistance for 2 (#31 and #51) out of a total sample of 31, and
5.
Failing to round or check in on residents who require assistance every two hours for 1 (#6) out of a total sample of 31.
Findings:
Resident Council
Interviews conducted on 10/02/2023 at 1:00 p.m. during the facility Resident Council Meeting revealed 13 residents in attendance out of a total facility census of 86.
Three residents including Resident # 6 (BIMS of 15, cognitively intact) and Resident #9 (BIMS of 15, cognitively intact) stated that CNAs are not introducing themselves when they enter their rooms so the residents do not know who they are. Resident #6 stated when CNAs come on for the 3 p.m.-11 p.m. shift, they are not making rounds. Resident #6 stated sometimes it is 7:00 p.m. before a CNA came into her room. Multiple residents including Resident #6 and Resident #9 stated there were not enough CNAs (all shifts); the facility could not keep CNAs; and that the CNAs who were working were not doing the job they should be doing. Multiple residents including Resident #6 and Resident #9 stated they would use their call light and a CNA would come and cut it off and tell them they would be back and never return. Numerous residents stated they had to wait a long time for assistance. Resident #6 stated sometimes up to 3 hours.
Review of the Resident Council Meeting Minutes for July 26, 2023 revealed residents voiced complaints that there were not enough CNAs at night. There were 9 residents in attendance.
Review of the Resident Council Meeting Minutes for August 15, 2023 revealed complaints that CNA's need to learn manners. Residents would like to see administration more. There were 10 residents in attendance
Review of the Resident Council Meeting Minutes for September 13, 2023 revealed complaints of needing more CNAs. There were 8 residents in attendance.
Review of the Resident Council Meeting Minutes for October 2, 2023 revealed complaints concerning CNA staff at night, CNA's aren't reporting or making themselves known during the 3-11 shift. It was discussed that there were not enough CNAs during all shifts and that they were having to wait a long time for assistance from CNA's. There were 13 residents in attendance.
Resident #18
In an interview on 10/02/2023 at 10:00 a.m., Resident #18 stated she goes to dialysis three times per week. Resident #18 stated when she returns from dialysis she would like to be put back in bed but the staff just leave her in her wheelchair. Resident #18 stated she returns from dialysis at about 3:00 p.m., asks to be put back in bed, but staff make her wait until after supper was finished and after they have fed everyone, which is around 7:30 p.m. or 8:00 p.m. Resident #18 stated when she returns from dialysis, she is weak, feels like she is going to pass out, and just wants to lay down. Resident #18 said she had reported this problem to multiple nurses.
In an interview on 10/04/2023 at 8:45 a.m., Resident #18 stated she has sat in her room with the call light on for 3 hours waiting to be put to bed. Resident #18 said once recently she started hollering Help when a CNA was in the hall. Resident #18 said the CNA came in and said If you can holler like that, you can wait your turn. You're not hurting that bad. Resident #18 said she told her she had been waiting for hours.
Review of Resident #18's medical record revealed an admit date of 04/19/2022 with diagnoses that included, in part Heart Failure, Chronic Kidney Disease, Stage 5, and Dependence on Renal Dialysis.
Review of Resident #18's 06/20/2023 quarterly MDS revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of the MDS revealed Resident #18 require limited assistance by one person physical assist with bed mobility, extensive assistance by one person with transferring and toilet use, supervision with set up help with eating, and did not reject care.
Resident #31
In an interview on 10/02/2023 at 9:36 a.m., Resident #31 stated he only gets a bath once per week if he's lucky. Resident #1 stated he gets taken down to whirlpool maybe once a week but staff won't turn on the whirlpool. Resident #31 stated staff don't give him bed baths either. Resident #31 said he doesn't refuse bathing ever. Resident #31 said when he asks why he never got bathed on the previous day, staff say it is because they were too busy.
Review of Resident #31's yearly MDS with an ARD of 07/18/2023 revealed a BIMS score of 14 which indicated the resident was cognitively intact. Review of the MDS revealed Resident #31 required physical help in part of the bathing activity by one person physical assist and did not reject care.
Review of Resident #31's September 2023 ADL log revealed Resident #31 received 3 baths for the month and documented the resident declined twice.
Review of Resident #31's care plan revealed no care plan concerns related to the resident refusing baths.
Resident #51
In an interview on 10/02/2023 at 11:54 a.m., Resident #51 stated she had only been bathed by staff 4 times since she was admitted in January 2023. Resident #51 stated the CNAs come around and ask if she wants a bath and then never come back to bathe her. In an interview on 10/03/2023 at 2:03 p.m., Resident #51 stated she never refused any baths.
Review of Resident #51's Quarterly MDS with an ARD of 07/13/2023 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #51 required physical help limited to transfer only by one person physical assist with bathing and did not reject care.
Reveal of the September 2023 ADL log revealed Resident #51 received one whirlpool/tub bath in September and documented 3 refusals.
Review of Resident #51's care plan revealed she was not care planned for refusals of care.
Resident #17
Interview on 10/02/2023 at 12:35 p.m. with Resident #17 revealed it took an average time of one hour for staff to respond to his call light. Resident #17 stated he sometimes falls asleep in his wheelchair waiting for staff to answer and when he wakes up someone has come in and turned the light off. Resident #17 stated he used the clock on his wall to time the staff.
Review of Resident #17's Quarterly MDS with an ARD of 09/14/2023 revealed Resident #17 had a BIMS of 15 (cognitively intact); did not reject care; was always incontinent of bowel and bladder; had ROM limitation in both lower extremities; and required the extensive assistance of 1 person for toileting and personal hygiene.
Interview on 10/04/2023 at 2:40 p.m. with S3 LPN revealed Resident #17 would occasionally vent about night staff not changing him. S3 LPN stated she did not report Resident #17's complaints to administration because it would not do any good.
Interview on 10/04/2023 at 2:45 p.m. with S6 CNA revealed she worked the 7:00 a.m. to 3:00 p.m. shift. S6 CNA stated Resident #17 had complained to her about not being changed on the night shift. S6 CNA stated Resident #17 told her staff would come in and turn his call light off and say they're coming back to change him and never return. S6 CNA stated she had told S3 LPN about Resident #17's complaints.
Interview on 10/04/2023 at 2:50 p.m. with S10 CNA revealed she worked the 7:00 a.m. to 3:00 p.m. shift. S10 CNA stated Resident #17 had reported to her that he sometimes sits in his wheelchair wet all night because it took hours for someone to come and change him. S10 CNA stated Resident #17 last complained to her about not being changed on Sunday (10/01/2023). S10 CNA stated she had not reported Resident #17's complaints to anyone.
Resident #9
In an interview on 10/02/2023 at 10:31 a.m., Resident #9 stated she may have to wait 1 to 1.5 hours before someone came to assist her after calling for assistance.
Review of Resident #9's annual MDS with an ARD of 09/07/2023 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #9 required one person assist with toilet use; two person assist with transferring; extensive assistance by one person with bed mobility; and did not reject care.
Resident #34
In an interview on 10/02/2023 at 11:24 a.m., Resident #34 stated he had to wait a long time to get assistance at times. He stated he did not know the exact time, but it was too long.
Review of Resident #34's quarterly MDS with an ARD of 07/06/2023 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #34 was totally dependent on one person physical assistance with bed mobility and toilet use; was totally dependent on two person physical assist with transferring; and did not reject care.
Resident #42
In an interview on 10/02/2023 at 10:08 a.m., Resident #42 stated he had to wait 8-10 hours to get a diaper changed. Resident #42 stated he may get changed at 11:00 a.m. then not again until 11:00 a.m. or 12:00 p.m. the next day.
Review of Resident #42's quarterly MDS with an ARD of 09/08/2023 revealed a BIMS score of 10, which indicated the resident had moderately impaired cognition. Review of the MDS revealed Resident #42 required extensive two person physical assistance with bed mobility, toilet use, and transferring and did not reject care.
In an interview on 10/04/2023 at 1:10 p.m., S5 ADON/CNA Supervisor confirmed the facility had been having a difficult time with CNA staffing. S5 ADON stated the CNAs call in a lot and don't want to work the weekends. S5 ADON confirmed she had received complaints from the residents about not enough staffing coverage and not being bathed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect th...
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Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 82 residents that received meals prepared by the kitchen. Findings:
Observation on 10/02/2023 at 9:00 a.m. of the facility's dry storage room accompanied by S9 Dietary Manager revealed the following items on shelves for use: (1) unopened gallon jug of dijon honey mustard dressing with an expiration date of 08/17/2023 and (1) opened gallon jug of soy sauce with an expiration date of 09/30/2022. S9 Dietary Manager confirmed findings at the time of observation.
Observation on 10/02/2023 at 9:10 a.m. of the facility's walk in cooler accompanied by S9 Dietary Manager revealed (1) 64 ounce package of low fat vanilla yogurt on the shelf for use with an expiration date of 09/24/2023. Findings confirmed with S9 Dietary Manager at the time of observation.
Observation on 10/02/2023 at 9:15 a.m. of facility's upright cooler revealed the following items on the shelves for use: (1) 5lb. opened and undated container of pimento cheese spread and (1) opened gallon of dijon mustard dressing, dated as being opened on 12/08/2021. Observation of the 5lb. containers contents revealed the pimento spread was covered with mold.
Interview on 10/02/2023 at 9:17 a.m. with S9 Dietary Manager confirmed the opened 5lb. container of pimento cheese was undated, contained mold and should have been discarded and had not been. S9 Dietary Manager also confirmed the opened gallon of dijon honey mustard dressing had been opened over 18 months ago and should have been discarded but had not been.
Aug 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of funds/ex...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of funds/exploitation for 1 (#6) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents reviewed for abuse. Findings:
Resident #6
Review of Resident #6's medical record revealed an admit date of 07/04/2023, with diagnoses that included in part .Quadriplegia, Major Depressive Disorder, Restlessness and Agitation, Schizophrenia, and Pressure Ulcer of sacral region, Stage 4.
Review of Resident #6's admission MDS with an ARD of 07/14/2023 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #6 was totally dependent on two person physical assist with bed mobility, transferring, and toilet use. Resident #6 required limited assistance by one person with eating.
In an interview on 08/02/2023 at 4:45 p.m., Resident #6 stated that on 07/19/2023, a staff member stole $1,900 from him out of his friend/RP's (Responsible Party) car. Resident #6 stated he and his friend/RP were in front of the facility and his friend/RP was having a hard time getting him out of her car into a wheelchair. Resident #6 stated he had $1,900 in a bank envelope on the car console. Resident #6 stated S6 Housekeeper came out and reached inside the car to help get him out, then ran back in the facility, and returned a short time later. Resident #6 stated S6 Housekeeping took his money when he reached inside the car.
Review of a Grievance filed 07/19/2023 by Resident #6's friend/RP revealed S5 Administrator registered this complaint. The Grievance revealed in part .
Nature of complaint: Resident #6's RP/friend states that resident continuously calls her at all hours of day/night complaining of being soiled. She also complains resident never receives a bath.
Summary: Administrator visited with resident regarding the alleged concerns. Administrator asked resident if he had any concerns regarding his care at the facility, and resident replied, No, I'm ok. Administrator asked resident if he wanted to continue residing at the facility or did he want to go to another facility and resident stated, Nope, I'm good here (while pointing downward to the floor). DON interviewed resident regarding alleged concerns (bathing and stolen money) and resident states, That (his friend/RP) got my money! I can't prove it, but I know she got it. Ha ha ha ha. She owes me!
Date of discussion with resident - 07/20/2023.
Name of who complaint was discussed with and details: Administrator discussed resident interview with his friend/RP, who stated she did not want to be on anything of his anymore and she was tired of all his problems affecting her own life at home. Administrator informed resident RP/friend that Administrator would speak with resident regarding self-responsibility. Administrator spoke with resident regarding RP removal, and resident stated, Uh huh, she owes me! while laughing to self. Administrator asked resident if he wanted to make a police report against friend regarding the civil matter, and resident stated No, that's my girlfriend. Is matter resolved? Yes. Admissions Coordinator assisted resident with signing appropriate documentation for self-responsibility.
Review of nurses' notes for Resident #6 revealed the following entries:
07/19/2023 at 1:21 p.m. by Agency LPN: Approx. 1:10 p.m. Resident noted in facility parking lot with female friend in white 2 door car. Resident noted in a sitting position on side of car. No injuries noted at this time. Resident noted cursing and screaming at female friend for money. No money noted at present time while helping Resident into his wheelchair. DON made aware. Female friend noted looking around car for money. After assisting Resident to a sitting position in wheelchair female friend noted getting money out of a bag noted in the white car and giving money to the Resident. Unsure of amount. Resident continue to scream and asking for his money. DON noted asking Resident if he was coming in facility Resident stated no and cont to scream at female friend for his money. Safety maintained Resident noted in wheelchair with two foot pedals wheels locked. Will continue to monitor.
07/19/2023 at 1:37 p.m.: Resident escorted by female friend into facility. Resident noted sitting upright in wheelchair with 2 foot pedals in room ____ By Agency LPN
In an interview on 08/03/2023 at 10:29 a.m., S1 DON stated on 07/19/2023, therapy summoned her to the outside of the building, and when she arrived out in front of the building, Resident #6 and his friend/RP were screaming and hollering. S1 DON said Resident #6 was hollering at her saying, Give me my money! S1 DON said his friend/RP reached in her purse and grabbed out several hundred dollar bills. S1 DON said Resident #6 screamed he wanted all of his money. S1 DON stated his friend/RP then stood up and leaned over the hood of the car and said to staff If y'all took his money, give it to him! S1 DON stated she told the employees, If you work for [NAME], go back inside the building and that this was between the two of them (meaning Resident #6 and his friend/RP).
In an interview at 10:40 a.m. on 08/03/2023, Resident #6 stated he reported to S1 DON multiple times that S6 Housekeeper took his money. Resident #6 stated, Everyone here knows, all the nurses know he took my money. Resident #6 said S1 DON told me my friend/RP took the money. Resident #6 stated on 07/19/2023, they went to the bank. Resident #6 stated he gave his friend $1100 and kept $1900 in an envelope for himself. He said his bank envelope with the $1900 was on the console of the car. Resident #6 stated S6 Housekeeper helped him get out of the car, and reached in the car with his arm and his leg to help me. Resident #6 stated after that point, he told his friend/RP to get his money and the $1900 was missing. Resident #6 said his friend/RP then split the $1100 with him because his money (the $1900) was missing. Resident #6 said he did think his friend/RP had taken his money at first, but then realized that didn't make any sense because she wouldn't steal from me.
In an interview on 08/03/2023 at 11:30 a.m., S5 Administrator stated there was a situation where Resident #6's friend took him to the bank. S5 Administrator said when they returned from the bank, Resident #6 had fallen in the parking lot outside near her car. S5 Administrator stated a Housekeeper was out front and called her supervisor, S6 Housekeeper for assistance. S5 Administrator stated S6 Housekeeper assisted the resident to sit up while outside. S5 Administrator stated S1 DON went out there and told staff to go back inside because the resident was screaming at his friend/RP to give him his money. S5 Administrator stated an agency nurse came out and assisted him back to the wheelchair. S5 Administrator stated the nurse reported his friend reached in her purse and gave Resident #6 money, they stopped fussing, and came inside. S5 Administrator said then Resident #6's friend came into her office complaining about Resident #6 not being changed and bathed. S5 Administrator said the friend said she wanted her name off Resident #6's record because it was causing too many issues in her life. S5 Administrator said we changed the resident to his own RP. S5 Administrator stated no one ever accused staff of taking the money and Resident #6 accused his friend of taking it. S5 Administrator stated the next day, she asked Resident #6 if he wanted to call police and he said no. S5 Administrator stated Resident #6's friend called back to the facility a day or two later and wanted to know if they had camera footage of the front of the building, and she (S5 Administrator) said she told her no. S5 Administrator was asked to provide any investigation she had conducted into Resident #6's missing money. S5 Administrator confirmed she did not investigate the incident for misappropriation of Resident #6's funds because it was a civil matter between Resident #6 and his friend. S5 Administrator denied ever being told Resident #6 accused staff of stealing his money.
In a telephone interview on 08/03/2023 at 12:00 p.m., Resident #6's friend/former RP stated the money was on the console of the car, and she was trying to get him out of the car on the passenger side. She said a guy who worked for the facility (S6 Housekeeper) reached in the car to grab Resident #6's left arm to pull him out, and grabbed the money. She said he then ran inside the facility and came back to the car a short time later. Resident #6's friend/former RP stated that she said to S6 Housekeeper, Where's Resident #6's money? She said she told S6 Housekeeping to empty his pockets, and S6 Housekeeper said the money was in my purse. She said there were about 5 nurses present out there (she didn't know their names), and they said they were going to call the police, and she was glad. Resident #6's friend stated she waited, but the police never came, so she rolled Resident #6 inside the facility. Resident #6's friend stated she told the Administrator multiple times that S6 Housekeeper took the money, and asked the Administrator to check the cameras and the Administrator told her it didn't show anything. She said she asked to see the camera footage, but the Administrator refused to let her see the camera footage. She said she had filed a police report but hadn't heard back from them yet. Resident #6's friend stated during the incident, she screamed at the staff present and yelled, (S6 Housekeeper) just took Resident #6's money! Resident #6's friend/former RP stated when she reported the theft to the Administrator, S5 Administrator told her the facility had reputable employees and they would never steal.
In an interview on 08/07/2023 at 10:51 a.m., S7 Rehab Director confirmed three of her employees, S8 SLP, S9 PTA, and a PT who no longer worked here went out to the car on 07/19/2023. S7 Rehab Director stated last week they were asked to write statements about it, and the Administrator should have them.
In an interview on 08/07/2023 at 11:09 a.m., S6 Housekeeper stated he went out to help Resident #6. S6 Housekeeper stated Resident #6 was on the ground laying down and screaming and telling his friend to give him his money. S6 Housekeeper stated he just sat him (Resident #6) up in a sitting position. S6 Housekeeper denied ever reaching inside Resident #6's friend's car. S6 Housekeeper said, No, all I did was sit him up on the ground, and then the DON came out and took over. S6 Housekeeper said the DON instructed us to go back in the facility at that point.
In an interview on 08/07/2023 at 11:21 a.m., S1 DON confirmed during the incident, Resident #6's friend/RP stood up and leaned over the hood of the car and yelled out to staff, If y'all took his money, give it to him. S1 DON stated she did not investigate the money being missing because she felt like it was a civil issue. S1 DON stated she had not been asked to write any statements about what occurred on 07/19/2023.
In an interview on 08/07/2023 at 11:15 a.m., S5 Administrator confirmed she did not investigate Resident #6's money being missing because she felt like it was a civil matter.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the plan of care to meet the needs of 1 (#3) of 6 (#1, #2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the plan of care to meet the needs of 1 (#3) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to complete Resident #3's daily wound care as per physician's orders.
Findings:
Review of Resident #3's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Type 2 Diabetes Mellitus, Unspecified Severe Protein Calorie Malnutrition, Dependence on Renal Dialysis, Pressure Ulcer of Sacral Region-Stage 4, Urinary Tract Infection, Infections of Central Nervous System, and Drop Foot- Left and Right.
Review of Resident #3's Quarterly MDS with an ARD of 05/02/2023 revealed in part . Resident #3 had BIMS of 15 (Cognitively intact) and was totally dependent on staff for transfers, toileting, and bathing. Resident #3 required extensive, 1 person physical assist for personal hygiene. Resident #3 had 1 pressure ulcer-stage 4.
Review of Resident #3's Care Plan read in part Resident had a stage 4 pressure ulcer to sacrum. Interventions included: Turn and Reposition per schedule. Observe skin daily with ADL care or bath and report any problems to nurse. Weekly body audit. Observe current treatment for effectiveness.
Review of Resident #3's 08/2023 Physician Orders read in part . Stage 4 sacrum, cleanse with wound cleanser, pat dry, apply tincture of benzoin soaked gauze to peri wound then apply Santyl with gauze to wound, cover with dry dressing every day until resolved.
Interview with Resident #3 on 08/01/2023 at 10:20 a.m. revealed she had concerns of staff not performing dressing changes to her sacral wound daily.
Review of Resident #3's 07/2023 TAR revealed Resident #3 had above order for wound care to sacrum that had not been performed on 07/03/2023, 07/05/2023, 07/07/2023, 07/19/2023, 07/21/2023, and 07/28/2023.
Interview on 08/02/2023 at 3:05 p.m. with S2 Treatment LPN revealed she was responsible for completing daily dressing changes on Resident #3's sacral wound. Reviewed Resident #3's 07/2023 TAR with S2 Treatment LPN. S2 Treatment LPN stated she would have to go back and change the documentation on TAR to place a note because she did perform dressing changes on Resident # 3 daily when she was scheduled to work. S2 Treatment LPN stated on Resident's dialysis days, wound care is sometimes done before or after dialysis, but it was not documented on the TAR.
Interview on 08/02/2023 at 3:09 p.m. with S1 DON revealed Resident #3 did not have documented wound care performed on 07/03/2023, 07/05/2023, 07/07/2023, 07/19/2023, 07/21/2023, and 07/28/2023. S1 DON confirmed daily dressing changes for wound care should be documented as completed on the TAR, but was not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Da...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#3 and #4) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure Resident's (#3, #4) received a bath on their scheduled bath days.
Findings:
Review of the facility policy titled: Bathing read in part . Bathing- General Principals: To cleanse the body and promote skin health. Document in the clinical record.
Resident #3
Review of Resident #3's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Type 2 Diabetes Mellitus, Unspecified Severe Protein Calorie Malnutrition, Dependence on Renal Dialysis, Pressure Ulcer of Sacral Region-Stage 4, Urinary Tract Infection, Infections of Central Nervous System, and Drop Foot- Left and Right.
Review of Resident #3's Quarterly MDS with an ARD of 05/02/2023 revealed in part . Resident #3 had BIMS of 15 (Cognitively intact) and was totally dependent on staff for transfers, toileting, and bathing. Resident #3 required extensive, 1 person physical assist for personal hygiene.
Review of Resident #3's Care Plan revealed in part Resident needed staff assistance with late loss ADLS. Interventions included: Staff to provide late loss ADL care.
Interview with Resident #3 on 08/01/2023 at 10:20 a.m. revealed she had concerns of staff not bathing her on her scheduled days. Resident #3 stated she was to receive showers on Monday, Wednesday, and Friday, but she had not consistently received them.
Interview with S3 ADON on 08/01/2023 at 4:30 p.m. revealed the facility's current bathing schedule was female residents receive baths on Monday, Wednesday, and Friday and male residents on Tuesday, Thursday, Saturday. S3 ADON stated she was currently working on a new bathing schedule to improve the bathing process as there were identified concerns with the current schedule.
Review of Resident #3's Completed Care ADL documentation record for 07/2023 revealed Resident #3 had 1 documented bath on 07/28/2023, and Resident #3 did not receive a bath on 07/27/2023, 07/25/2023, 07/22/2023, and 07/10/2023 with documented reasons other-not bath day and Rescheduled.
Interview with S1 DON on 08/02/2023 at 2:00 p.m. revealed Resident #3 was to receive baths on Monday, Wednesday, and Friday. S1 DON stated staff are to document when Resident's are given a bath within the Resident's ADL record. S1 DON reviewed Resident #3's Completed Care ADL record and confirmed Resident #3 had 1 documented bath for 07/2023. S1 DON confirmed this information was the only documentation the facility had regarding bath's completed for Resident #3. S1 DON stated the CNAs did not document baths provided for Resident #3 within her medical record, but should have.
Resident #4
Review of Resident #4's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Dependence on Renal Dialysis, Major Depressive Disorder, Type 2 Diabetes Mellitus, Urinary Tract Infection, Unspecified Dementia, and Unspecified Sequelae of Cerebral Infarction.
Review of Resident #4's Quarterly MDS with an ARD of 05/23/2023 revealed in part . Resident #4 had BIMS of 15 (Cognitively intact) and required Supervision, setup help for Dressing and Personal Hygiene.
Review of Resident #4's Care Plan revealed in part Resident needed set up and supervision with ADLS (Dressing, Toileting, Bathing). Interventions included: Shower/Bathe per schedule, set up supplies for dressing and grooming.
Interview with Resident #4 on 08/01/2023 at 11:40 a.m. revealed she had concerns of staff not consistently bathing her. Resident stated she was unsure if she had scheduled days, but did not receive a bath consistently.
Review of Resident #4's Completed Care ADL documentation record for 07/2023 revealed Resident #4 had 4 documented baths on 07/14/2023, 07/11/2023, 07/06/2023, and 07/04/2023 and Resident #4 did not receive a bath on 07/20/2023, 07/17/2023, and 07/13/2023 with documented reasons other-not bath day and evening shift.
Interview with S1 DON on 08/02/2023 at 2:00 p.m. revealed Resident #4 was to receive baths on Monday, Wednesday, and Friday. S1 DON stated staff are to document when residents are given a bath on the Resident's ADL record. S1 DON reviewed Resident #4's Completed Care ADL record and confirmed Resident #4 had 4 documented baths for 07/2023. S1 DON confirmed this information was the only documentation the facility had regarding bath's completed. S1 DON stated the CNAs did not document ADL care provided for Resident #4 within her medical record, but should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and atta...
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Based on record review and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This was evidenced by a licensed practical nurse administering a medication to treat low blood pressure to Resident #1 with an elevated systolic blood pressure.
Findings:
Review of Resident #1's medical record revealed an admit date of 06/07/2023 with diagnoses that included in part .Hypotension, Hemiplegia following Cerebral Infarction, ESRD, and Dependence on Renal Dialysis.
Review of Resident #1's MDS with an ARD of 07/03/2023 revealed a BIMS score of 12, which indicated the resident had mildly impaired cognition. Review of the MDS revealed Resident #1 required extensive assistance by two persons with bed mobility and toilet use and was totally dependent on two persons with transferring.
Review of Resident #1's physician's orders revealed an order dated 06/27/2023 for Midodrine HCL 10 mg po three times a day. Do not give past 6 p.m. Review of the orders revealed an order dated 06/27/2023 for Dialysis three times per week on Tuesday, Thursday, and Saturday.
Review of Resident #1's nurses' notes revealed the following:
07/25/2023 at 1:02 p.m.: Resident out to dialysis via facility transportation. He left the facility in stable condition via facility transportation. Vital Signs: blood pressure 151/54, Pulse 98, Respirations 20, temperature 97.6. By S12 LPN.
Review of Resident #1's July 2023 MAR revealed Resident #1 received Midodrine (a medication used to treat low blood pressure) 10mg by mouth three times per day at 8:00 a.m., 12:00 p.m., and 4:00 p.m. with his blood pressure recorded with each dose. On 07/25/2023 the 8:00 a.m. dose was marked as given by S12 LPN and Resident #1's blood pressure was documented as 151/54. Review of the nurses' documentation at the end of the July 2023 MAR revealed the following:
10:52AM, 07/25/2023 (Scheduled 8:00 a.m., 07/25/2023, Midodrine HCL 10mg Tablet)
Pre Admin Blood Pressure-Generic: 151/54 / 07/25/2023 10:52 a.m. S12 LPN
In an interview on 08/01/2023 at 3:00 p.m., S12 LPN stated Resident #1 was stable when he left for dialysis on 07/25/2023. She said he was sitting up in a wheelchair alert and talking, like his normal status. S12 LPN stated the nurse called from dialysis and told her his blood pressure was up that day. S12 LPN stated she told the dialysis nurse she had given him medication to bring it up earlier that day. S12 LPN stated his blood pressure was fine that morning when she gave it to him but did not remember what his blood pressure was and didn't record it. S12 LPN stated the 151/54 was his blood pressure when he was leaving the facility to go to dialysis.
In a telephone interview on 08/01/2023 at 11:45 a.m. the Dialysis RN stated on 07/25/2023, Resident #1 was only at dialysis for about 15 minutes that day. She said they took his vital signs and his systolic blood pressure was 201. She said she talked with the doctor about it, called the nursing facility, and then sent him to the ER by ambulance. She stated Resident #1 was very drowsy and they had to use a sternal rub to get him to come to. She stated she called the nursing facility and spoke with the resident's nurse who told her she had given Resident #1 Midodrine that morning when his systolic blood pressure was 150 and the nurse didn't know that was a problem.
Review of the hospital records Emergency Provider report dated 07/25/2023 revealed Resident #1 was sent to the ER from dialysis with a change in mental status and patient complaint of hiccups. History and physical stated he only answers some questions and does seem confused. Patient was reportedly not dialyzed today because he was drowsy. Patient reportedly hypertensive at dialysis. Report that Nursing Home gave patient his Midodrine with initial systolic blood pressure of 150s.
Blood Pressure 211/103 at 12:38 p.m. on 07/25/2023 in ER.
In a telephone interview on 08/07/2023 at 10:31 a.m., S11 Medical Director was notified the facility nurse administered Midodrine 10 mg to Resident #1 when his blood pressure was 151/54. S11 Medical Director confirmed S12 LPN should not have given the medication.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that 4 (#2, #3, #4, and #5) out of 5 sampled residents who...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that 4 (#2, #3, #4, and #5) out of 5 sampled residents who required dialysis (#1, #2, #3, #4, #5) residents, received such services, consistent with professional standards of practice as evidenced by failing to ensure there was ongoing communication, coordination and collaboration between the nursing home and the dialysis staff.
Findings:
Resident #2
Review of Resident #2's medical record revealed an admit date of 06/22/2023 with diagnoses that included in part .Non-displaced fracture of the left femur, Encounter for orthopedic aftercare, ESRD, Dependence on renal dialysis, and Heart failure.
Review of Resident #2's current physician's order revealed an order for the resident to receive dialysis three days per week on Monday, Wednesday, and Friday.
Review of Resident #2's Dialysis communication sheets for the month of July 2023 revealed only two completed dialysis communication sheets. In an interview on 08/01/2023 at 4:12 p.m., S2 DON confirmed these two communication sheets were the only completed ones they could locate for Resident #2 for July 2023.
In an interview on 08/02/2023 at 3:30 p.m., S1 DON stated the dialysis communication sheets should return to the facility with the resident from dialysis but dialysis doesn't always send them back. S1 DON confirmed when the dialysis communication sheets didn't come back to the facility with the residents, the nurses should have called dialysis to get the sheet at that time.
Resident #3
Review of Resident #3's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Type 2 Diabetes Mellitus, Unspecified Severe Protein Calorie Malnutrition, Dependence on Renal Dialysis, Pressure Ulcer of Sacral Region-Stage 4, Urinary Tract Infection, Infections of Central Nervous System, and Drop Foot- Left and Right.
Review of Resident #3's Quarterly MDS with an ARD of 05/02/2023 revealed in part . Resident #3 had BIMS of 15 (Cognitively intact) and received dialysis treatments.
Review of Resident #3's Care Plan revealed in part Resident received dialysis three times a week on Monday/Wednesday/Friday. Interventions included: Check shunt site daily for bruit or thrill, pain, swelling, redness, excessive warmth, drainage. Diet as ordered.
Review of Resident #3's 07/2023 Dialysis Communication Forms revealed 6 forms with dates of: 07/03/2023, 07/05/2023, 07/17/2023, 07/21/2023, 07/24/2023, and 07/26/202.
Interview on 08/01/2023 at 4:20 p.m. with S4 Corporate RN revealed Resident #3 had 6 completed communication forms for 07/2023. S4 Corporate RN stated the facility is to complete and keep on file each residents dialysis communication form, but the facility had not.
Resident #4
Review of Resident #4's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Dependence on Renal Dialysis, Major Depressive Disorder, Type 2 Diabetes Mellitus, Urinary Tract Infection, Unspecified Dementia, and Unspecified Sequelae of Cerebral Infarction.
Review of Resident #4's Quarterly MDS with an ARD of 05/23/2023 revealed in part . Resident #4 had BIMS of 15 (Cognitively intact) and received dialysis treatments.
Review of Resident #4's Care Plan revealed in part Resident received dialysis three times a week on Monday/Wednesday/Friday. Interventions included: Weights as ordered. Check shunt site daily for bruit or thrill, pain, swelling, redness, excessive warmth, drainage. Diet as ordered.
Review of Resident #4's 07/2023 Dialysis Communication Forms revealed there were no completed forms for: 07/05/2023, 07/14/2023, and 07/31/2023.
Interview on 08/01/2023 at 4:12 p.m. with S1 DON revealed each resident who received dialysis services had dialysis communication forms located within a dialysis communication binder. S1 DON stated the residents brought the form to and from dialysis. S1 DON stated the nurse assessed resident upon return to facility and completed the dialysis communication form. S1 DON stated the facility had trouble locating some of the dialysis communication forms. S1 DON confirmed nursing staff should have completed the dialysis communication form for Resident #4 on 07/05/2023, 07/14/2023, and 07/31/2023, but had not.
Interview on 08/02/2023 at 10:00 a.m. with S4 Corporate RN revealed the facility had in-services in progress for dialysis communication procedures. Resident #4's 07/2023 Dialysis communication forms reviewed with S4 Corporate RN, and forms for: 07/05/2023, 07/14/2023, and 07/31/2023 were not completed. S4 Corporate RN confirmed the facility is to complete and keep on file each residents dialysis communication forms, but had not.
Resident #5
Review of Resident #5's medical record revealed an admission date of 05/03/2023 with diagnoses to include: Unspecified Fracture of right lower leg, Atherosclerosis of coronary, Local infection of the skin and subcutaneous tissue, End Stage Renal Disease, Iron Deficiency, Type 2 Diabetes, and Hypothyroidism, and Pain.
Review of Resident #5's medical record and MDS with an ARD of 05/10/2023 revealed a BIMS 15, which indicated the resident was cognitively intact.
Review of Resident #5's Physician Orders revealed an order to check tunnel Catheter Site to Right Chest Wall for Bruit or Thrill. Check for pain, swelling, redness, heat, drainage (s/s infection), check for coolness, dark blood, absence of bruit (s/s clotting), check for erosion of skin and bleeding. Obtain vital signs before and after Dialysis on Tuesday, Thursday, and Saturday.
Review of Resident #5's Dialysis communication sheets requested for month of July 2023 revealed 7 days of Dialysis Communication missing: July 4, 2023, July 6, 2023, July 11, 2023, July 13, 2023, July 15, 2023, July 18, 2023, and July 25, 2023.
Interview on 08/03/2023 at 10:05 a.m. with S1 DON confirmed the 7 missing Dialysis Clinic Communication Sheets. S1 DON stated Resident #5 had several missing Dialysis Communication Sheets and should not have.
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure a resident was treated with dignity and cared for in a manner that promoted the enhancement of his/her quality of life....
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Based on observation, interview, and record review the facility failed to ensure a resident was treated with dignity and cared for in a manner that promoted the enhancement of his/her quality of life. The facility failed to ensure a resident's urinary catheter drainage bag was covered to ensure privacy and promote dignity for 1 (#5) of 2 residents (#4, and #5) reviewed for dignity.
Findings:
Review of Resident' #5's Clinical record revealed admission date of 02/18/2022 with diagnoses that included Quadriplegia and Neuromuscular Dysfunction of Bladder.
Review of Resident #5's Quarterly MDS Assessment with ARD 02/07/2023 revealed the resident had a BIMS score of 15 (cognitively intact). The MDS revealed Resident #5 required total dependence with toilet use, and had an indwelling suprapubic urinary catheter.
Review of Resident #5's Care plan with target date of 05/23/2023 revealed a problem of resident had a diagnosis of Neurogenic Bladder and Quadriplegia, and had a suprapubic catheter with a goal for no complications.
Observation on 04/17/2023 at 10:35 a.m. while surveyor was in the hall revealed Resident #5 awake lying in bed. Resident #5's drainage collection bag was uncovered, and amber colored urine was noted in the drainage bag in view from the hallway.
Interview on 04/17/2023 at 1:55 p.m. with S6 CNA revealed she had just put Resident #5's catheter drainage collection bag inside of a protective cover because it was not in a protective cover bag earlier this morning when she emptied the urine from the drainage bag.
Observation on 04/18/2023 at 8:20 a.m. revealed Resident #5 awake sitting up in bed. Resident #5's GU drainage collection bag contained approximately 700 cc urine in GU drainage bag, and was in full visual view of residents and visitors from the door and hallway.
Interview on 04/18/2023 at 9:10 a.m. with S3 LPN revealed Resident #5's catheter drainage bag should have been emptied and placed inside of the protective cover and had not been done.
Interview on 04/18/2023 at 9:15 a.m. with S5 CNA stated she had forgot to put Resident #5's catheter collection drainage bag inside of a protective cover. S5 CNA stated the catheter drainage bag should have been in a protective cover, and was not.
Interview on 04/19/2023 at 11:55 a.m. with S2 DON confirmed that Resident # 5's urinary catheter drainage collection bag was not covered, and should have been.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
Based on record review, interview and observation, the facility failed to ensure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet th...
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Based on record review, interview and observation, the facility failed to ensure that nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safety and to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 (#4 and #5) of 3 residents (#1, #4 and #5) reviewed for pressure ulcers. The facility failed to ensure CNAs did not removed soiled dressings from Residents #4 and #5 pressure ulcers.
Findings:
Review of Wound care policy dated 11/2021 revealed in part .
This facility is committed to providing the highest quality of life supported by quality care for the aged and convalescent resident. To ensure resident health, safety, and proper care and treatment, each facility shall maintain a manual consisting of policies and procedures to detail effectively the scope of services. A competent staff of trained personnel is on duty 24 hours a day to meet the total needs of the residents in a comfortable, home-like environment.
Procedure: in part . Skin will be observed daily during care by the nursing assistant. If any skin concerns are noted, they are to be reported immediately to the designated nurse verbally and via the kiosk in electronic facilities.
PU Prevention and Treatment Intervention Guidelines
G. Education - Educate staff and develop appropriate treatment plan.
Resident #4
Review of Resident #4's medical record revealed an admission date of 03/28/2022 with diagnoses that included Osteomyelitis of Vertebra, Sacral and Sacrococcygeal region and Pressure Ulcer of Sacral region, Stage 4.
Review of Resident #4's Physician's Orders for 04/2023 revealed in part .
03/01/2023 - Stage 4 Sacrum PU cleanse with wound cleanser, pat dry, apply Santyl with saline soaked gauze, and cover with ABD pad daily until resolved and prn soiled/leakage.
04/14/2022 - Wound Vac to be changed at Cabrini Wound Clinic weekly.
Review of Resident #4's Quarterly MDS with ARD 01/05/2023 revealed a BIMS score of 13 (moderate cognitive impairment). Resident #4 required extensive assistance with 1 person assist for bathing, bed mobility, dressing and personal hygiene, and required total dependence with 1 person assist for transfers and toileting. Resident #4 always incontinent of bowels and unrated for urine. Resident #4 at risk for PU and had a Stage 4 PU. PU treatments included PU care and application of nonsurgical dressings.
Review of Resident #4's Care Plan with target date of 06/30/2023 revealed in part . Resident #4 has a stage 4 PU to sacrum. Observe skin daily with ADL care or bath and report any problems to nurse.
Observation and interview on 04/17/2023 at 2:15 p.m. revealed Resident #4 awake lying in bed, in preparation for wound care by S4 LPN Treatment Nurse by S7 CNA/Ward Clerk. Observation of Resident #4's sacral PU was open to air without dressing. S7 CNA/WC stated she removed Resident #4's wound dressing during her bed bath earlier due to her dressing was soiled with feces.
Interview on 04/17/2023 at 2:20 p.m. with S7 CNA/WC revealed S4 LPN treatment nurse had told her to remove resident's dressing if soiled. S7 CNA/ WC revealed she removed resident's dressing to her sacral area due to being soiled during her bed bath earlier this morning.
Interview on 04/19/2023 at 11:55 a.m. with S2 DON confirmed CNAs should contact the treatment nurse when resident's wound care dressings become saturated or not adhered to skin, and should not remove wound care dressings.
Resident #5
Review of Resident' #5's medical record revealed an admission date of 02/18/2022 with diagnoses that include Osteomyelitis of Vertebra, Sacral and Sacrococcygeal region; Quadriplegia; PU of Right Buttock, Stage 4; PU of Left Buttock, Stage 4; Non-chronic PU other part of right lower leg with muscle involvement and of right ankle, unstageable.
Review of Resident #5's Quarterly MDS Assessment with ARD 02/07/2023 revealed a BIMS score of 15 (cognitively intact). Resident #5 required total dependence with toilet use, had an indwelling suprapubic urinary catheter, and had a Stage 4 PU to bilateral buttocks and right ankle.
Review of Resident #5's Care plan with target date of 05/23/2023 revealed resident had a Stage 4 PU to right and left buttock with a goal for no increase in size of PU. Approaches included in part . to observe skin daily with ADL care or bath and report any problems to nurse.
Review of Resident #5's Physician's Orders for 04/2023 revealed in part .
04/10/2023 - Arterial ulcer right lower leg cleanse with wound cleanser, pat dry, apply Medi-honey cover with dry dressing, wrap with Kerlex secure with tape Wed and Fri until resolved.
02/18/2022 - Left ischium cleanse with wound cleanser, pat dry, apply Medi-honey pack with dry gauze and cover with dry dressing until resolved.
02/18/2022 - Right ischium cleanse with wound cleanser, pat dry, apply Medi-honey pack with dry gauze and cover with dry dressing until resolved.
02/18/2022 - Sacrum apply foam dressing q 3 days for prevention and prn dislodgement.
Observation on 04/17/2023 at 1:45 p.m. revealed S4 LPN performed wound care for Resident #5 with assistance of S6 CNA. Observation revealed the PU wounds to bilateral buttocks were open to air without dressing.
Interview on 04/17/2023 at 1:50 p.m. with S4 LPN revealed she had instructed S6 CNA to remove the dressing to bilateral buttocks if the dressing was saturated when the CNA gives his bed baths/ showers on MWF.
Interview on 04/17/2023 at 1:55 p.m. with S6 CNA revealed S4 LPN asked her to remove the dressings to his buttocks area during his bath before S4 LPN does his wound care. S6 CNA stated she removed the dressing to resident's buttocks and cleansed his buttocks area with warm soap and water while giving his bed bath. S6 CNA stated she used 2 bath basins during his bed bath, one basin of warm soap and water and the other basin with clean water.
Interview on 04/19/2023 at 11:50 a.m. with S4 LPN revealed she had instructed CNAs to remove resident's wound care dressings if soiled or came off during his bath or shower. S4 LPN confirmed resident had a urostomy and colostomy therefore his dressing did not get soiled. S4 LPN stated the Medi-honey would cause wound care dressings to not stay adhered to resident's skin and would come off.
Interview on 04/19/2023 at 11:55 a.m. with S2 DON confirmed CNAs should contact the treatment nurse when resident's wound care dressings become saturated or not adhered to skin. S2 DON confirmed CNAs should not remove residents wound care dressings. S2 DON confirmed wound care dressings should be changed by the treatment nurse and was not done for Resident #4 and Resident #5.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview the facility failed to ensure their grievance policy and procedure was followed by failing to initiate the Grievance/Complaint Form and start an inve...
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Based on observation, record review, and interview the facility failed to ensure their grievance policy and procedure was followed by failing to initiate the Grievance/Complaint Form and start an investigation for 1 of 3 random sampled residents (#R1, #R2, and #R3). The facility had a total census of 84 residents according to the CMS-802 form provided by the facility.
Findings:
Review of the facility Grievance policy revealed in part . upon receipt of a grievance/complaint the staff receiving the complaint will initiate the Grievance/Complaint Form NS-795. An investigation led by the Administrator based on the allegations will be set forth. NS-795 will be completed electronically in the Quality Assurance module.
Review of Resident Council minutes for January 2023 revealed the nursing department was short-staffed.
Review of Resident #R1's Face Sheet revealed an admission date of 04/11/2022 with diagnoses to include: Gout, Unilateral primary osteoarthritis (right knee), Unilateral primary (left knee), abnormalities of gait and mobility, and chronic pain syndrome.
Review of the Care Plan with an onset date of 04/11/2022 revealed Resident #R1 had impaired mobility with weakness to his bilateral lower extremities with an unstable standing balance and he required assistance with bed mobility. Resident #R1 had functional limited range of motion in his upper and lower extremities related to OA (Osteoarthritis). Resident #R1 needed staff assistance with late loss of ADLs: bed mobility, transfers, eating, and toileting.
Review of the Quarterly MDS with an ARD date of 01/04/2023 revealed a BIMS score of 14 (indicating the resident was cognitively intact). The MDS revealed Resident #R1 required extensive assistance for bed mobility and transfers (1 person), and limited assistance for dressing, toileting, personal hygiene (1 person).
Observation and interview on 02/08/2023 at 10:55 a.m. revealed Resident #R1 sitting in his motorized wheelchair. Resident #R1's bedrail had two urinals ½ full. Resident #R1 revealed he had not seen a CNA today. Resident #R1 revealed the facility was short-staffed and he had to wait over 1 hour before anyone answered his call light. Resident #R1 revealed the 3:00 p.m. to 11:00 p.m. shift was the worst. Resident #R1 revealed he had to wait every night until after 11:00 p.m. before a CNA came to put him in the bed. Resident #R1 revealed he learned how to put himself in the bed and to use his cane to pull the covers up over his body. Resident #R1 revealed he needed staff to empty his urinal at night. Resident #R1 revealed he voiced his concerns to S1 DON on 02/07/2023.
Interview on 02/08/2023 at 11:30 a.m. with S2 DON revealed Resident #R1 had complained about the evening shift (3:00 p.m. to 11:00 p.m.) on 02/07/2023. S1 DON stated she felt like it was an isolated incident so, she verbally counseled the CNAs on that shift. S1 DON confirmed she had not opened a grievance and she should have.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to have sufficient staff to attain or maintain the highes...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to have sufficient staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being for (Resident #3, Resident #4, Resident #R1, Resident #R2, and Resident #R3) of 85 total sample by failing to answer call lights in a timely manner.
Findings:
Review of Resident Council minutes for January 2023 revealed the nursing department was short- staffed.
Resident #3
Review of Resident #3's Face Sheet revealed an admission date of 02/11/2022 with diagnoses to include Fracture Upper end of right tibia, Morbid (severe) obesity due to excess calories, and Muscle weakness.
Review of Care Plan with onset date of 02/11/2022 revealed resident needed extensive to total staff assistance with late loss ADLs: Bed Mobility, Transfers, and Toileting feeds self with set up assistance.
Review of the Annual MDS with an ARD date of 01/03/2023 revealed a BIMS score of 15 (indicating the resident was cognitively intact). The MDS revealed Resident #3 required extensive assistance for transfers, dressing, toileting (1 person), and limited assistance for personal hygiene (1 person).
Review of hospital records dated 01/05/2023 revealed review of systems: reports rash-buttocks. On exam, there was no significant skin breakdown, but there was well demarcated erythema.
Interview on 02/06/2023 at 9:15 a.m. with Resident #3 revealed the facility was short- staffed especially around Christmas time and she was changed once a shift. Resident #3 revealed a male staff came in to provide ADL care; however, she refused to allow the male staff to provide the care. Resident #3 revealed she went to the hospital on [DATE] due to itching on her buttocks. Resident #3 revealed the ER physician told her the rash on her buttocks came from her lying in urine for long periods of time.
Resident #4
Review of Resident #4's Face Sheet revealed an admission date of 08/24/2022 with diagnoses to include Rt. Acquired absence of left leg below knee, Morbid (severe) obesity due to excess calories, and Fibromyalgia.
Review of the Care Plan with onset date of 08/24/2022 revealed resident needed staff assistance with late loss ADLs: Bed mobility, transfers, eating, and toileting. The Care Plan revealed Resident #4 had impaired physical mobility left BKA.
Review of the Quarterly MDS with ARD date of 08/24/2022 revealed a BIMS score of 15 (indicating the resident was cognitively intact). The MDS revealed Resident #4 required extensive assistance for bed mobility, transfers, toileting (1 person), and limited assistance for dressing and personal hygiene (1 person).
Interview on 02/06/2023 at 9:40 a.m. with Resident #4 revealed she could get on the bedpan without assistance; however, she needed assistance to get off the bed pan. Resident #4 revealed a few weeks ago she was on her bedpan for 1 ½ hours and she called several times to be taken off the bedpan. Resident #4 revealed the nurse turned the call light off and paged the CNA. Resident #4 revealed on 12/25/2022 Christmas evening there was only 1 CNA on her wing. Resident #4 stated 02/04/2023 (Saturday) night the facility was short-staffed of CNAs and she was on the bedpan for 1 hour.
Resident #R3
Review of Resident #3's Face Sheet revealed an admission date of 03/17/2017 with diagnoses rheumatoid arthritis, acquired absence of left knee, and contracture of muscle, right lower leg.
Review of the Care Plan with onset date of revealed 05/05/2022 impaired mobility has old left leg amputation wheelchair dependent for mobility, resident required set up supervision assistance with dressing needs, and resident required set up help with grooming.
Review of the Quarterly MDS with ARD date of 11/15/2022 revealed a BIMS score of 12 (indicating the resident was cognitively intact). The MDS revealed Resident #R3 required supervision and setup for bed mobility, transfers, dressing, toileting, and personal hygiene.
Interview on 02/08/2023 at 10:40 a.m. with Resident #R3 revealed the facility was short of staff and he did not know if his call light worked. Resident #R3 revealed he did everything for himself; however, at times he needed assistance, but, when he turned the light on for the CNAs the CNAs would not come.
Review of Resident #R1's Face Sheet revealed an admission date of 04/11/2022 with diagnoses to include: Gout, Unilateral primary osteoarthritis (right knee), Unilateral primary (left knee), abnormalities of gait and mobility, and chronic pain syndrome.
Review of the Care Plan with an onset date of 04/11/2022 revealed Resident #R1 had impaired mobility with weakness to his bilateral lower extremities with an unstable standing balance and he required assistance with bed mobility. Resident #R1 had functional limited range of motion in his upper and lower extremities related to OA (Osteoarthritis). Resident #R1 needed staff assistance with late loss of ADLs: bed mobility, transfers, eating, and toileting.
Review of the Quarterly MDS with an ARD date of 01/04/2023 revealed a BIMS score of 14 (indicating the resident was cognitively intact). The MDS revealed Resident #R1 required extensive assistance for bed mobility and transfers (1 person), and limited assistance for dressing, toileting, personal hygiene (1 person).
Observation and interview on 02/08/2023 at 10:55 a.m. revealed Resident #R1 sitting in his motorized wheelchair. Resident #R1's bedrail had two urinals ½ full. Resident #R1 revealed he had not seen a CNA today. Resident #R1 revealed the facility was short of staff and he had to wait over 1 hour before anyone answered his call light. Resident #R1 revealed the 3:00 p.m. to 11:00 p.m. shift was the worst. Resident #R1 revealed he had to wait every night until after 11:00 p.m. before a CAN came to put him in the bed. Resident #R1 revealed he learned how to put himself in the bed and to use his cane to pull the covers up over his body. Resident #R1 revealed he needed staff to empty his urinal at night. Resident #R1 revealed he voiced his concerns to S1 DON on 02/07/2023.
Interview on 02/08/2023 at 11:30 a.m. with S2 DON revealed Resident #R1 had complained about the evening shift (3:00 p.m. to 11:00 p.m.) on 02/07/2023. S1 DON stated she felt like it was an isolated incident so, she verbally counseled the CNAs on that shift. S1 DON confirmed she had not opened a grievance and she should have.
Resident #R2
Review of #R2's Face Sheet revealed an admission date of 12/24/2021 with diagnoses to include Osteomyelitis of vertebra, acquired absence of left leg above knee, and quadriplegia.
Review of the Care Plan with onset date of 11/03/2021 revealed the resident needed staff assistance with late loss ADLs: Bed mobility, transfers, eating, and toileting. The Care Plan revealed Resident #R2 was a quadriplegia and he required assistance with all ADLs.
Review of the Annual MDS with ARD date of 11/08/2022 revealed a BIMS score of 15 (indicating the resident was cognitively intact). The MDS revealed Resident #R2 was totally dependent on staff for bed mobility and transfers (2 persons), and totally dependent on staff for dressing, toileting, and personal hygiene (1 person), and extensive assistance for eating (1 person).
Interview on 02/08/2023 at 11:40 a.m. with Resident #R2 revealed the 3:00 p.m. to 11:00 p.m. CNAs would come in his room and turn his call light off and would not return.
Interview on 02/08/2023 09:00 a.m. with 3 anonymous staff revealed the facility was short-staffed on every shift. These staff were fearful of losing their jobs and asked to remain anonymous.
Interview on 02/08/2023 3:53 p.m. with anonymous staff revealed the facility was short-staffed on every shift. The staff revealed all staff are afraid to communicate with the surveyors.
Interview on 02/08/2023 at 5:15 p.m. with S1 DON revealed the facility was short-staffed of Administrative nursing staff.
Oct 2022
8 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
Based on observation and interview, the facility failed to ensure a cognitively impaired resident was treated with dignity and care in a manner that promotes enhancement of his or her quality of life....
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Based on observation and interview, the facility failed to ensure a cognitively impaired resident was treated with dignity and care in a manner that promotes enhancement of his or her quality of life. The facility failed to ensure a resident's urinary catheter drainage bag was covered to ensure privacy for 1 (Resident #45) of 2 (Resident #24 and Resident #45) residents reviewed for dignity.
Findings:
Review of Resident #45's clinical record revealed an admit date of 07/29/2022 with diagnoses that included: Encounter for Surgical Aftercare following Surgery on the Skin; Pressure Ulcer of Sacral Region, Stage 3; Rhabdomyolysis; Unspecified Dementia; and Anxiety Disorder.
Review of Resident #45's admission MDS with an ARD of 08/05/2022 revealed a BIMS score of 8 indicating moderate cognitive impairment. Further review revealed Resident #45 was total dependence with toilet use and had an indwelling catheter.
Review of Resident #45's Care Plan with a Target Date of 10/31/2022 revealed a problem of Resident #45 needs extensive staff assistance with late loss ADLs and has an indwelling catheter due to a Stage 3 pressure ulcer.
Observation on 10/03/2022 at 11:04 a.m. from the hall revealed Resident #45's catheter hanging from the side of the bed without a privacy bag.
Observation on 10/03/2022 at 2:38 p.m. from the hall revealed Resident #45's catheter hanging from the side of her bed without a privacy bag.
Observation on 10/04/2022 at 7:47 a.m. from the hall revealed Resident #45's catheter hanging from the side of the bed without a privacy bag.
Observation on 10/04/2022 at 7:53 a.m. with S4 LPN in Resident #45's room revealed her catheter hanging on the side of the bed without a privacy bag. Interview with S4 LPN confirmed her catheter did not have a privacy bag but it should have had one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure meal trays were not left in rooms for extensive periods of time ...
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Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure meal trays were not left in rooms for extensive periods of time for 1 (#13) of 4 (#13, #43, #60 and #184) sampled residents for environment.
Findings:
Observation on 10/03/2022 at 10:55 a.m. revealed Resident #13 was seated on the side of her bed eating a bowl of spaghetti. Further observation revealed a strong foul odor coming from a fold over tray on the nightstand next to Resident #13's bed. Further observation revealed a label on the tray was noted to have the Resident's name and was dated 10/01/2022 Dinner. Upon opening the tray the strong odor of rotted food permeated the room. The tray was noted to contain a hardened piece of fried chicken, soured mashed potatoes with gravy and soured vegetables.
Attempted interview at the time of observation revealed Resident #13 was oriented to person only.
Interview on 10/03/2022 at 11:00 a.m. with S3 LPN confirmed the above findings during an observation of the room. She stated the tray should have been removed from the room on 10/01/2022 and had not been.
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, and record review, the facility failed to ensure services were implemented according to the resident's person-centered plan of care for 2 (Resident #57 and Resident #7...
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Based on observation, interview, and record review, the facility failed to ensure services were implemented according to the resident's person-centered plan of care for 2 (Resident #57 and Resident #73) of 41 sampled residents. The facility failed to ensure hand rolls were placed bilaterally for Resident #57 and failed to ensure a wanderguard bracelet was applied to Resident #73.
Findings:
Resident #57
Review of Resident #57's Clinical Record revealed an admit date of 09/21/2010 with diagnoses that included: Type 2 Diabetes Mellitus; Personal History of Traumatic Brain Injury; Contracture, Unspecified Joint; and Polyneuropathy.
Review of Resident #57's Quarterly MDS with an ARD of 08/23/2022 revealed a BIMS was not conducted and Resident #57 is rarely/never understood and her cognitive skills for daily decision making was severely impaired. Further review revealed Resident #57 was totally dependent with bed mobility, transfer, dressing, personal hygiene, and bathing, and she had impairment on both sides of upper extremities and lower extremities
Review of Resident #57's Care Plan with a Target Date of 11/25/2022 revealed a problem of Resident #57 had contractures to bilateral upper/lower extremities with approaches that included hand rolls in place bilaterally.
Review of Resident #57's Physician Orders for October 2022 revealed an order to
cleanse bilateral hands with hibiclens 4% solution, dry, and apply hand roll daily for hand contractures with a start date of 12/21/2021.
Observation on 10/03/2022 at 9:43 a.m. revealed Resident #57 had contractures to bilateral hands and no hand roll was noted to either hand.
Phone interview on 10/03/2022 at 3:30 p.m. with Resident #57's responsible party revealed sometimes when he comes she does not have hand rolls in her hands.
Observation on 10/04/2022 at 7:45 a.m. revealed Resident #57 had no hand roll in place to either hand.
Interview on 10/04/2022 at 7:54 a.m. with S3 LPN revealed the treatment nurse and the hall nurse are responsible for ensuring Resident #57 had hand rolls in place.
Observation on 10/04/2022 at 7:55 a.m. of Resident #57 with S3 LPN revealed the resident did not have a hand roll in place to either hand. Interview with S3 LPN confirmed Resident #57 did not have a hand roll in place to either hand but she should have.
Resident #73
Review of the Facility's Elopement/Wandering General Policy revealed in part
All residents shall be observed and evaluated for demonstration of elopement risk by using Form NS-874 Admission/readmission Nurse Screening on admission/readmission and Form NS-712 Nurse Data Collection and Screening in the observation period of each MDS. In the event that a resident attempts to leave the facility unescorted or is found to be missing, they will be considered high risk. After reviewing this key information, the nursing staff will determine if the resident is at risk for wandering/ elopement. A resident determined to be at risk to wander will be identified on the resident's comprehensive plan of care.
Review of Resident #73's medical record revealed an admission date of 08/24/2022 with diagnoses that included: Metabolic Encephalopathy, Type 2 DM, Critical Illness Myopathy, Generalized Muscle Weakness, Unspecified Psychosis and other Abnormalities of Gait and Mobility.
Review of Resident #73's admission MDS with an ARD of 09/05/2022 revealed a BIMS score of 8 indicative of moderately impaired cognition. Resident #73 required extensive assistance with walking in room and locomotion on/off unit.
Review of Resident #73's Admission/readmission Nurse Screening Form dated 08/24/2022 revealed Resident #73 displayed cognitive deficits, disorientation, intermittent confusion, or any other cognitive impairments that contribute to poor decision-making skills in reference to elopement. Resident #73's family communicated the resident had eloped or attempted to elope form home, or shared concerns that the resident may have wandering/ elopement tendencies. Resident #73 at risk for elopement. Elopement Risk Summary revealed a Care Plan was in place for at risk for elopement and resident representative notified of risk of elopement.
Review of Resident #73's Care Plan with a target date of 11/24/2022 revealed a problem of Resident #73 at risk for elopement due to Delusional Encephalopathy, Dementia and statements of wanting to leave and to Bust out of this place. Further review revealed approaches which included: apply wanderguard bracelet, check placement every shift, and observe function of wanderguard daily.
Review of Resident #73's MARS for August 2022, September 2022, and October 2022 revealed orders with a start date of 08/25/2022: elopement risk and to check for proper placement of security bracelet every shift. Review of elopement risk and check for proper placement of security bracelet every shift revealed they were documented as performed.
Observation on 10/04/2022 at 8:38 a.m. revealed Resident #73 did not have a wanderguard/security bracelet in place.
Observation on 10/04/2022 at 12:15 p.m. revealed Resident #73 did not have a wanderguard/security bracelet in place.
Observation on 10/04/2022 at 2:41 p.m. revealed Resident #73 did not have a wanderguard/security bracelet in place.
Observation on 10/05/2022 at 8:45 a.m. revealed Resident #73 did not have a wanderguard/security bracelet in place.
Observation on 10/05/2022 at 10:15 a.m. of Resident #73 in his room with S5 CNA revealed he did not have a wander guard/security bracelet in place. Interview with S5 CNA revealed she was not aware Resident #73 was supposed to have a wanderguard/security bracelet on.
Interview on 10/05/2022 at 11:00 a.m. with S3 LPN in Resident #73's room revealed she had put a wander guard/security bracelet on his left ankle right before this surveyor came in. Observation at this time revealed Resident #73 with a wanderguard/security bracelet on his left ankle. S3 LPN stated she was unaware how long Resident #73 had not had his wanderguard/security bracelet in place. S3 LPN confirmed Resident #73 did not have a wander guard/security bracelet in place as documented on his MAR but he should have.
Interview on 10/05/2022 at 1:34 p.m. with S2 DON confirmed Resident #73 was assessed to be at risk for elopement and should have had a wander guard/security bracelet in place but did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #45 and Resident #23) of 3 (Resident #45, Resident #23, and Resident #14) residents reviewed for ADLs.
Findings:
Resident #45
Review of Resident #45's clinical record revealed an admit date of 07/29/2022 with diagnoses that included: Encounter for Surgical Aftercare following Surgery on the Skin; Pressure Ulcer of Sacral Region, Stage 3; Rhabdomyolysis; Unspecified Dementia; and Anxiety Disorder.
Review of Resident #45's admission MDS with an ARD of 08/05/2022 revealed a BIMS score of 8 indicating moderate cognitive impairment. Further review revealed Resident #45 required extensive assistance with personal hygiene and was totally dependent with bathing.
Review of Resident #45's Care Plan with a Target Date of 10/31/2022 revealed a problem of Resident #45 needs extensive staff assistance with late loss ADLs.
Observation on 10/03/2022 at 11:05 a.m. revealed Resident #45 in bed with her hair matted and knotted in clumps and she had a brush in her bed. Interview with Resident #45 revealed she was trying to brush her hair but was unable to get the knots out. Resident #45 reported the staff did not help her brush her hair.
Observation on 10/04/2022 at 11:13 a.m. revealed Resident #45 in bed with her hair up in a ponytail. Further observation revealed her hair was matted and knotted in clumps. Interview with Resident #45 revealed the staff would not brush her hair for her. Resident #45 reported they want to take her to the shower and wash it when it is knotted and that makes it worse. Resident #45 stated staff should come in everyday and brush it but they do not.
Observation on 10/04/2022 at 11:15 a.m. with S3 LPN in Resident #45's room revealed S3 LPN removing the ponytail and looking at Resident #45's hair. Further observation revealed her hair was matted and knotted in clumps. Interview with S3 LPN confirmed Resident #45's hair was matted and knotted in clumps and should not have been. Resident #45 reported to S3 LPN that the CNAs do not want to brush her hair.
Phone interview on 10/04/2022 at 11:34 a.m. with Resident #45's responsible party revealed Resident #45 was a very neat person. She reported Resident #45 likes her hair in a ponytail with her hair straight and the bottom curled under.
Resident #23
Review of the Face Sheet for Resident #23 revealed he was admitted to the facility on [DATE] with diagnoses which included: Type II Diabetic Peripheral Angiopath without Gangrene, Chronic Obstructive Pulmonary Disease, Pain in Unspecified Joint, Contracture of Left Hand and Unspecified Dementia.
Review of Resident #23's MDS with an ARD of 07/21/2022 revealed a BIMS score of 10 (indicating moderately impaired cognition). Further review revealed the Resident required total assistance with bathing and personal hygiene.
Review of Resident #23's Care Plan with a review date of 10/30/2022 revealed a problem of: Resident is dependent on staff for bathing needs and Resident has functional limited range of motion in upper and lower extremities with approaches for CNA to shower per schedule and assist Resident with ADL's as needed.
Observation and interview on 10/03/2022 at 9:44 a.m. revealed Resident #23 lying in bed. Resident's fingernails noted to be extremely long (approximately 3 inches) with hard black particles underneath them. Resident stated he didn't know what happened because staff use to cut his fingernails but not anymore.
Observation and interview on 10/04/2022 at 10:21 a.m. revealed Resident #22 lying in bed. Resident's fingernails noted to be extremely long (approximately 3 inches) with hard black particles underneath them. Resident stated he would like his fingernails trimmed and cleaned.
Observation and interview on 10/04/2022 at 11:49 a.m. with Resident #23 accompanied by S7 ADON revealed Resident's fingernails to be extremely long (approximately 3 inches) with hard black particles underneath them. S7 ADON confirmed Resident 23's fingernails were extremely long with hard black particles underneath them and needed to be cleaned and trimmed.
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 and record review the facility failed to ensure 1 (#48) of 5 (#11, #43, #48, #56, and #7) sampled resident reviewed for pressure ulcers, received the treatments necessa...
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Based on observation, interview and record review the facility failed to ensure 1 (#48) of 5 (#11, #43, #48, #56, and #7) sampled resident reviewed for pressure ulcers, received the treatments necessary to promote wound healing. Findings:
Review of Resident #48's clinical record revealed an admit date of 04/29/2016 with diagnoses that included: Bipolar Disorder, Essential Hypertension, Dementia, and Ataxia.
Observation on 10/05/2022 at 11:38 a.m. revealed Resident #48 seated in a geri-chair in the facility dining area visiting with family. Interview with Resident #48's RP at the time of observation revealed the resident was being treated for pressure ulcers on her buttocks.
Review of Resident #48's wound assessments revealed the resident had a Stage 2 pressure ulcer to the Left buttock measuring 3.00cm x 4.30cm x 0.10cm, Stage 2 to the Right buttock measuring 0.20cm x 0.20cm x 0.10cm and a Stage 2 to the Right lower buttock measuring 0.50cm x 0.50cm x 0.10cm.
Review of Resident #48's October 2022 TAR revealed Resident #48 was receiving Zinc Oxide to her bilateral buttocks for Stage 2 pressure ulcers, daily until healed with an order date of 09/13/2022.
Review of Physician's Wound Progress Notes dated 09/14/2022 revealed in part
Wound location: Bilateral buttock. Stage 2. Stable. Continue current treatment. Apply cream BID.
Interview on 10/05/2022 at 11:50 a.m. with S2 DON revealed the orders for Zinc Oxide cream should have been updated to reflect the Physician's Order on 09/14/2022 to apply cream BID and had not been.
Interview on 10/05/2022 at 1:00 p.m. with S6 LPN/Treatment Nurse revealed she made rounds with the wound care doctor on 09/14/2022. She confirmed Resident #48's wound care orders for Zinc Oxide cream had not been changed to BID after the physician's order on 09/14/2022 and should have been. S6 LPN/Treatment Nurse confirmed Resident #48 was only receiving treatments daily to ulcers on her buttocks.
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 interview and record review, the facility failed to ensure care and services were provided to meet a resident's needs as evidenced by failure to notify the physician of RD recommendations for...
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Based on interview and record review, the facility failed to ensure care and services were provided to meet a resident's needs as evidenced by failure to notify the physician of RD recommendations for a resident assessed by the RD to be at nutritional risk for 1 (Resident #68) of 3 (Resident #15, Resident #43, and Resident #68) residents reviewed for nutrition.
Findings:
Review of Resident #68's clinical record revealed an admit date of 08/15/2022 with diagnoses that included: Cerebral Palsy; Gastrostomy status; Dysphagia, Oropharyngeal Phase; Unspecified Intellectual Disabilities; Unspecified sequelae of Cerebral Infarction; Pressure Ulcer of left buttock, Stage 3; Alzheimer's Disease; and Gastroesophageal Reflux Disease.
Review of Resident #68's Significant Change MDS with an ARD of 9/09/2022 revealed a BIMS score of 9 indicating moderate cognitive impairment. Further review revealed Resident #68 required extensive assistance with eating.
Review of Resident #68's Care Plan with Target Date of 12/09/2022 revealed a problem of a Stage 3 Pressure Ulcer to the Left Buttock with approaches that included dietary consult PRN and observe labs as ordered. Further review revealed a problem of: Receives a mechanically altered diet with approaches that included RD consult as needed and weigh as ordered.
Review of Resident #68's RD progress notes revealed in part .
09/08/2022 11:49 a.m. Resident's current weight is 109.5 lbs. noted with significant wt. loss then weight gain x 3 weeks since admit. BMI 14.8. admitted on PEG feedings. Requested po (by mouth) diet and was referred for MBSS with result for po diet. Now receiving a Mechanical soft diet and tolerating at this time. Continues with flushes to peg. RECOMMENDATION: Continue with current diet order. Monitor weights, po intake, hydration, skin and labs. Refer to RD PRN.
09/08/2022 12:35 p.m. Addendum: Stage 3 Pressure Ulcer to Left Buttocks remains. Check prealbumin - if decreased add House Protein Liquid 30 ml bid.
09/15/2022 11:37 a.m. Resident's Current wt. 109 lbs. stable x 1 week. BMI 14.6. Stage 3 Pressure Ulcer to Left Buttock noted. On Vitamin C and Zinc Sulfate for healing. RECOMMENDATION: check prealbumin - if decreased add House Protein Liquid 30 ml bid
Review of Resident #68's lab report dated 09/09/2022 revealed a prealbumin level of 16.0 which was flagged as Low.
Review of Resident #68's Physician Orders for September 2022 and October 2022 revealed no order for House Protein Liquid 30 ml bid.
Interview on 10/05/2022 at 8:27 a.m. with S7 ADON revealed she and S6 LPN were responsible for following up with the RD recommendations. S7 ADON reported the RD put the notes in her box and S6 LPN's box. S7 ADON reported S6 LPN was responsible for following up with the RD recommendations for the residents who had wounds.
Interview on 10/05/2022 at 8:33 a.m. with S6 LPN revealed she and S7 ADON were both responsible for following up with the RD recommendations. S6 LPN reported she followed up on the recommendations for residents with wounds. S6 LPN reported Resident #68 had a Stage 3 Pressure Ulcer to the Sacrum. S6 LPN stated she had a copy of the RD notes from 09/08/2022 but not the notes from 09/15/2022. S6 LPN confirmed she did not notify the MD of the RD's recommendation on 09/08/2022 to check his prealbumin level and if decreased to add House Protein Liquid 30 ml bid but she should have. S6 LPN pulled up the RD's note in the chart from 09/15/2022 and reported the RD recommended to check his prealbumin level and if decreased to add House Protein Liquid 30 ml bid. S6 LPN confirmed she did not notify the MD of that recommendation but she should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#29) of 1 residents reviewed for respiratory care. The ...
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Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (#29) of 1 residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly cleaned and stored.
Findings:
Review of the facility policy titled: Nebulizer, revealed in part . Disconnect nebulizer from tubing. Rinse under hot tap water to remove residual after each use. Air dry parts on clean paper towels. Store in clean plastic bag.
Observation of Resident #29's room on 10/03/22 at 2:16 p.m. revealed an Aerosol mask attached to nebulizer on the floor next to the residents bed. The aerosol mask was open to air and nebulizer machine was noted to be dirty and stained with red liquid.
Observation on10/04/2022 at 10:00 a.m. revealed Resident #29 seated in a wheelchair at his bedside. A nasal cannula was observed draped over the foot of the Resident's bed. Further observation revealed an Aerosol mask attached to a Nebulizer machine on the floor next to the Resident's bed open to air. The nebulizer machine was noted to be dirty and stained with red liquid. Interview with Resident #29 at the time of observation revealed he used the nebulizer every day.
Interview on 10/04/2022 at 10:05 a.m. with S7 ADON confirmed the above findings. S7 ADON stated all respiratory equipment should be bagged when not in use. She also confirmed Resident #29's nebulizer machine was dirty and stained and needed to be cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure medications were:
1. Stored and labeled properly in accordance with currently acceptable professional principles on 2 ...
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Based on observation, interview, and record review, the facility failed to ensure medications were:
1. Stored and labeled properly in accordance with currently acceptable professional principles on 2 (Wing B medication cart and Wing C medication cart) of 2 medication carts.
2. Stored under proper temperature controls for 2 (Wing A medication refrigerator and Wing B medication refrigerator) of 2 medication refrigerators.
Findings:
Review of the facility's policy titled Medication Storage revealed in part .
Medication storage shall meet all applicable federal, state, and local guidelines.
Medication rooms, refrigerators and medication/treatment carts shall be maintained in a clean and orderly manner per the facilities' policy and procedures. See Medication Rooms Policy and Procedure.
Review of the facility's policy titled Medication Rooms revealed in part .
1. Refrigerators:
a. Record refrigerator temperature every night on Form NS-811 - Medication Room Refrigerator Temperature Log.
Observation on 10/05/2022 at 10:52 a.m. with S4 LPN of the Wing B medication cart revealed 3 loose pills in the left third drawer, 1 loose pill in the right second drawer, and 6 loose pills in the right third drawer. Interview with S4 LPN confirmed 3 loose pills were in the left third drawer, 1 loose pill was in the right second drawer, and 6 loose pills were in the right third drawer but they should not have been.
Review of the Wing B Medication Refrigerator Temperature Log on 10/05/2022 at 10:57 a.m. with S4 LPN revealed the temperature was not checked daily. Interview with S4 LPN revealed the medication refrigerator should be checked daily by the night shift. S4 LPN confirmed the temperature was not checked daily but it should have been.
Observation on 10/05/2022 at 11:17 a.m. with S8 LPN of the Wing C medication cart revealed 7 loose pills in the left third drawer and 3 loose pills in the left fourth drawer. Interview with S8 LPN confirmed 7 loose pills were in the left third drawer and 3 loose pills were in the left fourth drawer but they should not have been.
Review of the Wing A Medication Refrigerator Temperature Log on 10/05/2022 at 11:21 a.m. with S3 LPN revealed the temperature was not checked daily. Interview with S3 LPN revealed the medication refrigerator should be checked daily by the night shift. S3 LPN confirmed the temperature was not checked daily but it should have been.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 35 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $36,140 in fines. Higher than 94% of Louisiana facilities, suggesting repeated compliance issues.
- • Grade F (35/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Matthews Memorial Health's CMS Rating?
CMS assigns MATTHEWS MEMORIAL HEALTH CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Louisiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Matthews Memorial Health Staffed?
CMS rates MATTHEWS MEMORIAL HEALTH CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Louisiana average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Matthews Memorial Health?
State health inspectors documented 35 deficiencies at MATTHEWS MEMORIAL HEALTH CARE CENTER during 2022 to 2024. These included: 1 that caused actual resident harm and 34 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Matthews Memorial Health?
MATTHEWS MEMORIAL HEALTH CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE BEEBE FAMILY, a chain that manages multiple nursing homes. With 124 certified beds and approximately 81 residents (about 65% occupancy), it is a mid-sized facility located in ALEXANDRIA, Louisiana.
How Does Matthews Memorial Health Compare to Other Louisiana Nursing Homes?
Compared to the 100 nursing homes in Louisiana, MATTHEWS MEMORIAL HEALTH CARE CENTER's overall rating (2 stars) is below the state average of 2.4, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Matthews Memorial Health?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Matthews Memorial Health Safe?
Based on CMS inspection data, MATTHEWS MEMORIAL HEALTH CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Louisiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Matthews Memorial Health Stick Around?
Staff turnover at MATTHEWS MEMORIAL HEALTH CARE CENTER is high. At 61%, the facility is 15 percentage points above the Louisiana average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Matthews Memorial Health Ever Fined?
MATTHEWS MEMORIAL HEALTH CARE CENTER has been fined $36,140 across 1 penalty action. The Louisiana average is $33,440. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Matthews Memorial Health on Any Federal Watch List?
MATTHEWS MEMORIAL HEALTH CARE 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.